Blepharitis

Table of Contents

  1. Overview
  2. Epidemiology
  3. Anterior vs. Posterior Blepharitis
  4. The Demodex Connection
  5. Meibomian Gland Dysfunction and Dry Eye
  6. Seborrheic Dermatitis Association
  7. Symptoms and Diagnosis
  8. Warm Compresses and Lid Hygiene
  9. Baby Shampoo Versus a Dedicated Eyelid Cleanser
  10. Medications: Azithromycin, Doxycycline, Topical Steroids, Lotilaner
  11. Intense Pulsed Light (IPL) for MGD-Associated Blepharitis
  12. Key Research Papers
  13. Connections
  14. Featured Videos

Overview

Blepharitis is inflammation of the eyelid margins — the rims of the eyelids where the lashes grow. The 2012 Cochrane review of treatments describes it as a common condition, associated with itchiness, redness, flaking and crusting of the eyelids, that affects both children and adults in all ethnic groups and at all ages. In a 2009 United States survey, ophthalmologists reported seeing blepharitis in 37% of their patients and optometrists in 47% (Lemp and Nichols).

The same Cochrane review notes that, although it is infrequent, blepharitis can lead to permanent changes of the eyelid margin or to vision loss from superficial keratopathy, corneal neovascularization and ulceration. More commonly it causes burning, irritation, tearing, red eyes, light sensitivity and blurred vision. The cause is thought to be multifactorial: chronic low-grade bacterial infection of the ocular surface, infestation with Demodex mites, and inflammatory skin conditions such as atopy and seborrhea.

Across 34 trials (2,169 participants), the review found no strong evidence that any treatment cures chronic blepharitis. Lid hygiene may provide symptom relief in both anterior and posterior blepharitis, and topical antibiotics gave some symptom relief and cleared bacteria from the lid margin in anterior blepharitis; the effects of topical steroids and oral antibiotics were inconclusive. The authors also observed that commercial products are marketed and prescribed without substantial evidence of effectiveness.

Blepharitis is classified by where on the lid it occurs. Anterior blepharitis (staphylococcal and seborrheic) affects the front of the lid margin and the lashes; posterior blepharitis is meibomian gland dysfunction (MGD), affecting the oil glands set deeper in the lid. A 2010 review notes that each form can incite or propagate the other, and many people have both.

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Epidemiology

Good prevalence data are scarce. The 2009 survey paper by Lemp and Nichols describes blepharitis as a poorly defined condition with little good data on how common it is. Its two surveys found:

The 2021 Cochrane review of oral antibiotics, by contrast, describes posterior blepharitis as becoming more common with age, and lists rosacea, meibomianitis and infections among its associated conditions.

Demodex mites are common on the eyelids of older adults. In a 2021 cross-sectional study of 119 older people with dry-eye symptoms or signs, Demodex was found in 68.9%, with an average count of 4.2 mites (Cheng and colleagues).

Blepharitis on one side only can have other causes. A 2015 review of sebaceous carcinoma of the eye region reports that this malignancy often masquerades as chronic unilateral conjunctivitis or blepharitis, typically in older patients (Shields and colleagues). In a 1999 series of six patients whose persistent inflammation was finally biopsied after prolonged medical treatment, the biopsies showed squamous neoplasia or carcinoma (two), sebaceous carcinoma (two) and conjunctival lymphoma (two); the authors concluded that a high index of suspicion and early histopathologic examination are essential (Akpek and colleagues).

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Anterior vs. Posterior Blepharitis

The Cochrane review divides chronic blepharitis by anatomy: anterior blepharitis, which includes staphylococcal and seborrheic forms, and posterior blepharitis, which is meibomian gland dysfunction. Its authors recommend that future trials separate participants by type (for example staphylococcal blepharitis versus MGD), because mixing them limits what trials can show.

Anterior Blepharitis

Anterior blepharitis involves the front of the lid margin — the skin, the lash follicles and the lash bases. Signs graded in the trials cited here include crusting at the lash bases, cylindrical collarettes (sleeve-like deposits around the base of the lashes) and eyelid redness. In the anterior-blepharitis trials reviewed by Cochrane, topical antibiotics cleared bacteria from the lid margin.

Posterior Blepharitis

Posterior blepharitis involves the meibomian glands, which secrete the oily layer of the tear film. Trials of posterior blepharitis grade meibomian gland plugging and the quality of the expressed secretion (Luchs 2008). A Cochrane review of intense pulsed light describes MGD as the major cause of evaporative dry eye disease, the more common form of dry eye (Cote and colleagues, 2020).

Mixed Blepharitis

A 2010 review describes the two forms as linked: untreated anterior blepharitis can lead to meibomian gland disease, and vice versa (Luchs). Blepharitis is also associated with dermatitis, dry eye, conjunctivitis and keratitis.

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The Demodex Connection

Two species of Demodex mite live on human eyelids. A 2015 review reports that Demodex folliculorum causes chronic anterior blepharitis, whereas Demodex brevis causes posterior blepharitis, meibomian gland dysfunction, recurrent chalazia and refractory keratoconjunctivitis; lash sampling with microscopic counting and in-vivo confocal microscopy are the key diagnostic methods (Cheng, Sheha and Tseng).

Bacteria carried by the mites may add to the inflammation. In a 2012 study of 38 patients with Demodex-related chronic blepharitis and 30 healthy people, 23 bacterial isolates cultured from the epilated lashes were identified as Bacillus oleronius; the authors propose that the mite carries this bacterium as a co-pathogen in severe blepharitis (Szkaradkiewicz and colleagues).

In the 2021 study of older people with dry eye, those with Demodex were more likely to report itching and had more cylindrical dandruff and lid vascularity; itching and cylindrical dandruff were the findings most specific for Demodex, and a count of 2 or more mites best matched both (Cheng and colleagues). A 2025 chart audit of 192 US patients with Demodex blepharitis found that over 40% were not examined for it at first presentation and that diagnosis took 6.5 months on average (Periman and colleagues).

Lotilaner

The FDA approved lotilaner ophthalmic solution 0.25% on 25 July 2023 to treat Demodex blepharitis (FDA, Novel Drug Approvals for 2023). Its prescribing information describes lotilaner as a member of the isoxazoline family and a GABA-gated chloride channel inhibitor selective for mites, whose inhibition paralyses and kills the mite; the labeled dose is one drop in each eye twice daily, about 12 hours apart, for 6 weeks (FDA label, NDA 217603). The trial results are summarized under Medications below.

Tea Tree Oil

Tea tree oil is widely used against Demodex, but the 2020 Cochrane review of six randomized trials (562 participants) found uncertainty about whether 5% to 50% tea tree oil is effective for the short-term treatment of Demodex blepharitis, and three trials found no difference in symptom scores between tea tree oil and other treatments. Six participants given tea tree oil had ocular irritation or discomfort; the reviewers wrote that, if it is used, lower concentrations may be preferable to avoid irritation (Savla and colleagues).

In a 2025 laboratory study of mites taken from patients' lashes (10 mites per agent), lotilaner 0.25% gave the shortest median survival time, 5% tea tree oil killed mites in a median 27 minutes, and olive oil (the control) left them alive a median 360 minutes; the authors call for studies in people before conclusions about clinical use (Demirci and Erdur). The 2015 review describes terpinen-4-ol, the most active ingredient of tea tree oil, as helping eradicate Demodex mites and reduce ocular surface inflammation (Cheng, Sheha and Tseng).

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Meibomian Gland Dysfunction and Dry Eye

Posterior blepharitis — meibomian gland dysfunction — is tied closely to dry eye. The 2009 survey paper reports wide agreement that MGD is the most common cause of evaporative dry eye disease (Lemp and Nichols), and the 2020 Cochrane review calls MGD the major cause of evaporative dry eye, the more prevalent form of dry eye (Cote and colleagues).

A 2012 clinic-based study of 224 people with dry eye classified 159 of them: 79 had MGD only, 23 had pure aqueous-deficient dry eye, and 57 had both. In all, 86% of those classified showed signs of MGD, and the authors concluded that evaporative dry eye from MGD far outweighs pure aqueous deficiency in a general clinic population (Lemp and colleagues).

The 2011 International Workshop on Meibomian Gland Dysfunction produced a consensus report on the disease (executive summary: Nichols and colleagues). A 2020 analysis of registered MGD trials found that the workshop had had minimal impact on how interventional trials defined the condition and measured outcomes (Ngo and colleagues).

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Seborrheic Dermatitis Association

Seborrheic blepharitis is one of the two anterior forms in the Cochrane classification, and the review lists inflammatory skin conditions such as seborrhea and atopy among the suspected causes of blepharitis. A 2010 review likewise notes that blepharitis is associated with systemic conditions such as dermatitis (Luchs).

The Cochrane authors recommend that future trials separate participants by type of blepharitis, so that results for any one form, including seborrheic blepharitis, can be read on their own.

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Symptoms and Diagnosis

Symptoms

The symptoms reported in the Cochrane review and the trials cited on this page include:

Itching was the symptom most specific for Demodex in the 2021 study of older people with dry eye.

Diagnosis

Diagnosis is clinical. Signs graded in the trials on this page include:

For Demodex, lashes are epilated and the mites counted under a microscope; the Saturn-2 trial epilated four or more lashes per eye and counted mites per lash (Gaddie and colleagues). In-vivo confocal microscopy is another method (Cheng, Sheha and Tseng). A chronic, one-sided case that does not respond to treatment raises the question of an ocular surface tumor such as sebaceous carcinoma (see Epidemiology).

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Warm Compresses and Lid Hygiene

Lid hygiene — warm compresses and cleaning of the eyelid margin — is the conventional treatment. The 2012 Cochrane review found that lid hygiene may provide symptom relief for anterior and posterior blepharitis, and the 2026 Cochrane review of topical immunosuppressants concluded that conventional lid hygiene and warm compresses remain valid treatment options (Kam and colleagues). The 2012 reviewers asked that medical treatments and commercial products be compared against these conventional measures in future trials.

Warm Compresses

A 2008 randomized study measured inner eyelid temperature during warm compress use. Compresses heated to 45 °C and applied for 15 minutes without reheating brought the inner lower lid to a maximum of 38.8 °C; with reheating every 2 minutes and close contact with the lower lid, the inner lower lid passed 40 °C. The authors concluded that heating meibomian glands effectively with compresses takes a precise, customized and labor-intensive procedure (Blackie and colleagues).

Eyelid Cleansers

Lid cleansers range from diluted baby shampoo to dedicated surfactant cleansers, cleansers containing tea tree oil or terpinen-4-ol, and hypochlorous acid solutions. In a 2017 study of 71 eyes, a saline hygiene solution containing 0.01% hypochlorous acid reduced the staphylococcal load on the periocular skin by more than 99% 20 minutes after application, including antibiotic-resistant strains (Stroman and colleagues; several authors disclosed employment by or consulting for a pharmaceutical company). The evidence on tea tree oil is summarized under The Demodex Connection, and the comparison with baby shampoo in the next section.

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Baby Shampoo Versus a Dedicated Eyelid Cleanser

Diluted baby shampoo has long been used as a lid cleanser. A 2018 randomized, double-masked, paired-eye trial in 43 people with blepharitis compared it with a dedicated eyelid cleanser: each person used the cleanser on one eye and diluted baby shampoo on the other, twice daily for 4 weeks (Sung and colleagues).

The authors concluded that only the dedicated cleanser reduced ocular surface inflammation, and that the long-term effect of reduced goblet cell function with baby shampoo needs further study. This was a single 4-week trial.

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Medications: Azithromycin, Doxycycline, Topical Steroids, Lotilaner

Medications are used alongside lid hygiene. The 2012 Cochrane review found some symptom relief from topical antibiotics in anterior blepharitis and inconclusive evidence for topical steroids and oral antibiotics.

Topical Azithromycin

Azithromycin 1% eye drops, in a polymer-based vehicle, are approved for bacterial conjunctivitis; a 2010 review describes their use for posterior blepharitis as off-label, proposed on the basis of the drug's anti-infective and anti-inflammatory properties and tissue penetration (Luchs). That paper is a review, not a trial. In a small randomized, open-label trial (21 patients with posterior blepharitis, 20 completing), azithromycin drops plus warm compresses for 14 days — twice daily for 2 days, then once daily — gave significantly greater improvement in meibomian gland plugging, gland secretion and eyelid redness than warm compresses alone (Luchs 2008). A 2025 review of antibiotics for MGD reports that topical azithromycin offers similar or superior efficacy to oral regimens with less systemic exposure, but that benefits are usually limited to the treatment period and the best dose and duration remain uncertain (Arita).

Oral Doxycycline

The 2021 Cochrane review of oral antibiotics for chronic blepharitis found two placebo-controlled trials (220 participants) and reports that there are no guidelines on antibiotic type, dose or duration:

The reviewers concluded that the evidence was insufficient for meaningful conclusions (Onghanseng and colleagues). The 2025 review reports that oral azithromycin may be at least as effective as doxycycline, with a shorter course and fewer adverse events (Arita).

The doxycycline prescribing information (DailyMed label) lists these hazards:

Topical Corticosteroids

The 2026 Cochrane review of topical immunosuppressants (12 trials, 2,752 participants, mostly of corticosteroids, then cyclosporine and tacrolimus) concluded that topical corticosteroids, with or without antibiotics, and cyclosporine may make little to no difference to the signs and symptoms of blepharitis at 4 to 12 weeks compared with placebo or antibiotics alone, with very low-certainty evidence for most comparisons. Corticosteroids plus antibiotics probably improve corneal staining compared with antibiotics alone, and ocular hypertension was reported more often in the corticosteroid groups than with antibiotics alone. The review notes that long-term steroid use is limited by side effects such as increased intraocular pressure, glaucoma and cataract (Kam and colleagues).

Lotilaner 0.25%

Lotilaner ophthalmic solution 0.25% was tested against its vehicle in two pivotal trials, Saturn-1 (NCT04475432) and Saturn-2 (NCT04784091), with 833 participants in total, twice daily for 6 weeks (pooled analysis: Yeu and colleagues, 2025). Results at day 43:

92.0% of Saturn-1 and 90.7% of Saturn-2 patients rated the drop neutral to very comfortable. The FDA label reports instillation-site stinging and burning in 10% of patients as the most common adverse reaction, and chalazion/hordeolum and punctate keratitis in under 2%. In an extension study of 239 Saturn-1 patients, 39.8% of the lotilaner group versus 2.7% of the vehicle group had 0 to 2 collarettes at day 180, and 23.5% versus 2.9% at day 365 (Sadri and colleagues). A 2024 meta-analysis of five studies also found significant effects on collarettes, mite eradication and erythema (Akhtar and colleagues). Several authors of the trial reports were employees of the drug's manufacturer.

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Intense Pulsed Light (IPL) for MGD-Associated Blepharitis

Intense pulsed light was first used for vascular and inflammatory skin disorders in dermatology and is applied to the skin near the eyelids to treat MGD, often together with meibomian gland expression.

Mechanisms

A 2026 review lists the proposed mechanisms below and notes that they remain incompletely established (Yan and colleagues). A 2024 review also describes the mechanism as still unclear (Gupta and colleagues).

Clinical Protocol and Evidence

The 2020 Cochrane review found only three randomized trials (114 adults). Pooling the two sham-controlled paired-eye trials showed little to no reduction in dry-eye symptoms with IPL, with very low-certainty evidence. Tear break-up time may improve with IPL (low-certainty evidence). The reviewers concluded that whether IPL helps the symptoms or signs of evaporative dry eye is currently uncertain, and noted 14 trials then in progress (Cote and colleagues). The 2020 tea tree oil review reports one trial in which the IPL group had complete Demodex eradication at 3 months, with very low certainty (Savla and colleagues).

Later reviews are more favorable. The 2024 review reports that recent randomized trials show IPL improving meibomian gland function, tear film quality and dry-eye symptoms (Gupta and colleagues). The 2026 review notes that responses vary, treatment parameters are not standardized, and long-term safety data and high-quality randomized trials remain limited (Yan and colleagues).

Patient Selection and Safety

The 2020 Cochrane review could not determine the safety of IPL for MGD, because most trials did not report adverse events in a structured way. Individual studies describe mild pain and burning, and partial loss of eyelashes through clinician error (Cote and colleagues). The 2024 review stresses attention to each patient's Fitzpatrick skin type and protection of the eye to reduce the risk of adverse effects, and lists cost, accessibility and a limited duration of effect as drawbacks (Gupta and colleagues).

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Key Research Papers

  1. Ngo W, Gann D, Nichols JJ (2020). Impact of the 2011 International Workshop on Meibomian Gland Dysfunction on clinical trial attributes for meibomian gland dysfunction. Ocular Surface — PubMed PMID: 31589925
  2. Periman LM, Whitley WO, Maiti S, et al. (2025). The patient journey and burden of disease in Demodex blepharitis in the United States. Journal of Medical Economics — PubMed PMID: 40314599
  3. Muhammad Muneeb Akhtar S, Fareed A, Sohaib Asghar M, et al. (2024). Efficacy and Safety of Lotilaner Ophthalmic Solution 0.25% for the Treatment of Demodex Blepharitis: A Meta-Analysis of Randomized Controlled Trials. Contact Lens and Anterior Eye — PubMed PMID: 38514290
  4. Sung J, Wang MTM, Lee SH, et al. (2018). Randomized double-masked trial of eyelid cleansing treatments for blepharitis. Ocular Surface — PubMed PMID: 29128682
  5. Luchs J (2010). Azithromycin in DuraSite for the treatment of blepharitis (a review). Clinical Ophthalmology — PubMed PMID: 20689782
  6. Arita R (2025). Targeted therapies for meibomian gland dysfunction - The role of antibiotics in meibomian gland dysfunction management. Taiwan Journal of Ophthalmology — PubMed PMID: 41523132
  7. Yan J, Chen W, Li J (2026). Intense pulsed light as a multi-target intervention paradigm for refractory ocular surface diseases: a review. Eye and Vision — PubMed PMID: 42816895
  8. Lemp MA, Crews LA, Bron AJ, et al. (2012). Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea — PubMed PMID: 22378109
  9. Lindsley K, Matsumura S, Hatef E, Akpek EK (2012). Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews — PubMed PMID: 22592706
  10. Demirci G, Erdur SK (2025). Comparative in vitro efficacy of ivermectin, lotilaner, lime sulfur, tea tree oil, and lemongrass oil against Demodex folliculorum. Contact Lens and Anterior Eye — PubMed PMID: 40721364
  11. Ferreira J, Embalo A, Rodrigues A, et al. (2026). Recurrent Red Eye Misdiagnosed as Conjunctivitis: Ocular Rosacea With Corneal Neovascularization in a Young Patient (case report). Cureus — PubMed PMID: 42281673
  12. Blackie CA, Solomon JD, Greiner JV, et al. (2008). Inner eyelid surface temperature as a function of warm compress methodology. Optometry and Vision Science — PubMed PMID: 18677234
  13. Nichols KK, Foulks GN, Bron AJ, et al. (2011). The international workshop on meibomian gland dysfunction: executive summary. Investigative Ophthalmology & Visual Science — PubMed PMID: 21450913
  14. Cheng AM, Sheha H, Tseng SC (2015). Recent advances on ocular Demodex infestation. Current Opinion in Ophthalmology — PubMed PMID: 26058028
  15. Yeu E, Wirta DL, Karpecki P, et al. (2023). Lotilaner Ophthalmic Solution, 0.25%, for the Treatment of Demodex Blepharitis: Results of a Prospective, Randomized, Vehicle-Controlled, Double-Masked, Pivotal Trial (Saturn-1). Cornea — PubMed PMID: 35965392
  16. Gaddie IB, Donnenfeld ED, Karpecki P, et al. (2023). Lotilaner Ophthalmic Solution 0.25% for Demodex Blepharitis: Randomized, Vehicle-Controlled, Multicenter, Phase 3 Trial (Saturn-2). Ophthalmology — PubMed PMID: 37285925
  17. Yeu E, Paauw JD, Vollmer P, et al. (2025). Safety and Efficacy of Lotilaner Ophthalmic Solution (0.25%) in Treating Demodex Blepharitis: Pooled Analysis of Two Pivotal Trials. Ophthalmology and Therapy — PubMed PMID: 39873946
  18. Sadri E, Paauw JD, Ciolino JB, et al. (2024). Long-Term Outcomes of 6-Week Treatment of Lotilaner Ophthalmic Solution, 0.25%, for Demodex Blepharitis: A Noninterventional Extension Study. Cornea — PubMed PMID: 38334465
  19. Luchs J (2008). Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Advances in Therapy — PubMed PMID: 18781287
  20. Onghanseng N, Ng SM, Halim MS, Nguyen QD (2021). Oral antibiotics for chronic blepharitis. Cochrane Database of Systematic Reviews — PubMed PMID: 34107053
  21. Kam KW, Mehraban Far P, Yim TW, et al. (2026). Topical immunosuppressants for blepharitis in adults. Cochrane Database of Systematic Reviews — PubMed PMID: 42153421
  22. Savla K, Le JT, Pucker AD (2020). Tea tree oil for Demodex blepharitis. Cochrane Database of Systematic Reviews — PubMed PMID: 32589270
  23. Cote S, Zhang AC, Ahmadzai V, et al. (2020). Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database of Systematic Reviews — PubMed PMID: 32182637
  24. Gupta AS, Massaro M, Bunya VY (2024). Intense pulsed light treatment for the management of meibomian gland dysfunction. Current Opinion in Ophthalmology — PubMed PMID: 38813738
  25. Lemp MA, Nichols KK (2009). Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocular Surface — PubMed PMID: 19383269
  26. Szkaradkiewicz A, Chudzicka-Strugała I, Karpiński TM, et al. (2012). Bacillus oleronius and Demodex mite infestation in patients with chronic blepharitis. Clinical Microbiology and Infection — PubMed PMID: 22114987
  27. Cheng AM, Hwang J, Dermer H, Galor A (2021). Prevalence of Ocular Demodicosis in an Older Population and Its Association With Symptoms and Signs of Dry Eye. Cornea — PubMed PMID: 32956104
  28. Stroman DW, Mintun K, Epstein AB, et al. (2017). Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clinical Ophthalmology — PubMed PMID: 28458509
  29. Shields JA, Saktanasate J, Lally SE, et al. (2015). Sebaceous Carcinoma of the Ocular Region: The 2014 Professor Winifred Mao Lecture. Asia-Pacific Journal of Ophthalmology — PubMed PMID: 26147013
  30. Akpek EK, Polcharoen W, Chan R, Foster CS (1999). Ocular surface neoplasia masquerading as chronic blepharoconjunctivitis. Cornea — PubMed PMID: 10336029

PubMed Topic Searches

  1. PubMed: Baby shampoo and the ocular surface
  2. PubMed: Topical azithromycin for blepharitis
  3. PubMed: MGD and evaporative dry eye prevalence
  4. PubMed: Lid scrubs and lid hygiene in blepharitis
  5. PubMed: Warm compresses for meibomian gland dysfunction

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Connections

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