eMedicine Specialties > Ophthalmology > Infectious Disease

Demodicosis

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

Updated: Apr 7, 2008

Introduction

Background

Observation of the arachnid, Demodex folliculorum, has been reported since 1840. This hair follicle mite is the only metazoan organism commonly found in the pilosebaceous components of the eyelid of humans. Coston "opened the eyes" of ophthalmologists when he described 22 patients with demodectic eyelid signs and symptoms.¹

Pathophysiology

D folliculorum (all stages) is found in small hair follicles and eyelash hair follicles. In all forms, immature and adult, it consumes epithelial cells, produces follicular distention and hyperplasia, and increases keratinization leading (in eyelashes) to cuffing, which consists of keratin and lipid moieties. Demodex brevis (all stages) is present in the eyelash sebaceous glands, small hair sebaceous glands, and lobules of the meibomian glands. Adults and immature forms consume the gland cells in all of these loci and, when infestations are heavy, can affect the formation of the superficial lipid layer of the tear film coacervate. Demodectic mites produce histologically observable tissue and inflammatory changes, epithelial hyperplasia, and follicular plugging.

Infestation of the eyelash hair follicle results in easier epilation and more brittle cilia. These mites also serve as vectors of infective elements and interrupt tissue integrity. They have been implicated in meibomian granulomas and are associated with certain dermatologic changes. All reported histologic sections of lid follicles infested with D folliculorum show distention and thickening. Coston claims that less than one half of the specimens he observed showed perifollicular lymphocytic infiltration.¹

Follicular inflammation produces edema and results in easier epilation of the eyelashes. It also affects cilia construction, and lashes are observed to be more brittle in the presence of demodicosis. Madarosis (loss of lashes) is associated with abundant mites, the loss of eyelashes as a result of intercellular edema in the hair shaft, and loss of hair resiliency. Although epithelial hyperplasia associated with follicular plugging is often encountered, dermal changes seldom extend beyond the perifollicular epidermal area. Once believed to be mite excreta, this plugging is now known to be epithelial hyperplasia with interspersed layers of lipid. The formation of a collar of tissue around the base of the lashes is observed clinically. This occurs significantly more often in follicles infected with D folliculorum. The epithelial hyperplasia is hypothesized to be most likely a product of the abrasive action of the mite's claws.

Accumulation of waste material of the follicle mite may occur in affected follicles or sebaceous glands. Electron micrographs of the mite surface and feces show bacterial, viral, and rickettsial elements. Specific reports have revealed that both species pierce epithelial cells and consume cytoplasm. Only D brevis has been observed with channels burrowed to the germinal epithelium in the sebaceous glands.

Demodex species-induced pathologic changes have been implicated in dry eye conditions. When follicular plugging involves the meibomian gland (D brevis) or the gland of Zeis (D folliculorum or D brevis), reduction of the superficial lipid layer of the tear film occurs. The effect of D brevis on the meibomian structure has been implicated in chalazion formation. Chalazia are granulomatous inflammation of the meibomian glands, made of an organized core of epithelioid cells and histocytes surrounded by fibroblasts, lymphocytes, and plasma cells. These defense cells encircle particles too large for normal macrophages to engulf. D brevis has been observed in the center of these meibomian granulomas. Lid infestation by the Demodex species may or may not accompany dermatologic changes of the nose, the cheek, or the forehead.

D folliculorum has been suggested as a factor in pityriasis folliculorum. This dermal inflammation manifests itself as a diffuse erythema of the affected areas; scaly, dry skin; and, in certain cases, rosacealike lesions. The dry skin cycle described by Ayres is initiated when the demodectic mite plugs the follicle and reduces the sebaceous outflow, which leads to scaling as well as rough and dry skin texture.² Sebaceous outflow is further reduced when patients inadvertently decide to apply facial cream. The mite flourishes in this environment of oily additives, leading to an increase in the population of the mites and a continuation of the dry skin cycle.

Frequency

International

Several individuals have attempted to estimate the prevalence of D folliculorum in the eyelash follicles. The initial report in 1961 suggested a prevalence of 95%.³

Mortality/Morbidity

Madarosis (loss of lashes) may result from untreated demodicosis.

Race

No racial predilection has been observed.

Sex

Infestation by these parasites is equal in males and females. Infestation is correlated to the number of sebaceous glands but not to the density of the hair follicles.

Age

Post reported that D folliculorum was observed in 84% of the sample population with a mean age of 61 years and in 100% of those older than 70 years.⁴

Clinical

History

• Symptoms
  • Ocular irritation
  • Itching
  • Scaling of lids
• Past ocular history - Recurrent failed treatment of blepharitis

Physical

• Gross observation  
  • Lid thickening
  • Scaling of lids
  • Madarosis (loss of lashes)
  • Conjunctival inflammation
  • Meibomian gland dysfunction
  • Rosacea
  • Decreased vision
• Slit lamp findings  
  • Collar of tissue around the base of the eyelashes
  • Follicular distention
  • Dry eye
  • Cornea  
    • Superficial corneal vascularization
    • Marginal corneal infiltration
    • Phlyctenule-like lesion
    • Superficial corneal opacity
    • Nodular corneal scar

Causes

• Demodex species specific to humans occupy 2 periocular sites hidden from external observation. They are small in size and possess the ability to move across the skin surface.
• D folliculorum is found in hair and eyelash follicles associated with pilosebaceous glands in the eye or elsewhere on the face and the body. A single follicle may contain as many as 25 D folliculorum organisms.
• D brevis leads a much more solitary lifestyle in sebaceous glands of the body and in the meibomian gland and the gland of Zeis.
• D folliculorum measures 0.3-0.4 mm in length, whereas D brevis is one half the size of D folliculorum (0.15-0.2 mm) with similar structure of the head and the thorax but a shorter abdomen.
• The 8 legs of this arachnid are segmented and provide locomotion at a rate of 8-16 mm/h.
• D folliculorum and D brevis, also known as follicle mites, are believed to be more active in the dark, although capture in daylight is possible.
• The bright light of the day and especially the biomicroscope cause the mite to recede back into the follicle. Therefore, the mite can be observed only when an epilated lash is observed under a low-power microscope.
• The life stages of D folliculorum begin with copulation at the mouth of the follicle. Reproduction is believed to occur in darkness; a fact that is significant in symptomatology and treatment.
• Following copulation, the female burrows back into the follicle near the opening of the pilosebaceous gland and lays her eggs.
• Spickett reported the life cycle of D folliculorum and estimated that only 14.5 days elapse from ovum to adult stage, including 120 hours as an adult. Females may live an additional 5 days after oviposition.³
• Sexes are separate; sexual maturity is reached in the larval form (neoteny).
• Females are territorial; they remain in their respective follicles and wait for the nomadic philandering males that travel over the surface of the skin from one follicle to another in seek of females.
• Adults reside in the follicle parallel to the hair shaft, head inward, often with the tail end (opisthosoma) protruding onto the surface of the skin at the base of the eyelash.

Differential Diagnoses

Blepharitis, Adult
Chalazion
Dry Eye Syndrome
Hordeolum

Other Problems to Be Considered

Rosacea
Phthiriasis (pubic lice) of the lids
Meibomian gland dysfunction

Workup

Laboratory Studies

• Diagnosis is made on a high index of clinical suspicion.
• Occasionally, nasal skin scrapings may be requested to rule out the possibility of acne rosacea.

Imaging Studies

• By visualizing the metazoan parasite under high-power magnification, a definitive diagnosis can be made.
• An epilated lash examined under low-power magnification may demonstrate the organism.
• Adding a fluorescein solution after mounting further helps in detecting and counting the mites that are embedded in cylindrical dandruff of epilated eyelashes.⁵
• Electron microscopy has been used to visualize the organism.

Procedures

• Slit lamp biomicroscopy

Histologic Findings

All reported histologic sections of lid follicles infested with D folliculorum show distention and thickening. Coston claims that fewer than one half of the specimens he observed showed perifollicular lymphocytic infiltration.¹ Follicular inflammation produces edema and results in easier epilation of the eyelashes. It also affects cilia construction, and the lashes are observed to be more brittle in the presence of demodicosis. Dermal changes seldom extend beyond the perifollicular epidermal area, although epithelial hyperplasia associated with follicular plugging is often encountered.

Treatment

Medical Care

The treatment regimen 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.
• 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.⁶
• The latest popular treatment regimen includes the use of 50% tea tree oil with Macadamia nut oil, applied with cotton tip applicators, after one drop of tetracaine.⁷
• 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.
• Home regimen includes the following:  
• Use tea tree shampoo on hair and eye lashes every day.
• Use tea tree soap or face wash every day.
• Buy new makeup and discard old makeup; do not use makeup for 1 week.
• Clean sheets and buy new pillows.
• Check spouse; if both have this problem, both need to be treated.
• Check pets.
• 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.

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.

Medication

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.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.

Erythromycin ointment (E-Mycin)

Belongs to the macrolide group of antibiotics. Basic and readily forms a salt when combined with an acid. Inhibits protein synthesis without affecting nucleic acid synthesis.
Used for the treatment of ocular infections involving the lids, conjunctiva, and/or cornea caused by organisms susceptible to it.

Dosing

Adult

Apply 1-inch ribbon hs on each lid; spread vigorously

Pediatric

Apply 0.5-inch ribbon hs on each lid; spread vigorously

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal infections of eye; patients using steroid combinations after uncomplicated removal of a foreign body from cornea should avoid using this product

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)

Mercury oxide 1% ointment

For infestation of eyelashes; inspect eyelids and mechanically remove nits. This compound may be ordered from Leiter's Park Avenue Pharmacy and Professional Compounding Center (Leiter's Park Avenue Pharmacy).

Dosing

Adult

Apply 1-inch ribbon hs on each lid; spread vigorously

Pediatric

Apply 0.5-inch ribbon hs on each lid; spread vigorously

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid direct contact with eye; cornea may be inadvertently de-epithelialized from mechanical spreading of ointment on base of eyelashes

Cholinergics/miotic agents

Dosage and frequency of administration must be individualized. Patients with darkly pigmented irides may require higher strengths of pilocarpine.

Pilocarpine 4% gel (Akarpine, Adsorbocarpine, Pilagan)

Produces miosis through contraction of iris sphincter muscle, which pulls iris root away from trabecular meshwork in angle-closure glaucoma and allows aqueous humor to exit eye, thereby lowering IOP. Also causes ciliary muscle contraction, resulting in accommodation and increased tension on and opening of trabecular meshwork spaces, facilitating aqueous humor outflow and lowering IOP in open-angle glaucoma.

Dosing

Adult

Apply 1-inch ribbon hs on each lid; spread vigorously

Pediatric

Apply 0.5-inch ribbon hs on each lid; spread vigorously

Interactions

May be ineffective when used concomitantly with nonsteroidal anti-inflammatory agents

Contraindications

Documented hypersensitivity; acute inflammatory disease of anterior chamber

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution during application; cornea may be inadvertently de-epithelialized from mechanical spreading of ointment on base of eyelashes; because of lower body weight in children, accidental systemic overdose may occur; adverse effects include conjunctival hyperemia, miosis, shallowing of anterior chamber, iritis, pupillary cysts, accommodation, brow ache, anterior and posterior subcapsular lens opacities, retinal detachment, and acute alterations in electrical properties of the retina

Follow-up

Further Outpatient Care

• 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.
• 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.
• Preventive facial hygiene with daily soap and water washes is encouraged. Long-term compliance may be a problem in patients with dry skin.
• Dermatologic consultation may be helpful in a patient with recurrent episodes or in those with accompanying dermatologic involvement.
• 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.
• 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.
• If the patient is unresponsive to treatment, consider noncompliance or other underlying etiologies.

Inpatient & Outpatient Medications

• 50-50 mixture of baby shampoo and water
• Erythromycin ointment
• Mercury oxide 1% ointment
• Pilocarpine 4% gel
• 10% tea tree oil ointment

Prognosis

• The prognosis of symptomatic relief from D folliculorum is very good.
• Previous clinical experience shows that total eradication is unlikely, but the mite population can be brought down to an acceptable level with little effort and easily maintained with proper hygiene.
• There are promising reports of total eradication with the use of tea tree oil.
• Recurrence of the symptoms is possible if proper hygienic measures are not used.

Patient Education

• The suggested home treatment, including the eyelash scrub technique, should be demonstrated to the patient.  
  • Soak the washcloth in warm water, and wring it.
  • Apply enough baby shampoo to form lather on the washcloth.
  • With the eye closed, massage the lashes on the lid margin, moving from left to right, 15 times. (Do not touch the eye itself.) Repeat on the other eye.
  • Rewet the cloth, and rinse off the shampoo.
  • Squeeze 1 inch of the ointment onto the index finger and gently rub into the lashes with the eye closed. Repeat on the other eye.
• To the eye care professional, the presence of Demodex species together with signs or symptoms of lid inflammation is of greater concern than the prevalence of Demodex species in a general population.

Multimedia

Media file 1: Illustration of Demodex folliculorum. Reprinted from BIODIDAC, Arthropoda Chelicerata Demodex, submitted by Livingstone, with permission from Antoine Morin, Biodidac, University of Ottawa.

Media file 2: 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 from Am J Ophthal Vol. 91, English FP, Nutting WB, Demodicosis of Ophthalmic Concern, 362-372, 1981, with permission from Elsevier Science.

Media file 3: Section of sebaceous gland of an eyelash shows Demodex brevis (M). Note gland cell (C) destruction (McManus, X375). Reprinted from Am J Ophthal Vol. 91, English FP, Nutting WB, Demodicosis of Ophthalmic Concern, 362-372, 1981, with permission from Elsevier Science.

Media file 4: 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 from Am J Ophthal Vol. 91, English FP, Nutting WB, Demodicosis of Ophthalmic Concern, 362-372, 1981, with permission from Elsevier Science.

Media file 5: Section of eyelid shows eyelash (L), cuffing (C), and small segment of Demodex folliculorum (M). Note layering of cuff (Masson, X275). Reprinted from Am J Ophthal Vol. 91, English FP, Nutting WB, Demodicosis of Ophthalmic Concern, 362-372, 1981, with permission from Elsevier Science.

Media file 6: Demodex folliculorum.

Media file 7: Demodex along the shaft of the cilia.

Media file 8: Demodex along the shaft of the cilia (higher magnification).

Media file 9: Backsides of numerous pubic crabs with infestation of the lashes and secondary blepharitis. Reprinted with permission from H.D. Riley, OD, Indiana University School of Optometry.

Media file 10: Phthiriasis (Phthirus pubis) pubic crab lash infestation and secondary blepharitis. Reprinted with permission from H.D. Riley, OD, Indiana University School of Optometry.

Media file 11: Phthiriasis (pubic lice). Reprinted with permission from H.D. Riley, OD, Indiana University School of Optometry.

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Keywords

Demodex folliculorum, Demodex folliculorum longus, Demodex folliculorum brevis, Demodex folliculorum hominis, Demodex mites, follicle mites, blepharitis, common ectoparasites of the ocular adnexa, hair follicle mites

Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

The author was a fellow and affiliated with the Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, HarvardMedicalSchool, while performing this work.

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