Medication Summary
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. A tea tree oil product (Cliradex) can be used. [15] Terpinen-4-ol is the most active component of tea tree oil.
The antiparasitic ophthalmic solution lotilaner (Xdemvy) was approved by the FDA for treatment of Demodex blepharitis in July 2023. [31, 32]
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Erythromycin ophthalmic (Ilotycin)
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.
Cholinergics/miotic agents
Class Summary
Dosage and frequency of administration must be individualized. Patients with darkly pigmented irides may require higher strengths of pilocarpine.
Pilocarpine ophthalmic (Pilopine HS 4%, Isopto Carpine)
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.
Anthelmintics
Class Summary
Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
Ivermectin topical (Sklice, Soolantra)
Pediculicide derived from fermentation of a soil-dwelling actinomycete, Streptomyces avermitilis.
Causes parasite death by selective, high-affinity binding to glutamate-gated chloride channels located in invertebrate nerve and muscle cells; this results in increased cell membrane permeability to chloride ions with hyperpolarization of the nerve or muscle cells, and ultimately parasite paralysis and death.
Ivermectin cream (Soolantra) has both anti-inflammatory and antiparasitic activity.
Lotilaner ophthalmic (Xdemvy)
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. It is indicated for adults for treatment of Demodex blepharitis.
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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.
