Universitatea Libera Internationala din Moldova

The
demodex

By:Caplencov Irina
prof: Dimo Olga
 Chisinau 2014
Demodex
We have all seen the chronic blepharitis patient that has attempted numerous unsuccessful
treatment regimens and has visited numerous eye doctors looking for some relief. Interestingly, the
cause of their chronic blepharitis might be secondary to Demodex infestation.

The Demodex mite is an eight-legged (an arachnid) ectoparasite (living on the surface of the host)
that can reside in our hair follicles and sebaceous glands. Of the 65 described Demodex species,
only Demodex brevis and Demodex folliculorum are found on humans. Demodex is contracted and
spread by either direct contact or dust containing eggs.

The adult D. brevis mite is about 0.2 mm long and tends to live inside the lashs sebaceous glands
and in meibomian glands. It has been suggested that D. brevis can be associated with meibomian
gland disease and subsequent tear lipid deficiency. D. folliculorum buries itself face down near the
root of the eyelash and it is associated with anterior blepharitis.
D. folliculorum is longer, at about 0.4 mm in length, and has a more slender, tapered body than D.
brevis. D. folliculorum often live in clusters, where D. brevis are more solitary.

Life cycle, survival of Demodex

The typical Demodex life cycle is usually 2 to 3 weeks. A female Demodex mite lays 15 to 20 eggs
inside the hair follicle near the sebaceous glands. The eggs develop into larvae, which eventually
become an adult eight-legged mite. The adult male Demodex mite will leave the follicle in search of
a mate, while the adult female mite remains in the follicle. The mites are capable of walking
approximately 10 mm/h and tend to be more active in the dark.

It is thought that both D. folliculorum and D. brevis consume epithelial cell cytoplasm by piercing
through the cell membrane. D. folliculorum infestation causes follicular hyperplasia with subsequent
increase in keratinization near the base of the eyelash. This keratinization mixed with lipids produces
the classical clear cylindrical dandruff that is associated with Demodex blepharitis. This dandruff is
thought to be a product of the mites claws scrapping around the follicle.
Eyelashes infested with Demodex often are brittle and are easily epilated. On about every tenth
eyelash, one or more Demodex mites can be detected even in healthy asymptomatic patients.

Patients who suffer from Demodex infestation may complain of eyelid and eyebrow itching
(especially in the morning), madarosis, a burning sensation and a foreign body sensation that seems
to originate beneath their lids. Demodex blepharitis is observed equally in males and females and is
age related. A study by Junemann showed that Demodex is found in 25% of 20-year-olds, 30% of
50-year-olds and 100% in patients older than 90 years.

Patient exam, diagnosis

During slit lamp evaluation, become suspicious of the possibility of Demodex blepharitis if you notice
cylindrical dandruff. Cylindrical dandruff is a clear tubular cuff that is attached to the eyelid margin
and encircles the eyelash base. Some doctors feel that clinical evidence of cylindrical dandruff is
pathognomonic for D. folliculorum infestation and that the extent of the infection is associated with
the number of eyelashes containing the cylindrical tubules.

Definitive diagnosis of Demodex involves viewing an epilated eyelash under the microscope. It is
important to understand that the mite has to be firmly attached to the eyelash when it is epilated for it
to be seen. In all probability, some of the mites will have remained in the follicle after epilation. In
fact, if you move the lash side to side, you can see the Demodex tails protruding from the eyelash
base with the slit lamp on high magnification.

When selecting a lash to epilate, look for those with cylindrical dandruff, especially if the lash is
discolored or brittle. A study by Gao and colleagues showed that lashes with cylindrical dandruff
were 10 times more likely to contain Demodex mites.

Next grab the base of the lash and move it from side to side and then up and down and pull slowly. I
have found this produces a larger bulb of tissue around the root with a greater number attached
mites.

I then place the eyelash on the microscope slide and gently add a drop of 0.25% fluorescein. I place
a cover slip and view the specimen with low magnification under the microscope. This will help
detect a mite that was loosely attached to the lash, but floated away.

The cylindrical dandruff cuff will sometimes remain attached to the lid after epilation. Remove this
with your forceps and add this to the microscope slide, as these cuffs often contain Demodex.

Next, add 100% alcohol underneath the cover to help evaluate for additional Demodex yield. The
alcohol will soften the cuff and will stimulate and irritate the Demodex inside and cause them to
move out of the cuff for easier viewing.

Treatment regimen

Demodex blepharitis treatment goals include: eradicating the adult mites and their offspring,
prevention of further mating, avoiding re-infestation and alleviating the patients symptoms.
Understanding the mites life cycle and habits will help us design a logical treatment plan.

There are a number of published treatment regimens that report good results. My regimen is a
modification of some of these.

First, therapy begins with educating the patient about their condition and showing them photos of the
Demodex mites living in their hair follicles. Compliance is not an issue once the patient sees the
crawling mites. I use a digital microscope that can take both photographs and video.

Initial treatment involves an in-office lid scrub/dbridement. Start by instilling a drop or two of
TetraVisc (tetracaine 0.5%, Cynacon/OcuSoft) or other long-lasting anesthetic. Then thoroughly
dbride the lashes and eyebrows with a cotton tip applicator soaked in 20% to 50% tea tree oil.

Tea tree oil also has excellent concentration-dependent Demodex-killing properties. Keep in mind
that the readily available 100% tea tree oil solution is very irritating and, as such, should be diluted.
One can prepare a mixture of 50% tea tree oil by diluting the tea tree oil in either macadamia or
walnut oil.

For mild cases of cylindrical dandruff, I will often use a commercially available tea tree oil, 20%
Desert Essence .This irritates the mites and stimulates them to come out of the follicle. Repeat this
procedure in 10 minutes.
Next, apply an antibiotic/steroid ointment to help keep the mites from moving and possibly suffocate
them. The steroid also helps calm down the inflammation secondary to the chemical and mechanical
irritation of the in-office treatment, in addition to suppressing the possible inflammatory cascade
associated with the decaying mites. The patient will return in 2 weeks for repeat office treatment.

Patient instructions

Send patients home with specific instructions. They should immediately wash sheets and pillow
cases in hot water and dry with the high dryer setting and discard their pillows. They should not use
makeup for at least 1 week and discard all old makeup. Recommend using tea tree soap on their
face and consider tea tree hair shampoo as well. Make an appointment for the patients spouse to
have an evaluation, as they are frequently also infested.

Ask the patient to purchase a supply of Ocusoft Plus Lid Scrub pads (Cynacon/Ocusoft). They
should thoroughly scrub the lash margins, then work the eyelids and eyebrows. Do not rinse.

Allow the solution to dry, then apply a light film of antibiotic/steroid combination ointment over the
lashes. In the morning, lids should be scrubbed again and rinsed well. The steroid/antibiotic ointment
should be discontinued in a week and substituted with a bland ophthalmic ointment. This regimen
should be continued for 3 more weeks (4 weeks total).

As a maintenance regimen, the patient should continue lid scrubs at least twice a week indefinitely. A
follow-up appointment should be scheduled for 6 months.