Demodex Blepharitis: Diagnosis and Treatment

Demodex Blepharitis: Diagnosis and Treatment


Demodex infestation on the face has been implicated in causing rosacea (Fig.1A).1-5 In the eyelids, Demodex infestation gives rise to blepharitis.6-9 Such blepharitis is frequently associated with mite-harboring cylindrical dandruff in eyelashes (Fig.1B).10 Demodex folliculorum tends to be clustered to the root of the lashes (Fig. 1C), while demodex brevis tends to present individually in sebaceous and meibomian glands.

As previously reported,11-13 office lid scrub with 50% tea tree oil (TTO) combined with daily lid hygiene with 5% TTO ointment and shampoo can eradicate ocular demodex.

Figure 1a

Figure 1b

Figure 1c

Ocular Manifestations


Lashes with cylindrical dandruff are pathognomonic for ocular demodex infestation (Fig. 1B).10 Demodex has also been associated with intermittent trichiasis, meibomian gland dysfunction, conjunctival inflammation (Fig. 2A),12corneal vascularization, infiltration, superficial opacities, and nodular scarring (Fig. 2B, 2C).13

Figure 2a

Figure 2b

Figure 2c


A modified method of sampling and counting demodex has been established.10,14 Under the slit lamp, epilate two lashes, with cylindrical dandruff, from each eyelid (8 lashes from both eyes). Place the lashes on a slide, one for each eye, and examine them using the light microscope. Fluorescein 0.25% drops can improve the visibility of the mites (Fig. 3A, 3B).14

Figure 3a

Figure 1b

Thermal Manifestations

It has been reported that infrared photography illustrates that temperature and skin inflammation are directly proportional to the amount of infestation resulting in “Fire-Red Demodex Face” (Fig 4).12

Figure 4a

Figure 1b

Figure 2c

Figure 2c


1. Office/Home lid scrub regimen (Regimen A) using 50% TTO oil to clean the lashes and kill the mites.

2. Home regimen (Regimen B) using 5% TTO cream to cover the skin around the lids to prevent mating and re-infestation from the skin around the eye.

As reported,12,13 patients receiving 50% TTO lid scrub show dramatic improvements in symptoms, ocular surface inflammation, lipid tear film stability, corneal epithelial smoothness, and visual acuity (Fig. 5). The demodex count usually drops to zero in 4 weeks without recurrence in a majority of cases.

Before Treatment Figure 5a

Before Treatment Figure 5b

Before Treatment Figure 5c

After Treatment Figure 5a

After Treatment Figure 5b

After Treatment Figure 5c



  1. 1. Basta-Juzbasic A, Subic JS, Ljubojevic S. Demodex folliculorum in development of dermatitis rosaceiformis steroidica and rosacea-related diseases. Clin Dermatol 2002;20:135-140.
  2. Erbagci Z, Ozgoztasi O. The significance of Demodex folliculorum density in rosacea. Int J Dermatol 1998;37:421-425.
  3. Forton F, Germaux MA, Brasseur T, De LA, Laporte M, Mathys C, Sass U, Stene JJ, Thibaut S, Tytgat M, Seys B. Demodicosis and rosacea: epidemiology and significance in daily dermatologic practice. J Am Acad Dermatol 2005;52:74-87.
  4. Abd-El-Al AM, Bayoumy AM, bou Salem EA. A study on Demodex folliculorum in rosacea. J Egypt Soc Parasitol 1997;27:183-195.
  5. Georgala S, Katoulis AC, Kylafis GD, Koumantaki-Mathioudaki E, Georgala C, Aroni K. Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. J Eur Acad Dermatol Venereol 2001;15:441-444.
  6. Kamoun B, Fourati M, Feki J, Mlik M, Karray F, Trigui A, Ellouze S, Hammami B, Chaabouni M, Ayadi A. [Blepharitis due to Demodex: myth or reality?]. J Fr Ophtalmol 1999;22:525-527.
  7. Humiczewska M. [Demodex folliculorum and Demodex brevis (Acarida) as the factors of chronic marginal blepharitis]. Wiad Parazytol 1991;37:127-130.
  8. Coston TO. Demodex folliculorum blepharitis. Trans Am Ophthalmol Soc 1967;65:361-392.
  9. Heacock CE. Clinical manifestations of demodicosis. J Am Optom Assoc 1986;57:914-919.
  10. Gao Y-Y, Di Pascuale MA, Li W, Liu D, Baradaran-Rafii A, Elizondo A, Kuo IC, Kawakita T, Raju VK, Tseng SCG. High prevalence of ocular demodex in lashes with cylindrical dandruffs. Invest Ophthalmol Vis Sci 2005;46:3089-3094.
  11. Gao Y-Y, Di Pascuale MA, Li W, Baradaran-Rafii A, Elizondo A, Raju VK, Tseng SCG. In vitro and in vivo killing of ocular demodex by tea tree oil. Br J Ophthalmol 2005;89:1468-1473.
  12. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007;26:136-143.
  13. Kheirkhah A, Casas V, Li W, Raju VK, Tseng SC. Corneal manifestations of ocular demodex infestation. Am J Ophthalmol 2007;143:743-749.
  14. Kheirkhah A, Blanco G, Casas V, Tseng SC. Fluorescein dye improves microscopic evaluation and counting of demodex in blepharitis with cylindrical dandruff. Cornea 2007;26:697-700