What Is Demodex?

The Demodex mite is a type of parasite that lives on humans and can reside in hair follicles and sebaceous glands. These mites are arachnid (eight-legged) and invisible to the naked eye, varying in size from 0.1mm to 0.4 mm long. They typically live on the face and in the hair follicles of the eyebrows, eyelids, roots of the eyelashes, facial hair, and around the ears and are associated with various skin problems of the eyes and face, such as blepharitis and acne rosacea.

Demodex can affect humans at any age, but their presence increases in prevalence with increasing age. Immunity compromised patients such as diabetics, patients on long-term corticosteroids or chemotherapy, or patients who have HIV/AIDS also have increased risk and prevalence of Demodex infection. Usually, when the immune system is weakened and the parasitic population has colonized, this disease can badly damage the skin.

How Can Demodex be Transmitted?

For transmission of mites from one person to another, direct contact of hair and sebaceous glands on the nose, or dust containing eggs is required. Since the disease processes begin when there is an overpopulation of Demodex, the vast majority of cases of mites go unobserved and don't show any adverse symptoms. However, in certain cases, the mite populations migrate and multiply in the eyelashes.

What Are The Types of Demodex?

There are two existing types of Demodex mites: Demodex folliculorum, which live in the hair follicles and feed on skin cells and Demodex brevis, which live in the sebaceous (oil) glands and feed on the sebum (oil).

What Are The Symptoms of Demodex?

In the early stages, there are often no noticeable symptoms, but if left untreated Demodex infestation can worsen. Symptoms vary among patients and may include:

  • dry eyes
  • red eyes
  • severe itching along the eyelid margin and eyebrows, especially in the morning
  • eyelid irritation and burning sensation,
  • foreign body sensation that seems to originate beneath the eyelids,
  • heaviness in the eyelids
  • blurry vision
One of the earliest signs of mite infestation is cylindrical dandruff (CD), which is the accumulation of fine, waxy, dry debris that collects at the base of the eyelash and extends up to 2 mm along the length of the lash. It is usually most noticeable on the upper lashes.

How Is Demodex Diagnosed?

Demodex mites can be diagnosed by a slit-lamp (biomicroscope) evaluation and by carefully removing and viewing an epilated eyelash under the microscope.

How Is Demodex Treated?

Patients of all severity levels should also be instructed to discard their make-up, use hot water to wash their clothes and linens, and machine dry on HIGH setting WEEKLY

Initial treatment involves the daily use of Tea Tree oil shampoos to wash the hair and all areas of facial hair. Patients with Demodex are also typically prescribed an eyelid cleanser (that contains tea tree oil or hyperchlorous acid) twice daily in order to eradicate the Demodex mites. They are instructed to cleanse the lids and lashes, as well as smear the lid cleanser onto the eyelash roots of both the upper and lower eyelid margin.  Complete coverage of the eyelash base by the tea tree oil lid cleanser is necessary to be effective so that mites are unable to lay eggs and hatch more Demodex mites. Patients should be instructed to use the wipes on their eyelashes, forehead, eyebrows, and cheeks as the mites live in all of those areas and scrubbing the eyelids/eyelash area with an eyelid foam twice a day.   Some common over the counter demodex treatments include:

  • Cliradex®:  Cliradex® is a lid wipe that contains terpinen-4-ol.
  • OCuSOFT® Lid Scrub Plus :  OCuSOFT® Lid Scrub Plus contains a 0.5% solution of 1,2-octanediol, which when used over a 4-week period has been shown to decrease Demodex infestation.
  • OUST™ Demodex® Swabstix™ and OUST™ Demodex® Cleanser (premoistened pads) by OCuSOFT®
  • Avenova®:  Studies have shown a reduction in the number of Demodex mites with management of hypochlorous acid.

For SEVERE CASES ONLY: Weekly in-office treatments may be necessary to manage a severe Demodex infestation.  These treatments could include:

  • Treatment with high concentrations of tea tree oil (50%) performed weekly.  High concentrations of tea tree oil may cause dermatitis, allergy, and ocular irritation.  The goal of the weekly office lid scrub with 50% tea tree oil solution is to stimulate the mites’ migration out of the lash follicle. This is then followed by daily home lid scrub with tea tree oil to prevent Demodex replication on the surface of the skin. Patients typically need to return for several in-office treatments of tea tree oil over the course of weeks to months in addition to performing daily home therapy.
  • In addition, every 3–6 months, severe patients may be treated with BlephEx™, a device by Rysurg utilized to remove the eyelash collarettes by a method known as microblepharoexfoliation. Microblepharoexfoliation involves removal of the biofilm on the surface of the lids and lashes using a high-speed rotary sponge soaked in lid cleanser. This also helps remove the eggs of the mites at the base of the eyelash follicle.

What Should Patients with Demodex Do?

Patients diagnosed with Demodex need to follow a few simple instructions:

  • Immediately WASH bedding, pillowcases towels and clothes in HOT water and dry in a heated dryer on HIGH before beginning treatment, and REPEAT THIS WEEKLY thereafter.

  • Wash face, nostrils, hair, external ear and neck with a tea tree oil cleanser twice daily.

  • Scrub the eyelids with a demodex eyelid foam and wipes twice a day.

  • Avoid using makeup for at least 1 week and discard all old makeup.

  • Avoid oil-based cleansers, greasy makeup, lotions, and sunscreens which can provide further "food" for the mites.

  • Exfoliate face once or twice a week to remove dead skin cells and trapped sebum. Keep pets away from sleeping surfaces.

With the proper medical care, treatment, and hygiene, the Demodex count usually drops to zero in 4-6 weeks without recurrence in the majority of cases. Patients receiving therapy show dramatic improvements in symptoms, eye inflammation, tear film stability and vision.

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