Ocular Rosacea and Demodex

January 27, 2018 by S P

This is an article I’ve shared before but it is so powerful in demonstrating the role of proper diagnosis and treatment that I’m highlighting it again.

Brown M, Hernández-Martín A, Clement A, Colmenero I, Torrelo A. Severe Demodexfolliculorum–Associated Oculocutaneous Rosacea in a Girl Successfully Treated With Ivermectin. JAMA Dermatol. 2014;150(1):61–63. doi:10.1001/jamadermatol.2013.7688

Brown et al discuss a 12 year old girl with both facial and ocular manifestations of rosacea.  She had blepharitis, conjunctivitis and even corneal scarring.  She had been treated for over a year with traditional therapies including doxycycline pills, isotretinoin pills (Accutane), steroid eye drops, tacrolimus ointment, cyclosporine 0.05% eye drops (Restasis) without resolution.  She had numerous skin biopsies and the fourth one revealed some demodex mites. A single dose of oral ivermectin (anti-parasite or anti-mite) medications achieved full resolution without recurrence for two years of both her skin and her eye symptoms!

What is rosacea?

Rosacea is a skin condition typically known for redness and dilated blood vessels (telangectasias) on the face (nose, cheeks, chin, forehead).  It is most commonly seen in fair-skinned individuals but can occur in any race.  The cause of rosacea is not well known. The National Rosacea Society developed a classification system in 2002 and updated it in 2017.  The primary features include flushing or redness which is transient or nontransient, papules and pustules and telangectasias.  The secondary features including burning/stinging, elevated plaques, dry skin appearance, swelling of the skin, ocular changes (see below), and growth or thickening of the skin especially of the nose (rhinophyma).

What is ocular rosacea?

Ocular rosacea includes dilated blood vessels (telangectasias) on the eyelids which can lead to eyelid and eye redness (conjunctivitis), crusting (blepharitis), increased risk of infection of the meibomian glands (styes), scarring of the meibomian glands (chalazions), and chronic dry eye disease.  Persistent untreated disease can lead to blurry vision and even corneal scarring. Eye manifestations can occur even without facial signs of rosacea.

What is demodex?

Demodex are tiny mites that live in hair follicles.  The two species which live on humans live in the eyelashes (!) but can also live on the face, eyebrows and other places on your body.  They can be transferred from person to person with contact with the face especially hair and sebaceous glands and likely from shared makeup as well.

What can demodex do to your skin and eyes?

At times, having demodex does not bother the patient at all or cause problems. In other patients, it can cause significant eyelid itching, redness/conjunctivitis, crusting/blepharitis, can worsen rosacea, cause cystic acne (as highlighted in the case above).  Chronic inflammation from demodex can lead to dry eye disease with blurry vision which can lead to corneal changes (punctate keratitis, Salzmann’s nodules, corneal ulceration).  Demodex can also lead to loss of hair (alopecia) on the head or the eyelashes (madarosis).  On the eyelashes, the classic appearance of demodex reveals a cylindrical cuff of dandruff at the base of the lashes known as collarettes.  Gently removing one lash can also reveal numerous demodex mites living buried in the lash follicle.

How is demodex treated?

The first step is to eliminate possible reinfection so please wash your sheets and pillow cases on high heat and in the dryer and get new pillows or wash your pillows as well as no makeup for 2-4 weeks and when you resume, it should be a new supply of makeup. Do not ever share makeup.

The second step is eliminating the crusting on the lashes which is protecting the mites.  You can do this with gentle scrub of the base of your eyelashes at home 2x per day with tea tree oil eyelid cleansers (like Eye Eco – available in our office), or in the office with a BlephEx treatment (available in our office) to jump start your treatment. Don’t forget to also scrub your eyebrows.

The third step is killing the mites which can be achieved with either Tea Tree Oil (20-50% concentration diluted in walnut or olive oil), tea tree oil wipes (like Cliradex – available in our office) and if needed, prescription topical ivermectin cream (Soolantra) or ivermectin pills (anti-mite medication like in the highlighted case above).  If you have lesions on other parts of your body, consider using Tea Tree Oil soap and shampoo as well.  Intense Pulse Light (IPL) treatment (available in our office) also has been shown to help rosacea, ocular rosacea, eyelash crusting (blepharitis) and may help kill the demodex mites as well.

Topical treatment typically takes approximately 6 weeks to kill demodex and their larvae.

If you have any symptoms or signs consistent with rosacea, ocular rosacea or demodex, come in for an evaluation with Dr. Pradhan and find the right treatment for your eyes and skin.