eMedicine Specialties > Ophthalmology > Infectious Disease

Demodicosis: Treatment & Medication

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
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; 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
Contributor Information and Disclosures

Updated: Apr 7, 2008

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.

Adult

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

Pediatric

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

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

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).

Adult

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

Pediatric

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

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.

Adult

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

Pediatric

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

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

Documented hypersensitivity; acute inflammatory disease of anterior chamber

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

More on Demodicosis

Overview: Demodicosis
Differential Diagnoses & Workup: Demodicosis
Treatment & Medication: Demodicosis
Follow-up: Demodicosis
Multimedia: Demodicosis
References
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References

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  33. Nutting WB, Beerman H. Demodicosis and symbiophobia: status, terminology, and treatments. Int J Dermatol. Jan-Feb 1983;22(1):13-7. [Medline].

  34. Skrlin J, Richter B, Basta-Juzbasic A, Matica B, Ivacic B, Cvrlje M, et al. Demodicosis and rosacea. Lancet. Mar 23 1991;337(8743):734. [Medline].

  35. Zimmerman TJ, et al, eds. Textbook of Ocular Pharmacology. 1997.

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Further Reading

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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

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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.

 
 
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