Blepharitis: Symptoms, Types, Causes and Treatment

Blepharitis is a common, often chronic, inflammatory condition that affects the eyelids. It can cause discomfort, visual disturbances, and impact quality of life. Understanding its symptoms, forms, underlying causes, and current treatment options is crucial for effective management. This comprehensive overview synthesizes the latest research and expert consensus on blepharitis.

Symptoms of Blepharitis

Blepharitis can be bothersome, presenting with a variety of symptoms that range from mild irritation to significant discomfort and visual disruption. Recognizing these symptoms early is essential for diagnosis and management. While some may experience only a few signs, others might have a complex mix that can significantly affect their daily life.

Symptom	Description	Frequency/Severity	Source(s)
Itching	Persistent urge to scratch eyelids/eyes	Common	3 5 4
Burning	Sensation of heat or stinging in eyes	Common	3 5
Redness	Eyelid margin or conjunctival redness	Moderate to High	1 3 5
Grittiness	Sandy/foreign body sensation	Common	1 3 5
Flaking/Dandruff	Skin flakes or crusts at eyelid base	Moderate	5 4
Sticky Eyelids	Eyelids stuck together, especially in AM	Occasional	5
Swelling	Puffy or heavy feeling in eyelids	Occasional	1 5
Tearing	Watery eyes or excessive tearing	Occasional	3 5
Photophobia	Sensitivity to light	Possible	3
Blurred Vision	Temporary, often improves with blinking	Possible	3
Crusting	Hard crusts at lash base, especially in AM	Common	5 6

Table 1: Key Symptoms

Understanding the Symptoms

Blepharitis symptoms often overlap with other ocular surface diseases, which can complicate diagnosis. They can be broadly grouped into irritation and debris-related complaints 5. Let’s explore these in more detail.

Irritative Symptoms

• Itching and Burning: The most frequent complaints, causing daily discomfort. Patients may describe a persistent urge to rub their eyes or a sensation of heat/stinging 5 3.
• Grittiness or Foreign Body Sensation: Feeling as if sand or debris is trapped under the eyelid is typical 1 5.
• Redness and Swelling: Eyelid margins may appear red, puffy, or inflamed. Redness may extend to the conjunctiva (the white of the eye) 1 3.

Debris and Discharge

• Flaking and Crusting: Many individuals notice small flakes or “dandruff” at the base of their eyelashes. In more advanced cases, hard crusts can form overnight, sometimes causing eyelids to stick together in the morning 5 6.
• Sticky Eyelids and Tearing: Sticky eyelids, especially upon waking, and excessive tearing (epiphora) are common 3 5.

Visual Disturbances

• Blurred Vision and Photophobia: While less common, some patients report temporary blurred vision or increased sensitivity to light. These symptoms often resolve after blinking, as the tear film is replenished 3.

Additional Features

• Heavy or Puffy Eyelids: Patients sometimes describe eyelids as feeling heavy or swollen 1 5.
• Associated Ocular Surface Changes: Chronic blepharitis may lead to superficial keratopathy or, rarely, more severe complications like corneal ulceration if left untreated 3.

Types of Blepharitis

Blepharitis isn’t a single disease but a spectrum of related disorders. Understanding the different types can guide both diagnosis and tailored treatment approaches.

Type	Main Characteristics	Typical Location or Cause	Source(s)
Anterior	Affects skin/lash base; crusting, redness	Eyelash follicles, skin	2 3 7
Posterior	Involves meibomian glands; oil issues	Inner eyelid margin	2 3 7
Mixed	Both anterior and posterior features	Both skin/lashes & meibomian glands	4 7
Staphylococcal	Redness, ulcers, lash loss; S. aureus	Bacterial (S. aureus)	6 7
Seborrheic	Greasy flakes, less inflammation	Sebaceous gland dysfunction	2 7
Demodex-related	Cylindrical dandruff, intense itching	Demodex mites (follicles/glands)	4 9 10
Ulcerative	Severe, ulcers, crusting, lash loss	Often with Candida in atopic pts	12

Table 2: Types of Blepharitis

Anterior Blepharitis

This form affects the outer edge of the eyelid, where the eyelashes grow. It is commonly due to either staphylococcal infection or seborrheic dermatitis 2 3. Features include redness, crusting, and scaling at the lash base. The staphylococcal type is often more inflamed and may lead to lash loss or ulceration 6 7. Seborrheic anterior blepharitis presents with greasy scales and is less inflamed.

Posterior Blepharitis (Meibomian Gland Dysfunction)

Posterior blepharitis involves the inner edge of the eyelid, where the meibomian glands are located. These glands secrete oils that help stabilize the tear film. Dysfunction results in thickened, altered secretions, and often a frothy tear film. Posterior blepharitis is frequently associated with skin conditions like rosacea and seborrheic dermatitis 2 3 7.

Mixed Blepharitis

Many patients have features of both anterior and posterior blepharitis. This overlap, sometimes called “mixed blepharitis,” is common and may be more symptomatic or chronic 4 7.

Special Types

• Demodex Blepharitis: Caused by infestation with Demodex mites, especially D. folliculorum (anterior) and D. brevis (posterior/meibomian gland involvement). Characterized by cylindrical dandruff at the lash base and intense itching 4 9 10.
• Ulcerative Blepharitis: A severe form, often with ulceration of the lash follicles, prominent crusting, and lash loss. Candida species can be a culprit in atopic patients 12.

Causes of Blepharitis

Blepharitis arises from a complex interplay of microbial, inflammatory, and environmental factors. Understanding the underlying causes can help target treatment and identify associated conditions.

Cause Type	Examples / Details	Relevance/Features	Source(s)
Bacterial	Staph. aureus, Coag-neg Staph, P. acnes	Most common in staphylococcal type	2 3 6 11
Seborrheic	Seborrheic dermatitis, oily skin	Linked to skin, scalp, and facial oil	2 7
Demodex Mites	D. folliculorum (lashes), D. brevis (glands)	Cause both anterior/posterior types	4 9 10 11
Fungal	Candida species (esp. in atopic patients)	Severe, ulcerative cases	12
Inflammatory	Rosacea, eczema, atopy	Often co-exists with other skin disease	2 3 7
Environmental	Dust, allergens, contact lens use	May exacerbate or trigger symptoms	3 4

Table 3: Major Causes

Bacterial Overgrowth

• Staphylococcus aureus is a common culprit, especially in classic anterior blepharitis. Other bacteria like coagulase-negative staphylococci and Propionibacterium acnes are frequently found on the lid margins 2 6 11.
• These bacteria can form biofilms and trigger inflammation by releasing toxins and enzymes, leading to chronic irritation 2 6.

Seborrheic and Inflammatory Skin Conditions

• Seborrheic dermatitis, rosacea, and eczema are strongly linked to blepharitis 2 3 7.
• These conditions may alter the composition of skin oils, promoting microbial growth and inflammation.

Demodex Mite Infestation

• Demodex folliculorum and D. brevis are microscopic mites that live in hair follicles and sebaceous glands.
• Their presence is significantly higher in people with blepharitis, especially those with cylindrical dandruff, intense itching, and severe or treatment-resistant disease 4 9 10 11.
• Mites can block hair follicles/glands, trigger immune responses, and carry bacteria, all contributing to inflammation 10 11.

Fungal Infections

• In certain populations, particularly atopic individuals, Candida species may cause or worsen ulcerative blepharitis 12.
• Fungal infection is rare but should be considered in severe, non-responsive, or ulcerative cases.

Other Contributing Factors

• Environmental: Dust, allergens, and irritants can worsen symptoms or trigger flares 3 4.
• Immunity: Decreased local or general immunity may increase susceptibility to infections and Demodex infestation 10 12.
• Tear Film Abnormalities: Meibomian gland dysfunction can destabilize the tear film, perpetuating inflammation and dryness 2 3 7.

Treatment of Blepharitis

Although blepharitis is rarely “cured,” it can be effectively managed. The mainstay is a combination of long-term lid hygiene, targeted therapies for infection or inflammation, and addressing underlying causes such as mites or skin disease.

Treatment	Main Approach/Agent	Key Features/Efficacy	Source(s)
Lid Hygiene	Warm compresses, lid scrubs, cleansers	Foundation of all therapy	2 3 8 14
Topical Antibiotics	Azithromycin, erythromycin, bacitracin	Reduce bacterial load, relieve symptoms	1 2 3 6 8
Topical Steroids	Weak steroids (short-term)	For significant inflammation	2 3 8
Combination Therapy	Antibiotic + steroid drops/ointments	Address both infection & inflammation	8
Oral Antibiotics	Doxycycline, tetracycline	For severe/posterior/MGD cases	2 3
Demodex Treatments	Tea tree oil, metronidazole, ivermectin	Eradicate mites, reduce symptoms	9 10 13
Antifungal Agents	For Candida/ulcerative cases	Target fungal infection	12
Dedicated Cleansers	Commercial eyelid cleansers	May outperform baby shampoo	14

Table 4: Treatment Approaches

Lid Hygiene: The Foundation

• Daily lid hygiene is the cornerstone of blepharitis management 2 3 8 14.
• Simple techniques include:
  • Warm compresses to loosen debris and melt oily secretions
  • Gentle scrubbing of the lid margin with a cotton swab and diluted baby shampoo or a dedicated eyelid cleanser
• Recent studies suggest commercial eyelid cleansers may reduce inflammation more effectively and are often preferred by patients 14.

Topical Antibiotics

• Topical antibiotics such as azithromycin, erythromycin, or bacitracin ointment can target bacterial overgrowth, especially in anterior/staphylococcal blepharitis 1 2 3 6 8.
• A 4-week azithromycin regimen has shown significant improvement in both signs and symptoms, with lasting benefits 1.
• Antibiotics may also reduce the bacterial load associated with Demodex infestation 11.

Topical Steroids and Combination Therapy

• For patients with prominent inflammation, short-term use of mild topical corticosteroids can provide relief 2 3 8.
• Combination drops or ointments (antibiotic + steroid) can be effective for both infectious and inflammatory components, but should be used under medical supervision 8.

Oral Antibiotics

• Oral tetracyclines (doxycycline, tetracycline) are sometimes prescribed for posterior blepharitis or meibomian gland dysfunction, especially in adults 2 3.
• These agents have both antibacterial and anti-inflammatory properties.

Demodex-Targeted Therapies

• For Demodex-related blepharitis, eradication of mites is crucial.
• Tea tree oil lid scrubs (50%) or lid massages (5%) are effective and reduce both mites and inflammation 9 13.
• Metronidazole gel/ointment and oral ivermectin may also be beneficial, especially in resistant or severe cases 10 13.
• Local treatments generally have fewer side effects compared to systemic options 13.

Antifungal and Other Therapies

• In rare cases of ulcerative blepharitis due to Candida (especially in atopic patients), antifungal therapy is warranted 12.
• Additional options, such as sulfur ointments or permethrin, may be used in some Demodex cases 10.

Long-Term Management

• Blepharitis is a chronic condition. Maintenance therapy, including ongoing lid hygiene and periodic use of medical treatments, is usually necessary 2 3 7 8.
• Patient education and regular follow-up are key to preventing recurrences and complications.

Conclusion

Blepharitis is a diverse and persistent eyelid condition, but with proper understanding and management, most people can achieve significant relief. Here’s a summary of the main points covered:

• Symptoms: Include itching, burning, redness, grittiness, flaking, and occasional visual disturbances. Symptoms often overlap and can impair quality of life 3 5.
• Types: Classified as anterior, posterior, mixed, staphylococcal, seborrheic, Demodex-related, and ulcerative, based on anatomical location and cause 2 3 7 9 10.
• Causes: Multifactorial—includes bacterial overgrowth, seborrheic skin changes, Demodex mites, fungi (rare), and environmental/immune factors 2 3 4 6 7 9 10 11 12.
• Treatment: Relies on lid hygiene, topical/oral antibiotics, steroids, mite-targeted therapy, and, in rare cases, antifungals. Long-term care and patient adherence are essential for control 2 3 8 9 10 13 14.

By staying informed and following a tailored management plan, individuals with blepharitis can minimize symptoms and maintain eye comfort and health.