Rotating Through the Demodex World with an Icon: Part 2
Michael S. Cooper, OD
In Part 1 of our Demodex discussion, Dr. Katherine Mastrota, Director of Optometry for the New York Hotel Trade Council Employee Benefit Funds, spoke candidly about the impact of Demodex on the ocular biome. There is a fine line between calm symbiosis and environmental upheaval of these sub-populations that can result in inflammation, infection and loss of local function. In this issue, she sheds light on her diagnostic protocol and treatment methods and provide practice management pearls for future thought.
1. Can you describe your diagnostic protocol and do you utilize any special techniques/equipment to confirm their presence?
I assume that we all harbor Demodex, almost everywhere, albeit in different numbers. The goal is to decide if Demodex overpopulation is the concern.
First, a complete medical and medication history is invaluable in making a "Demodex blepharitis" diagnosis. Is the patient immunocompromised in any way? Does the patient have diabetes? What type of diet do they keep?
A global evaluation of the patient’s face under an overhead light is in order. Checking for signs of rosacea (redness, pustules, phymas) slowly progressive, disorders of the face and ears that represent the end stage of rosacea such as the nose (rhinophyma), the chin (gnatophyma), forehead (metophyma), one or both ears (otophyma), and eyelids (blepharophyma), atopy, or eczema.1,2 In addition, seborrheic dermatitis is a chronic inflammatory disorder affecting areas of the head and trunk where sebaceous glands are most prominent. Lipophilic yeasts of the Malassezia genus, as well as genetic, environmental and general health factors, contribute to this disorder.3 As it is unclear as to what Demodex “eat”, I believe it is crucial to identify patients who may have extra "food" for the mites, be it oils, microbes, yeasts, or cell cytoplasm. Demodex species possess an "oral needle" in their "mouth" area that is believed to pierce cells to extract cellular contents.10 Of course, any medical concern of an altered immune status “red-flags” this patient as one who is at risk for parasite "takeover".
Next is a look at the eyelashes and lid margin. As Demodex, particularly the folliculorum species are inhabitants of hair follicles, individuals with demodex overgrowth may have altered eyelash growth in that they may fall out, be short or sparse, have less pigment, or lose their natural "curl". Remember though, this can be hair anywhere on the body—ears, armpits, chest, etc.4 Various mechanisms have been proposed for the effects of Demodex on eyelash growth: induction of inflammation by the presence of an immune-active lipase in the Demodex mite that ultimately precipitates a downstream, T-cell-related fibrosis of the hair follicle, alteration of the local hormone metabolism by the Demodex-related inflammatory reaction, and/or exhaustion of the hair bulb and shifting of hair cycle from anagen to telogen through long-term invasion by the parasite.5,6
Volcano-shaped debris heaped at the base or the lash and/or debris that "climbs" up the eyelash shaft are good indicators that Demodex are harbored in greater numbers than usual. This debris most likely is a mélange of sebum, dead skin cells, chitin from deceased mite carcasses, and perhaps “regurgitation” of mite-ingested foods.7 Often, by simply brushing away this debris, the tails of embedded Demodex can be seen, generally looking like a bunch of tail-ends of little bananas stuffed into the eyelash follicle, under high magnification at the slit lamp.7 You need go further in making your diagnosis. Although epilation of the lash has been suggested to confirm the Demodex-related blepharitis/inflammation diagnosis, it is easier and more comfortable for the patient to simply rotate the eyelash around its axis (I like to call this the Mastrota Rotation) to "churn" the organism up from its home.8 Or, another way to coax Demodex out of the follicle is to gently pull on the lash. Gentle traction will pull the deeply-rooted lash a short distance from its elastic follicle with the "head-down" mite, out for viewing, attached to it. Once the traction is released, the lash will retract into the follicle with the mite. As you can imagine, the mites are nestled very deeply within the follicle making it difficult to "kill" them with any topical treatment. The greatest concentration of mites is protected from treatment, safely buried with a debris-wall barricade at the front.
2. What treatment methods have you used successfully to manage the Demodex population in your practice?
I believe the goal in managing demodex overpopulation is to balance the local and entire body environment. Consultation with dermatology for rosacea treatment is important. Care of the skin of the eye area, face and body is paramount. A balanced diet, perhaps supplementing with the fatty acid gamma linolenic acid (GLA) with products such as HydroEye (ScienceBased Health, Houston), sets the stage for a better gut biome and skin. In the shower, a gentle body, face and eye area “buffing” to remove applied creams, oils, makeup, deodorants etc., exfoliate dead skin, stimulate blood flow, perhaps with a mild tea tree oil-containing soap, is recommended. Attention to the skin with sunscreen and quality skin moisturizer is important. Of course, the eyelids are of the greatest concern for us, and a concentrated effort is required. Lid hygiene products such as Cliradex wipes and Light (BioTissue, Doral), BlephaDex (Morris, AL), OCuSOFT Lid Scrub Plus or Oust formulas (Rosenberg, TX), Zocular (Okra, Cypress) and the Eye Eco TTO facial cleaners (Temecula, CA), can be added at the doctor’s discretion if the above approach does not yield satisfactory results. Consider that it can take weeks to months of this type of gentle treatment to effect change.
3. Can you provide a few practice management pearls that have worked well in your practice? Essentially, do you have a blue ocean strategy for those interested in creating a new niche in this continuously burgeoning area of eye care?
In discussing blepharitis with my patients, I avoid discussion of the mite and never use the word “infestation”. I merely report an overpopulation of the natural co-inhabitants of the skin. I may show some photographs of the eyelashes where “macro debris” of makeup, dead skin cells and lash collarettes. You can also purchase devices from manufacturers such as Celestron or Levenhuk that can be bought for less than $150 if you wish to examine mites outside the slit lamp for the purpose of patient education. Furthermore, color external photography (CPT 92285) such as TelScreen (Micro-Med, Louisville) can be performed and reimbursed by federal, state, and commercial insurance carriers as long as there is a separate interpretation and report entered into the chart note. In general, these techniques are usually enough to drive lid hygiene adherence to therapy. There is an aesthetic component that should be emphasized to encourage attention to this: longer, better eyelashes, less lid erythema and eye injection equating to clearer, healthier skin.
4. If you had an opportunity to think about the future, do you have any pie in the sky ideas where treatment and management of Demodex might be heading for Optometrists to ponder for the next few years?
I don’t think it’s too far-fetched to see the management of Demodex folded into a total-body “Medi-Spa” –Wellness concept. Certainly we have offices dedicated to the treatment of dry eye that employ sophisticated technology, including lasers to manage ocular surface disease. Notably, IPL has been demonstrated to positively impact rosacea, MGD and to impact Demodex organisms. In the future, imagine a specialized, customized care area of your practice that brings together a nutritionist, dietician, dermatologist, medical and spa esthetician and cosmetologist to cultivate a healthier and balanced skin and body protocol that can protect our patients against the environment slowing the natural course of aging and disease of the body and eye while guarding against inflammation…that’s the happy ending to this Fairy Tale!
Look out for our next edition where we take stock of the current technologies at our fingertips! Stay humble.
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Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med Microbiol. 2012; 61(11):1504-1510.
Draelos ZD. (2018). The effect of antibacterials on the skin. [online] Dermatology Times. Available at:
Litwin D, Chen W, Dzika E, et al. Human Permanent Ectoparasites; Recent Advances on Biology and Clinical Significance of Demodex Mites: Narrative Review Article. Iran J Parasitol. 2017; 12(1):12–21.
Akilor OE, Mumcuoglu KY. Association between human demodicosis and HLA classes. 2003; :70–73.
Murphy O, O’Dwyer V, Lloyd-McKernan A. The Clinical Use of Eyelash Manipulation in the Diagnosis of Demodex folliculorum. Eye Contact Lens. 2019; 45(3).
Rather PA, Hassan I. Human demodex mite: the versatile mite of dermatological importance. Indian J Dermatol. 2014; 59(1):60–66.
Mastrota KM. Method to identify Demodex in the eyelash follicle without epilation. Optom Vis Sci. 2013; 90(6):172-174.
Michael S. Cooper, OD currently practices and is the Director of Research and Technological Innovation at Solinsky EyeCare in the Greater Hartford area. He specializes in anterior segment disease, treating a variety of conditions including dry eye and external lid diseases, allergy, and uveitis. He has produced research, participated on expert ocular surface disease round tables, and lectured domestically on topics such as corneal disease states, uveitis management, Lyme disease, emerging pathogens, complex glaucoma management, sports-related eye injuries in children, and AMD pedigree relationships. Currently, he is actively involved in global clinical studies for novel anti-infective therapeutics, ocular surface diagnostic validation, and AMD genetic research.