Treatment Options for Demodex Blepharitis: Patient Choice and Efficacy

Eyelid cleaning: Methods, tools, and clinical applications

Nowadays, people give more importance and pay closer attention to the condition of their eyelids and lid margins. This increased recognition of eyelid hygiene is due to the growing awareness that improper eyelid cleaning might lead to various ocular surface diseases such as blepharitis and meibomian gland dysfunction. These ocular surface diseases can greatly affect people's quality of life. This article reviews the latest procedures for proper eyelid cleaning, including indications, methods, tools, detergents, and clinical applications, to maintain a healthy ocular surface and assist in the treatment of dry eye and blepharitis.

Treatment of Demodex Blepharitis: A Prospective, Randomized, Controlled, Double-Masked Clinical Trial Comparing Topical Lotilaner Ophthalmic Solution, 0.25% Eyedrops to Vehicle

PURPOSE

To evaluate the efficacy and safety of lotilaner ophthalmic solution, 0.25% eyedrops compared to vehicle for the treatment of Demodex blepharitis.

METHODS

In this randomized, controlled, double-masked clinical trial, 54 participants were randomly assigned in a 1:1 ratio to receive either lotilaner ophthalmic solution, 0.25% (study group) or the vehicle (control group) bilaterally, twice daily for 42 days. Outcome measures were collarette cure (collarette grade 0, upper eyelid), mite eradication (mite density of 0 mites/lash), and composite cure (grade 0 for collarettes and erythema).

RESULTS

The proportion of participants achieving collarette cure (80.0% vs 15.8%; p < .001), mite eradication (73.3% vs 21.1%, p = .003) and composite cure (73.3% vs 10.5%, p < .001) at Day 42 was statistically significantly higher in the study group than the control group.

CONCLUSION

Twice-daily 42-day treatment with novel lotilaner ophthalmic solution, 0.25% is safe and effective for the treatment of Demodex blepharitis compared to the vehicle control. (Registry number: ACTRN12620000320954, dated 09/03/2020).

Delphi Panel Consensus Regarding Current Clinical Practice Management Options for Demodex blepharitis

Purpose

To obtain consensus on Demodex blepharitis (DB) treatment using a modified Delphi panel process.

Methods

Literature search identified gaps in knowledge surrounding treatment of DB. Twelve ocular surface disease experts comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). They completed a live roundtable discussion in addition to 3 surveys consisting of scaled, open-ended, true/false, and multiple-choice questions pertaining to the treatment of DB. Consensus for scaled questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panelists agreed.

Results

The experts agreed that an effective therapeutic agent for treatment of DB would likely decrease the necessity of mechanical intervention, such as lid scrubs or blepharoexfoliation (Median = 8.5; Range 2-9). When treating DB, panelists believed that collarettes serve as a surrogate for mites, and that eliminating or reducing collarettes should be the main clinical goal of treatment (Median = 8; Range 7-9). The panelists would treat patients with at least 10 collarettes, regardless of other signs or symptoms and agreed that DB can be cured, but there is always the possibility for a reinfestation (n = 12). There was also consensus that collarettes, and therefore mites, are the primary treatment target and the way by which clinicians can monitor patient response to therapy (Median = 8; Range 7-9).

Conclusion

Expert panelists achieved consensus on key facets of DB treatment. Specifically, there was consensus that collarettes are pathognomonic for DB, that DB patients with >10 collarettes should be treated even in the absence of symptoms, and that treatment efficacy can be tracked by collarette resolution. By increasing awareness about DB, understanding the goals of and monitoring treatment efficacy, patients will receive better care and, ultimately, better clinical outcomes.

Antiparasitic Activity of Tea Tree Oil (TTO) and Its Components against Medically Important Ectoparasites: A Systematic Review

Ectoparasites are pathogens that can infect the skin and cause immense pain, discomfort, and disease. They are typically managed with insecticides. However, the fast-emerging antimicrobial resistance and the slow rate of development of new bio-actives combined with environmental and health concerns over the continued use of neurotoxic insecticides warrant newer and alternative methods of control. Tea tree oil (TTO), as an alternative agent, has shown remarkable promise against ectoparasites in recent studies. To our knowledge, this is the first systematic review to assess preclinical and clinical studies exploring the antiparasitic activity of TTO and its components against clinically significant ectoparasites, such as Demodex mites, scabies mites, house dust mites, lice, fleas, chiggers, and bed bugs. We systematically searched databases, including PubMed, MEDLINE (EBSCOhost), Embase (Scopus), CENTRAL, Cochrane Library, CINAHL, ScienceDirect, Web of Science, SciELO, and LILACS in any language from inception to 4 April 2022. Studies exploring the therapeutic activity of TTO and its components against the ectoparasites were eligible. We used the ToxRTool (Toxicological data reliability assessment) tool, the Joanna Briggs Institute (JBI) critical appraisal tools, and the Jadad scale to assess the methodological qualities of preclinical (in vitro and in vivo) studies, non-randomised controlled trials (including cohort, case series, and case studies), and randomised controlled trials, respectively. Of 497 identified records, 71 studies were included in this systematic review, and most (66%) had high methodological quality. The findings of this review revealed the promising efficacy of TTO and its components against ectoparasites of medical importance. Most importantly, the compelling in vitro activity of TTO against ectoparasites noted in this review seems to have translated well into the clinical environment. The promising outcomes observed in clinical studies provide enough evidence to justify the use of TTO in the pharmacotherapy of ectoparasitic infections.

Randomized double-blind trial of wipes containing terpinen-4-ol and hyaluronate versus baby shampoo in seborrheic blepharitis patients

PURPOSE

To investigate the efficacy of lid wipes (LWs) containing terpinen-4-ol and sodium hyaluronate (Hy-ter^®) for the treatment of seborrheic blepharitis compared to baby shampoo (BS).

METHODS

This randomized, double-blind, active control, parallel group, multicentre clinical trial included 48 eyes of 48 patients with seborrheic blepharitis who were randomly divided into two treatment arms (1:1, n = 24) using block randomization. LWs or BS were prescribed twice a day for 8 weeks followed by a discontinuation period of 4 weeks. Change in Blepharitis Symptom measure (BLISS), Schirmer's test, tear breakup time (TBUT), noninvasive TBUT (NI-TBUT), ocular surface disease index (OSDI) score, corneal and conjunctival staining, meibography, and Demodex count at different visits (Baseline, 4th, 8th, and 12th week) were the main outcome measures.

RESULTS

The baseline values of both groups were similar (p > 0.05). Despite high clinical efficacy in both treatment arms, patients using LWs showed a lower BLISS score at the 8th and 12th-week visit (1.9 ± 2.2 versus 7.2 ± 6.6, p = 0.003; 4.0 ± 1.3 versus 5.8 ± 6.3, p = 0.026). NI-TBUT showed a significant increase starting from the 4th week for patients using LWs and 8th week for patients using BS. Both treatment modalities caused a reduction in the Demodex count after 4 weeks of treatment (p < 0.001). The treatment withdrawal did not cause any recurrence in both treatment arms.

CONCLUSION

BS or LWs containing Hy-ter^® can be used with good efficacy for the treatment of seborrheic blepharitis. However, LWs may provide a better symptomatic relief compared to BS after 8 weeks of treatment.

Comparison of the efficacy of tea tree (Melaleuca alternifolia) oil with other current pharmacological management in human demodicosis: A Systematic Review

Various treatments are found to be moderately effective in managing Demodex-related diseases except tea tree oil (TTO) and terpinen-4-ol (T4O), which showed superior miticidal and anti-inflammatory effects in numerous clinical studies. Their possible effects include lowering mite counts, relieving Demodex-related symptoms, and modulating the immune system. This review summarizes the current clinical topical and oral treatments in human demodicosis, their possible mechanisms of action, side-effects and resistance in treating this condition. TTO (especially T4O) is found to be the most effective followed by metronidazole, ivermectin and permethrin in managing the disease. This is because TTO has anti-parasitic, anti-bacterial, anti-fungal, anti-inflammatory and wound-healing effects. Furthermore, nanoTTO can even release its contents into fungus and Pseudomonas biofilms. Combinations of different treatments are occasionally needed for refractory cases, especially for individuals with underlying genetic predisposal or are immuno-compromised. Although the current treatments show efficacy in controlling the Demodex mite population and the related symptoms, further research needs to be focused on the efficacy and drug delivery technology in order to develop alternative treatments with better side-effects profiles, less toxicity, lower risk of resistance and are more cost-effective.

Mites, caterpillars and moths

Besides conditions such as scabies and hypersensitivity to house dust mites, other diseases caused by mites and caterpillars tend to be more uncommon in everyday practice. Nevertheless, there is a broad spectrum of medically relevant disorders associated with these arthropods. Mites may act as parasites that infect or colonize the skin (e.g., scabies, pseudoscabies, demodicosis) or they may pierce the host's skin and feed on tissue fluid and blood (trombiculosis). In the latter case, they also play a role as vectors transmitting Orientia tsutsugamushi, the pathogen that causes Tsutsugamushi fever. In addition to house dust mites, storage mites, too, are characterized by their allergenic potential. The terms erucism and lepidopterism are used for the various diseases caused by caterpillars and moths. Both terms are not used consistently. With respect to pathogenesis, various mechanisms have been described, including type I and type IV hypersensitivity as well as irritant and toxin-induced reactions. In Germany, skin reactions following exposure to the hairs of oak processionary caterpillars are particularly common. Extracutaneous manifestations including nausea, vomiting, hemorrhage, arthropathy or even life-threatening reactions have been reported in association with certain exotic species. Some species act as parasites by feeding on blood or tears. As natural silk can cause immediate and delayed-type hypersensitivity reactions, workers in the silk industry may develop allergic asthma, rhinitis, or conjunctivitis. Consumption of silkworm pupae is associated with the risk of food allergy.

Ocular Demodex: a systematic review of the clinical literature

PURPOSE

There is increasing clinical and research interest in the potential contribution of Demodex to ocular surface disease. The aim of this systematic review was to summarise and synthesise current clinical evidence relating to the aetiology, diagnosis and treatment of ocular Demodex.

RECENT FINDINGS

A comprehensive literature search was performed in OVID Medline, OVID Embase, and clinical trial registries, for studies published between 1990 and August 2019, examining Demodex on the ocular surface. The review included primary clinical research studies and systematic reviews of primary clinical research studies, where Demodex was considered in the context of the ocular surface and/or adnexa. Studies were categorised using the National Health and Medical Research Council evidence hierarchy. Risk of bias assessment was performed using validated tools for studies categorised as providing Level I or II evidence. A total of 87 studies were eligible for inclusion, including two systematic reviews. Most studies (60%) were observational, describing the prevalence of ocular Demodex in different clinical populations. There was a high degree of variability in the epidemiological data derived from cross-sectional aetiology studies. There was mostly consistent evidence to support an association between ocular Demodex and chronic blepharitis. Seven diagnostic test-accuracy studies were identified, which considered a range of techniques, including slit lamp examination for cylindrical eyelash collarettes and/or eyelash manipulation techniques, light microscopic evaluation of epilated eyelashes and in vivo confocal microscopy. There is currently no accepted gold-standard diagnostic method for ocular Demodex. For intervention studies, there was one systematic review, 11 published randomised trials, six trial registry entries, and nine case series. Despite a number of recent trials, the appropriate treatment regimen for ocular Demodex (including the optimal criteria and timing of an intervention) is not clearly established.

CONCLUSIONS

This comprehensive narrative synthesis has captured the landscape of clinical evidence relating to the prevalence, aetiology, diagnosis and treatment of ocular Demodex. There remain opportunities to enhance understanding of its role in ocular surface disease, best diagnostic approaches and optimal treatment protocols.

Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis caused by Demodex spp.: A randomized clinical trial

PURPOSE

To evaluate the efficacy of topical ivermectin-metronidazole combined therapy in the management of Demodex-associatedblepharitis.

METHODS

Sixty patients with a diagnosis of Demodex-associatedblepharitis were recruited in a randomized clinical trial. Thirty receiving topical ivermectin (0.1%)-metronidazole (1%) gel treatment on days 0, 15 and 30. Thirty additional patients were used as a control group receiving vehicle on days 0, 15 and 30. The primary efficacy measure was the number of Demodex spp. mitesin the eyelashes of patients. The secondary outcomes included clinical improvement of signs and adverse events.

RESULTS

Complete eradication of Demodex spp. was found in 96.6% of patients in the treatment group. Furthermore, a significant reduction of inflammation signs were found in all treated patients versus controls. None of the patients experienced any adverse effects associated with the treatment.

CONCLUSION

Demodex infection was controlled satisfactorily with the ivermectin (0.1%)-metronidazole (1%) gel, and no adverse effects were observed. Application of this gel for the treatment of different parasitic infections of the eyelids could be feasible, and this requires further exploration.

Efficacy and Safety of Wet Wipes Containing Hy-Ter® Solution Compared with Standard Care for Bilateral Posterior Blepharitis: A Preliminary Randomized Controlled Study

INTRODUCTION

A novel treatment for posterior blepharitis which involves the use of disposable wet wipes imbibed with a solution of terpinen-4-ol and hyaluronic acid (Hy-Ter^®) as well as aloe, natural anti-inflammatories and antiseptics (Blephapad Combo; Novelty Technology Care, Milan, Italy) has been proposed. The aim of this study was to compare the efficacy and safety of treatment with Blephapad Combo with standard treatment.

METHODS

We conducted 4-week, open-label, randomized controlled study with a closed sequential design at the Magna Graecia University of Catanzaro, Italy in which patients aged > 40 years with symmetrical bilateral posterior blepharitis were enrolled. Each eye represented a single experimental unit. Patients were randomly assigned using a computer-generated randomization list to apply a reusable heated compress to the eyelid of one eye before cleansing the eyelid with the Blephapad Combo wet wipe (Blephapad Combo treatment arm) or to use the standard treatment of applying a wet and warm gauze to the other eye (standard treatment arm), twice daily for 4 weeks. The primary endpoint was the percentage change from baseline to week 4 in meibomian gland dysfunction (MGD) grading scale scores.

RESULTS

Eighteen patients (9 men; 9 women) with a mean (± standard deviation) age of 66.9 ± 9.03 years were included in the study. Compared with the eye receiving the standard treatment, treatment with Blephapad Combo appeared to improve the MGD total score after 4 weeks of treatment (mean change from baseline - 29.9 vs. - 38.5%). The assessment of the investigators was that in 11 patients the eye treated with Blephapad Combo showed greater benefit, in two patients the eye treated with the standard treatment showed greater benefit and in four patients there was no difference between treatments. Blephapad Combo was well tolerated, with no serious adverse events (AEs) reported. Minor ocular AEs were reported in 44.4 and 38.9% of patients in the Blephard Combo and standard treatment arms, respectively.

CONCLUSIONS

Treatment with Blephapad Combo was more effective than the standard treatment in ameliorating MGD in patients with posterior blepharitis. Minor ocular AEs events were equally distributed between the two treatments arms.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03301844.

Evaluation of the Efficacy of Tea Tree Oil On the Density of Demodex Mites (Acari: Demodicidae) and Ocular Symptoms In Patients With Demodectic Blepharitis

The objective of this study was to examine the efficacy of 7.5% tea tree oil (TTO) eyelash shampoo on the density of Demodex (Acari: Demodicidae) and ocular symptoms in patients with demodectic blepharitis. A total of 135 patients diagnosed with demodectic blepharitis, following clinical inspection and parasitological examinations, were included in the study. Patients were treated with eyelash shampoo, with or without TTO. Full Demodex reduction was attained in 36% of the patients who used eyelash shampoo with TTO, and the average Demodex count was reduced from 6.33/eyelash to zero ( P < 0.001). In contrast, the average Demodex count in patients who did not achieve full reduction (64%) was reduced from 12.46/eyelash to 4.15/eyelash ( P < 0.001). Full reduction was observed in 11.7% of patients who used TTO-free eyelash shampoo, and average Demodex count reduced from 2.00/eyelash to zero ( P = 0.017). The average Demodex count was reduced from 11.98/eyelash to 7.91/eyelash in patients (88.3%) who did not achieve full reduction ( P = 0.024). Additionally, ocular symptom scores (which are generated based on subjective experiences of itching, burning, the feeling of a foreign body in the eye, eye redness, and cylindrical dandruff) were reduced significantly ( P < 0.001) in patients who used the eyelash shampoo with TTO. The symptom scores remained almost the same in patients who used TTO-free eyelash shampoo ( P > 0.05). In conclusion, it was determined that eyelash shampoo with TTO is 3 times more effective at achieving full Demodex reduction, significantly reducing the Demodex count, and relieving ocular symptoms in patients where full reduction cannot be attained, without adverse side effects.

Can the tea tree oil (Australian native plant: Melaleuca alternifolia Cheel) be an alternative treatment for human demodicosis on skin?

Australian tea tree oil (TTO) and its extract terpinen-4-ol (T4O) are found to be effective in moderating demodex-related diseases. Their possible effects are lowering the mite counts, relieving the demodex-related symptoms and modulating the immune system especially the inflammatory response. This review summarizes the topical treatments of TTO and T4O in human demodicosis, their possible mechanism of actions, side-effects and potential resistance in treating this condition. Although current treatments other than TTO and T4O are relatively effective in controlling the demodex mite population and the related symptoms, more research on the efficacy and drug delivery technology is needed in order to assess its potential as an alternative treatment with minimal side-effect profile, low toxicity and low risk of demodex resistance.

Demodex Mite Infections in Ophthalmic Patients on Indonesian Islands: The ICS Humanitarian Aid Report

Objective:

Demodex is the most common external human parasite. It has been suggested that the Demodex infection may be associated with malnutrition, nutritional deficiencies, reduced immunity, and poor hygiene. The patients who benefitted from humanitarian aid in Indonesia, often demonstrated the abovementioned risk factors. The aim of the present report was to assess the prevalence of Demodex infestation in ophthalmic patients in Indonesian.

Patients and methods:

A total of 217 individuals (132 women) with ocular discomfort, who presented to the ophthalmologist in mission points in Indonesia (Bali, Java, and Papua, the province of Indonesia in the New Guinea Island) were checked for the presence of Demodex on their eyelashes and underwent an anthropometric examination.

Results:

The prevalence of ocular demodicosis varies from 71.2% in Bali to 89.2% in Papua. There were no statistically significant differences between the islands, urban or rural areas, or between sexes. A statistically significant difference was found between nutritional status and Demodex infestation (P = 0.0007). Malnourished and overweight patients had odds of being infested with Demodex that were approximately 8 and 3 times higher, respectively, compared with subjects with a normal body mass index.

Conclusions:

Ocular demodicosis is very common in medically underserved areas of Bali, Java, and Papua, where it exceeds the frequency observed in countries of the northern hemisphere. An abnormal nutritional status comprising of both malnutrition and being overweight appears to be a risk factor for Demodex infection. This issue requires further research.

Satisfaction and convenience of using terpenoid-impregnated eyelid wipes and teaching method in people without blepharitis

Purpose

Demodex infestations cause blepharitis and are difficult to treat. Recently, a new type of eyelid wipes with terpenoids has been found effective. We aim to evaluate patient satisfaction after short-term use and compare two teaching modalities on the techniques of use.

Patients and methods

Eligible participants were taught to use eyelid wipes (Cliradex^®) by either live or online video demonstration based on random allocation. Participants used the wipes twice daily for a week. All participants had prior evaluation of socioeconomic status, dry eye symptoms, and meibomian gland features. After 1 week, competence of use was assessed by participants showing their technique to the investigator, and a questionnaire on comfort, ease, and convenience of use was administered. Higher scores indicate greater satisfaction, and these levels are compared among the two teaching modalities using chi square.

Results

A total of 50 participants were recruited, with a mean age of 42±16 years, and 88% of the participants were females. Overall, median comfort level was 4.0 (range: 1–6), ease level was 5.0 (3–6), and convenience level was 5.0 (2–6). Median stinging was 2.0 (1–4), which corresponded to some but mild stinging. The median competence level was 4.0 (2–4), which corresponded to excellent competence. These satisfactory levels (ease, comfort, and convenience) experienced were not significantly associated with different socioeconomic indicators, that is, housing type, income, highest education level, and were not different between teaching methods (p>0.05).

Conclusion

Short-term use of Cliradex eyelid wipes seems to be acceptable to most people. The teaching instructions before using these wipes were equally effective – whether live or online video demonstration was used.

A Clinical Scoring System for Diagnosis of Ocular Demodicosis

Background

Demodex may cause chronic and refractory blepharitis with associated ocular surface problems, and its diagnosis and treatment can be quite challenging. In this study, our aim was to assess the efficacy of tea tree oil in Demodex treatment on caucasian patients in an industrialized region of Turkey, and to develop a systematic scoring system for extremely accurate diagnosis in the absence of advanced facilities.

Material/Methods

Charts of 412 patients with blepharitis were reviewed. A group of 39 out of 412 cases were identified as chronic and treatment-refractory, and therefore were enrolled in this study. Eyelashes from each of the lower and upper eyelids of both eyes were evaluated at ×40 and ×100 magnification using light microscopy. Treatment was started with 4% tea tree oil eyelid gel and 10% eyelash shampoo. Symptoms and findings were scored according to the most common complaints.

Results

The mean age of the patients was 54.1±15.4 years. Seventeen (43.5%) patients were male and 22 (56.5%) patients were female. In 30 out of the 39 patients (76.9%) D. folliculorum was detected. Symptoms disappeared in 25 patients. The mean score of patients who were Demodex-negative was 2.7±1.0, and the mean score of patients who were Demodex-positive was 3.8±1.6 (p=0.047). Ninety-four percent of those with a score of 4 and over were found to be Demodex-positive (p=0.025).

Conclusions

Treatment with tea tree oil can be successful. If there is no facility to identify Demodex under light microscopy, we recommend starting treatment for patients who have scores of 4 and over using the scoring chart developed in this study.

[Treatment options for chronic blepharitis considering current evidence]

The goal of the treatment of chronic blepharitis lies in the reduction of inflammation, which can be achieved by warming, mechanical, and immunomodulatory measures as well as acaricide medication in cases with pathogenetically relevant demodicosis.