• Ask the person about eyelid hygiene. If this has been complied with, but is ineffective on its own, consider offering antibiotics (if not already tried):
• Topical antibiotics should usually be tried first, especially if there are signs of staphylococcal infection on the anterior lid margins. A 6-week trial course is usually adequate:
• Chloramphenicol eye ointment is a suitable first-line option (ointment is generally preferred to drops).
• Fusidic acid eye drops are an alternative.
• Treat for 4–6 weeks.
• Consider prescribing oral tetracyclines if topical antibiotics have failed to elicit an adequate response, or if there are signs of Meibomian gland dysfunction or rosacea:
• Low-dose tetracycline, oxytetracycline, lymecycline, or doxycycline is recommended.
• Prescribe for a minimum of 6 weeks. However, a 3-month course will usually provide a prolonged effect.
• Repeated courses are often required intermittently.

• Eyelid hygiene should be maintained throughout, as this is the mainstay of treatment.
• For information on the signs of staphylococcal infection and Meibomian gland dysfunction, see Examination.
• For further information on how antibiotics should be used and their contraindications and adverse effects, see Prescribing information:
• Topical antibiotics.
• Oral tetracyclines.

These recommendations are largely based on expert opinion, as only weak evidence from a few small clinical trials is available. CKS did not identify any UK guidelines on the management of blepharitis, but these recommendations are consistent with US guidelines on blepharitis [American Optometric Association, 2002; American Academy of Ophthalmology, 2003] and with expert reviews of good clinical practice [Denton et al, 1999; Pray and Pray, 2002].

Topical antibiotics:

• CKS found no relevant randomized placebo-controlled trial of a topical antibiotic for treating blepharitis. However, evidence from a small before-and-after trial and two small case series supports their use.
• Chloramphenicol is the first-line topical antibiotic of choice in the UK [BNF 54, 2007]:
• Chloramphenicol is one of the oldest antibiotics to be used in clinical practice. As such, controlled trials to support its effectiveness in the treatment of blepharitis are lacking. However, clinical experience over many years supports its use for this condition.
• Chloramphenicol is inexpensive and is well tolerated by most people. The eye ointment formulation is usually recommended, as it stays in contact with the skin and eyelid margin longer; however, eye drops may be suitable if there is coexisting conjunctivitis.
• Fusidic acid is an alternative topical antibiotic to chloramphenicol:
• Fusidic acid is only available as eye drops. It may be more suitable for people who also have corneal involvement or conjunctivitis.
• Ciprofloxacin is used extensively in the US [Bloom et al, 1994; Adenis et al, 1996]. However, it is usually reserved for second-line use in the UK because of concern about increasing resistance of bacteria to quinolones. The ointment formulation is currently undergoing post-marketing surveillance (black triangle) [BNF 54, 2007].

Topical corticosteroids, with or without antibiotics:

• Topical ocular corticosteroids (alone or combined with topical antibiotics) are not recommended for use in primary care (unless they are prescribed following specialist assessment), as they can result in severe adverse effects, including cataracts; glaucoma; and viral, bacterial, or fungal infections involving the eyelid, conjunctiva, and cornea [Watson and Coroneo, 2001; McGhee et al, 2002; BNF 54, 2007].

Oral tetracyclines:

• CKS found no relevant randomized placebo-controlled trial of an oral tetracycline for treating blepharitis, but evidence from a small before-and-after trial and a small case series supports the use of oral tetracyclines.
• The doses of tetracycline used during treatment are probably sub-therapeutic if the mechanism of action was solely that of an antibiotic. In vitro studies suggest that tetracyclines may inhibit bacterial lipases, with a subsequent reduction in free fatty acid production. Inhibition of keratinization and antimicrobial activity may also be important [Dougherty et al, 1991].
• Any tetracycline can be used, but oxytetracycline or doxycycline are probably most suitable:
• Oxytetracycline and tetracycline are inexpensive and only require twice-daily dosing. They should be avoided in people with renal dysfunction.
• Lymecycline and doxycycline only require once-daily dosing. Both can be taken with food, which may reduce gastrointestinal intolerance and improve compliance. However:
• Doxycycline should be avoided in people who are exposed to a lot of sunlight or other ultraviolet light sources.
• The dose of lymecycline cannot be tapered, unlike other tetracyclines.