Managing Demodex overpopulation can be frustrating for patients and practitioners due to the hardiness of those little mites as well as to the long-term compliance requirements. I interviewed two colleagues to obtain their insights. Dr. Peter Pham is an ophthalmologist in Houston and the CEO of Okra LLC and founder and CEO of Zocular. Dr. Rojas is an optometrist in Dallas who specializes in ocular surface disease and contact lenses.

When should a practitioner suspect Demodex overpopulation versus your average blepharitis?

Dr. Pham: The classic sign of Demodex overpopulation is the presence of cylindrical dandruff at the lash base (Figure 1). Many patients will also present with short, fragile lashes that fall out easily.

Dr. Rojas: It’s important to consider demodicosis as a differential diagnosis in refractory cases of blepharoconjunctivitis, madarosis, trichiasis, and recurrent hordeolum or in those who experience recurrence after discontinuation of lid hygiene therapy.

What is your preferred treatment protocol?

Dr. Rojas: For mild cases, I prescribe commercial 5% tea tree oil (TTO) scrubs b.i.d. on the lids and face for at least six weeks. However, advanced cases usually require in-office blepharoexfoliation—using a single-use disposable applicator containing 50% TTO—that is repeated in two to three weeks. All patients are educated on proper technique for home scrubs, washing bedding in hot water, and discontinuing the use of contaminated cosmetics.

Dr. Pham: For severe Demodex infestation, it is important to remove as much of the protective collars as possible. This is best done with an in-office procedure using manual techniques or an electromechanical device in combination with TTO, surfactant cleansers, or okra-based products. For recalcitrant cases, the addition of compounded 1% ivermectin ophthalmic ointment can be effective.

What is the biggest change that you’ve made in treating Demodex over the years?

Dr. Pham: I’m much more proactive than I used to be, especially with regard to the pre-surgical workup. A healthy ocular surface and lid margin are critical for the success of any ocular surgery. Also, many patients won’t necessarily appreciate the difference in how their eyes feel until after treatment. I also pay more attention in patients who have dry eye disease and meibomian gland dysfunction. There is so much to evaluate in a dry eye examination that it’s easy to miss the Demodex hiding in plain sight.

Do we want to eradicate Demodex completely?

Dr. Rojas: Complete eradication is not necessarily warranted from a balanced ocular ecology standpoint. Our goal should be to reduce the mite population to restore its contributions to the normal homeostasis of the eye while eliminating its contributions to ocular surface comorbidities.

Dr. Pham: I agree. Demodex is part of our normal skin flora. We should seek balance rather than total destruction. The goal of any treatment is to produce clinical results without causing undue injury or inflammation, thereby worsening the very problem that we’re trying to mitigate.

What have you found to increase patient buy-in and, therefore, therapy adherence?

Dr. Rojas: I routinely use anterior segment photography and even microscopic confirmation after lash epilation to inform patients of their condition. I have not encountered a single patient who doesn’t take the condition seriously after seeing their own mites on a microscope slide (video available below). CLS