Update on Demodex Blepharitis


  • Tassapol Singalavanija Ophthalmology department, Chulabhorn hospital, Chulabhorn Royal Academy


Demodex blepharitis, cylindrical dandruff, tea tree oil


Although Demodex mites are commonly found on normal human eyelids, these mites can cause anterior and posterior blepharitis. Underdiagnosis and undertreatment often occur because the symptoms of Demodex blepharitis considerably overlap with those of other anterior segment disorders. The presence of cylindrical dandruff around the base of the eyelashes and microscopic observation of the mites may support definitive diagnosis. Various treatments have been attempted, but specific eyelid cleansers with long-term eyelid scrubs are generally necessary to control Demodex infestation, improve clinical signs, and ameliorate patient symptoms. This article summarizes the pathogenesis, risk factors, clinical manifestations, diagnostic criteria, and clinical management of Demodex blepharitis.


Liu J, Sheha H, Tseng SCG. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510. https://doi.org/10.1097/ACI.0b013e32833df9f4

Gao Y-Y, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. Invest Ophthalmol Vis Sci. 2005;46(9):3089-3094. https://doi.org/10.1167/iovs.05-0275

Nicholls SG, Oakley CL, Tan A, Vote BJ. Demodex species in human ocular disease: new clinicopathological aspects. Int Ophthalmol. 2017;37(1):303-312. https://doi.org/10.1007/s10792-016-0249-9

Forton F, Germaux M-A, Brasseur T, et al. Demodicosis and rosacea: epidemiology and significance in daily dermatologic practice. J Am Acad Dermatol. 2005;52(1):74-87. https://doi.org/10.1016/j.jaad.2004.05.034

Salem DA-B, El-Shazly A, Nabih N, El-Bayoumy Y, Saleh S. Evaluation of the efficacy of oral ivermectin in comparison with ivermectin-metronidazole combined therapy in the treatment of ocular and skin lesions of Demodex folliculorum. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2013;17(5):e343-347. https://doi.org/10.1016/j.ijid.2012.11.022

Luo X, Li J, Chen C, Tseng S, Liang L. Ocular Demodicosis as a Potential Cause of Ocular Surface Inflammation. Cornea. 2017;36 Suppl 1:S9-S14. https://doi.org/10.1097/ICO.0000000000001361

Gao Y-Y, Di Pascuale MA, Elizondo A, Tseng SCG. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. 2007;26(2):136-143. https://doi.org/10.1097/01.ico.0000244870.62384.79

English FP, Cohn D, Groeneveld ER. Demodectic mites and chalazion. Am J Ophthalmol. 1985;100(3):482-483. https://doi.org/10.1016/0002-9394(85)90522-7

Liang L, Ding X, Tseng SCG. High prevalence of demodex brevis infestation in chalazia. Am J Ophthalmol. 2014;157(2):342-348.e1. https://doi.org/10.1016/j.ajo.2013.09.031

English FP, Nutting WB. Demodicosis of ophthalmic concern. Am J Ophthalmol. 1981;91(3):362-372. https://doi.org/10.1016/0002-9394(81)90291-9

Yam JCS, Tang BSF, Chan T-M, Cheng ACK. Ocular demodicidosis as a risk factor of adult recurrent chalazion. Eur J Ophthalmol. 2014;24(2):159-163. https://doi.org/10.5301/ejo.5000341

Bevins CL, Liu F-T. Rosacea: skin innate immunity gone awry? Nat Med. 2007;13(8):904-906. https://doi.org/10.1038/nm0807-904

Wilkin JK. Oral thermal-induced flushing in erythematotelangiectatic rosacea. J Invest Dermatol. 1981;76(1):15-18. https://doi.org/10.1111/1523-1747.ep12524458

Bernstein JE. Rosacea flushing. Int J Dermatol. 1982;21(1):24. https://doi.org/10.1111/j.1365-4362.1982.tb00483.x

Kulac M, Ciftci IH, Karaca S, Cetinkaya Z. Clinical importance of Demodex folliculorum in patients receiving phototherapy. Int J Dermatol. 2008;47(1):72-77. https://doi.org/10.1111/j.1365-4632.2007.03336.x

Li J, O’Reilly N, Sheha H, et al. Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea. Ophthalmology. 2010;117(5):870-877.e1. https://doi.org/10.1016/j.ophtha.2009.09.057

Liang L, Safran S, Gao Y, Sheha H, Raju VK, Tseng SCG. Ocular demodicosis as a potential cause of pediatric blepharoconjunctivitis. Cornea. 2010;29(12):1386-1391. https://doi.org/10.1097/ICO.0b013e3181e2eac5

Kheirkhah A, Casas V, Li W, Raju VK, Tseng SCG. Corneal manifestations of ocular demodex infestation. Am J Ophthalmol. 2007;143(5):743-749. https://doi.org/10.1016/j.ajo.2007.01.054

Hom MM, Mastrota KM, Schachter S. Demodex: Clinical Cases and Diagnostic Protocol. Optom Vis Sci. 2013;90(7):e198-e205.

Kheirkhah A, Blanco G, Casas V, Tseng SCG. Fluorescein dye improves microscopic evaluation and counting of demodex in blepharitis with cylindrical dandruff. Cornea. 2007;26(6):697-700. https://doi.org/10.1097/ICO.0b013e31805b7eaf

Gao Y-Y, Di Pascuale MA, Li W, et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol. 2005;89(11):1468-1473. https://doi.org/10.1136/bjo.2005.072363

Norn MS. Demodex folliculorum. Incidence and possible pathogenic role in the human eyelid. Acta Ophthalmol Suppl. 1970;108:7-85.

Mills C, Cleary BJ, Gilmer JF, Walsh JJ. Inhibition of acetylcholinesterase by Tea Tree oil. J Pharm Pharmacol. 2004;56(3):375-379. https://doi.org/10.1211/0022357022773

Tighe S, Gao Y-Y, Tseng SCG. Terpinen-4-ol is the Most Active Ingredient of Tea Tree Oil to Kill Demodex Mites. Transl Vis Sci Technol. 2013;2(7). https://doi.org/10.1167/tvst.2.7.2

Leibowitz HM, Capino D. Treatment of chronic blepharitis. Arch Ophthalmol Chic Ill 1960. 1988;106(6):720. https://doi.org/10.1001/archopht.1988.01060130790006

Navel V, Mulliez A, Benoist d’Azy C, et al. Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis. Ocul Surf. 2019;17(4):655-669. https://doi.org/10.1016/j.jtos.2019.06.004

Fulk GW, Murphy B, Robins MD. Pilocarpine gel for the treatment of demodicosis--a case series. Optom Vis Sci Off Publ Am Acad Optom. 1996;73(12):742-745. https://doi.org/10.1097/00006324-199612000-00004

Koo H, Kim TH, Kim KW, Wee SW, Chun YS, Kim JC. Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis. J Korean Med Sci. 2012;27(12):1574-1579. https://doi.org/10.3346/jkms.2012.27.12.1574

Filho PAN, Hazarbassanov RM, Grisolia ABD, Pazos HB, Kaiserman I, Gomes JÁP. The efficacy of oral ivermectin for the treatment of chronic blepharitis in patients tested positive for Demodex spp. Br J Ophthalmol. 2011;95(6):893-895. https://doi.org/10.1136/bjo.2010.201194

Schachter OS. A different approach to treating demodex blepharitis. optometrytimes.com. Published 2014. https://www.optometrytimes.com/view/different-approach-treating-demodex-blepharitis

Ngo W, Jones L, Bitton E. Short-Term Comfort Responses Associated With the Use of Eyelid Cleansing Products to Manage Demodex folliculorum. Eye Contact Lens. 2018;44 Suppl 2:S87-S92. https://doi.org/10.1097/ICL.0000000000000415

Murphy O, O’Dwyer V, Lloyd-McKernan A. The efficacy of tea tree face wash, 1, 2-Octanediol and microblepharoexfoliation in treating Demodex folliculorum blepharitis. Contact Lens Anterior Eye J Br Contact Lens Assoc. 2018;41(1):77-82. https://doi.org/10.1016/j.clae.2017.10.012

Cylindrical dandruff at the eyelash root




How to Cite

Singalavanija T. Update on Demodex Blepharitis. J Chulabhorn Royal Acad [Internet]. 2020 Jun. 26 [cited 2024 May 24];2(3):44-52. Available from: https://he02.tci-thaijo.org/index.php/jcra/article/view/241089



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