Azithromycin Versus Doxycycline for Meibomian Gland Dysfunction

Meibomian gland dysfunction (MGD) affects the eyelid glands. It needs distinguishing from dry eye caused by insufficient watery tears. The American Academy of Ophthalmology’s¹ 2024 guidance considers oral antibiotics when lid cleansing or gland expression has not adequately controlled MGD.¹

Trial comparison

137 Thai adults had treatment-resistant moderate-to-severe MGD; rosacea was excluded.²

Masked comparison: azithromycin 1 g weekly for three weeks with doxycycline 100 mg twice daily for six weeks. Both continued warming, massage and artificial tears.²

Were scores equivalent?

Equivalence allowed differences within ±2 MGD-score points and ±9 Ocular Surface Disease Index (OSDI) points, derived from score variability.²

Azithromycin-minus-doxycycline adjusted differences (95% confidence intervals):²

Outcome	Difference
MGD, week six	−0.33 (−1.70 to 1.03)
MGD, week eight	0.13 (−1.59 to 1.84)
OSDI, week six	−1.20 (−5.31 to 2.91)
OSDI, week eight	−1.59 (−5.73 to 2.55)

After Bonferroni correction for multiple tests, MGD equivalence held at six weeks (P = .04), but eight weeks was inconclusive (P = .07). OSDI equivalence held; each group’s improvement was below nine points.²

Intention-to-treat analysis imputed missing scores; no untreated comparator.²

Stomach side effects

Gastrointestinal events: 3/68 versus 11/69. Chiang Mai University funded it; no conflicts reported.²

What belongs in the prescribing discussion?

Both oral treatments are off-label for MGD under the cited US labels. A shorter regimen still needs a medication review.³⁴

Azithromycin can cause QT prolongation and potentially fatal abnormal heart rhythms, particularly with certain heart conditions, low potassium or magnesium, or other QT-prolonging medicines. Its label also warns about serious liver injury and worsening myasthenia gravis. Previous azithromycin-associated liver dysfunction is a contraindication.³

Doxycycline can cause esophageal irritation or ulceration and exaggerated sunburn. Review pregnancy, breastfeeding, isotretinoin, iron supplements and antacids before prescribing; some combinations increase harm or reduce absorption. The label advises adequate fluids with doses to reduce esophageal injury.⁴

Bring the exact eye diagnosis, previous lid-care routine, current medicines and any previous antibiotic reactions to the appointment. Ask which examination finding and symptom score will be reassessed, and when.

“When Skin Is a Clue” in Skin, Head to Toe puts eye symptoms alongside rosacea in the clinician-assessment category.