Medical Care
Historical management of Demodex blepharitis involves a treatment regimen that is divided into in-office care and at-home care.
In the office, D folliculorum can be lured to the follicle surface with the use of volatile fluids, such as ether (not allowed in the United States), brushed vigorously across the external lid margin, following 0.5% proparacaine instillation. Five minutes later, a solution of 70% alcohol is applied in a similar manner. This regimen is reported to successfully reduce both the symptoms and the observed number of mites by the end of 3 weekly visits. Ether and alcohol should be used with caution, and corneal contact should be prevented.
A combination of this in-office treatment with a home regimen is suggested. The home regimen includes scrubbing the eyelids twice daily with baby shampoo diluted with water to yield a 50% dilution and applying an antibiotic ointment at night until resolution of symptoms.
A novel in-office treatment using a mechanical rotating handpiece with a microsponge tip combined with polyaminopropyl biguanide foam solution removes oil, scurf, and debris; exfoliates the eyelids; and claims to decrease Demodex infestation. [9]
A novel in-office treatment using a mechanical rotating handpiece with a microsponge tip combined with PolyaminopropylBiguanide foam solution removes oil, scurf, and debris; exfoliates the eyelids, and claims to decrease Demodex infestation. Image courtesy of Rendia, Inc. Copyright 2017 Rendia, Inc.
Various treatments have been used to control Demodex mites. Most treatments involve spreading an ointment at the base of the eyelashes at night to trap mites as they emerge from their burrow and/or move from one follicle to another.
Mercury oxide 1% ointment is frequently used.
Pilocarpine gel reduced the number of mites and alleviated the symptom of itching in 11 patients in a nursing home. Celerio et al hypothesized that pilocarpine was directly toxic to the mites because its muscarinic action impedes respiration and motility. [10]
Lotilaner ophthalmic
Lotilaner ophthalmic solution (Xdemvy) was approved by the FDA for treatment of Demodex blepharitis in July 2023. Lotilaner is a gamma-aminobutyric acid (GABA)-gated chloride channel inhibitor selective for mites. Inhibition of these GABA chloride channels causes a paralytic action in the target organism, leading to its death.
Approval was based on 2 multicenter, randomized controlled trials (SATURN-1 and SATURN-2) in 833 patients. Patients who received active drug in the SATURN-1 trial had a statistically significantly higher collarette cure (81.3% vs 23%), complete collarette cure (44% vs 7.4%), mite eradication (67.9% vs 17.6%), erythema cure (19.1% vs 6.9%), and composite cure (13.9% vs 1%) than the control group (all values P < 0.0001). [31]
Similarly, in the SATURN-2 trial, patients who received lotilaner achieved a statistically significant (P < 0.0001) collarette cure (56% vs 12.5%), clinically meaningful collarette reduction to 10 collarettes or fewer (89.1% vs 33%), mite eradication (51.8% vs 14.6%), erythema cure (31.1% vs 9%), and composite cure (19.2% vs 4%) than the control group. [32]
Ivermectin 1% cream
Ivermectin 1% cream (Soolantra, Galderma Labs) has been approved by the FDA for the treatment of rosacea. It may be applied to eyelashes and eyelids once daily. It may have beneficial effects as early as 2 weeks and may be used safely up to 52 weeks, depending on the severity of the Demodex infestation.
Tea tree oil and terpinon-4-ol
Before treatment with terpinon-4-ol (Cliradex, a natural tea tree oil product), 50% tea tree oil with Macadamia nut oil was the most popular treatment method. This is applied with cotton tip applicators, after one drop of tetracaine. [6, 11, 12, 13] Aggressively debride the lashes and the lash roots first with scrubs. Try to get the oil into the lash roots and along the lashes to kill any eggs. Treat the eyebrows as well. Three applications, 10 minutes apart, per visit are recommended; treatment is completed with compounded 20% tea tree ointment. Repeat for 3 visits, each one week apart.
Gao et al [14] reported in 2012 that there is a strong correlation between symptomatic resolution and reduction of Demodex counts by daily massage with 5% tea tree oil ointment. [6]
Home regimen includes the following:
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Use tea tree shampoo on hair and eye lashes every day.
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Use tea tree soap or face wash every day.
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Apply 5% tea tree oil cream/ointment daily to cover the skin around the lids to prevent mating and reinfestation from the skin around the eye. [15]
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Buy new makeup and discard old makeup; do not use makeup for 1 week.
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Clean sheets and buy new pillows.
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Check spouse; if both have this problem, both need to be treated.
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Check pets.
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For the first few weeks, use the ointment at night after tea tree shampoo scrubs. If inflammation is present, combination steroid-antibiotic ointments may be applied for one week. This is then replaced with a pure antibiotic ointment or with compounded 10% tea tree ointment.
The latest promising treatment regimen includes the use of Cliradex, a commercially available natural product, isolating terpinon-4-ol from tea tree oil. A medicated towelette is used twice daily as an eyelid and eyelash wipe.
A double-blinded randomized clinical trial comparing two tea tree oil–based formulations in patients with chronic blepharitis showed improved ocular surface parameters in both study groups and reduced cytokines and Demodex count in the group who received advanced gel containing 3% tea tree oil plus essential oils and vitamins. [16] However, no comparison was done with placebo.
A systematic review and meta-analysis of treatment efficacy for Demodex blepharitis showed that local treatments continue to be promising. [17]
Intense pulsed light treatment of Meibomian gland dysfunction has been shown to decrease the population of Demodex. [18]
Intense pulsed light. Courtesy of OPTIMED (https://www.optimed.co.uk/), E-referral and patient engagement platform.
Consultations
Weekly follow-up visits for 4 weeks may be necessary in severe cases to monitor the effects of in-office and at-home treatment regimen.
Further Outpatient Care
Terpinon-4-ol (Cliradex) may be purchased as a home care kit. In the absence of Cliradex, the following outpatient care may be followed:
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Eyelash scrubs twice daily with a 50-50 mixture of baby shampoo and water using a cotton swab or a rough washcloth provide symptomatic relief. The assumption that patients are knowledgeable about this procedure should not be made; demonstrating the eyelash scrub technique to the patient may be necessary.
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The patient should be prescribed two 3.5-g tubes of a viscous ointment, preferably an antibiotic ointment, mercuric oxide ointment, or 10% tea tree oil ointment. The patient should be instructed to squeeze out 1 inch of ointment and apply liberally to each lid immediately before bedtime. This is believed to inhibit the reproductive attempts of the adult Demodex. The patient is also instructed to wash out the ointment every morning with the eyelash scrubs.
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Preventive facial hygiene with daily soap and water washes is encouraged. Long-term compliance may be a problem in patients with dry skin.
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Dermatologic consultation may be helpful in a patient with recurrent episodes or in those with accompanying dermatologic involvement.
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Typically, 3-4 weeks of treatment is necessary. In patients who respond to the above outlined treatment, the eyelid scrubs may be reduced to once a day and an ointment at bedtime.
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Consequently, the treatment is reduced until the condition resolves or recurs. If recurrence of symptoms occurs during the tapering period, the patient is advised to go back to the previous treatment level and to continue at that level.
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If the patient is unresponsive to treatment, consider noncompliance or other underlying etiologies.
Inpatient & Outpatient Medications
Inpatient and outpatient medications include the following:
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Lotilaner ophthalmic (Xdemvy)
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Terpinon-4-ol (Cliradex)
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Ivermectin 1% cream (Soolantra)
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50-50 mixture of baby shampoo and water
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Erythromycin ointment
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Mercury oxide 1% ointment
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Pilocarpine 4% gel
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10% tea tree oil ointment
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Illustration of Demodex folliculorum. Reprinted with permission from Antoine Morin, BIODIDAC, University of Ottawa.
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Eyelid section shows Demodex folliculorum (M) in the hair follicle. Note mite mouthparts (arrow) embedded in epithelium and straplike layers of keratin (hematoxylin and eosin, X400). Reprinted with permission from Elsevier Science.
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Section of sebaceous gland of an eyelash shows Demodex brevis (M). Note gland cell (C) destruction (McManus, X375). Reprinted with permission from Elsevier Science.
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Cross-section through small hair follicle of the eyelid. Note distension, hyperplasia, and moderate epithelial keratinization caused by the activities of Demodex folliculorum (arrow) (hematoxylin and eosin, X375). Reprinted with permission from Elsevier Science.
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Section of eyelid shows eyelash (L), cuffing (C), and small segment of Demodex folliculorum (M). Note layering of cuff (Masson, X275). Reprinted with permission from Elsevier Science.
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Demodex folliculorum.
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Demodex along the shaft of the cilia.
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Demodex along the shaft of the cilia (higher magnification).
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Backsides of numerous pubic crabs with infestation of the lashes and secondary blepharitis. Reprinted with permission from HD Riley, OD, Indiana University School of Optometry.
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Phthiriasis (Phthirus pubis) pubic crab lash infestation and secondary blepharitis. Reprinted with permission from HD Riley, OD, Indiana University School of Optometry.
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Phthiriasis (pubic lice). Reprinted with permission from HD Riley, OD, Indiana University School of Optometry.
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Demodex infestation is an under diagnosed cause of chronic blepharitis. Image courtesy of Rendia, Inc. Copyright 2017 Rendia, Inc.
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Blepharitis secondary to Demodex infestation. Image courtesy of Rendia, Inc. Copyright 2017 Rendia, Inc.
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A novel in-office treatment using a mechanical rotating handpiece with a microsponge tip combined with PolyaminopropylBiguanide foam solution removes oil, scurf, and debris; exfoliates the eyelids, and claims to decrease Demodex infestation. Image courtesy of Rendia, Inc. Copyright 2017 Rendia, Inc.
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Intense pulsed light. Courtesy of OPTIMED (https://www.optimed.co.uk/), E-referral and patient engagement platform.
