By: MICHELE PENDRAK BUSH, O.D.
One of the things I love about medicine is that we are constantly learning. Diagnostics and treatments are always evolving, with the recommendations I make for my patients changing right along with it.
When I was in school, we learned about blepharitis. This is inflammation of the eyelids that leaves crusting at the base of one’s eyelashes. We were taught to recommend that patients scrub their lids with baby shampoo.
Our knowledge has greatly increased since then and I’m sorry to say, that scrubbing eyelids with baby shampoo is nothing that should be encouraged. Read on to learn more about the progress we’ve made!
For starters, we now know that baby shampoo contains formaldehyde releasers. That would be the same ingredient that is used to embalm the frogs we all dissected in high school biology class.
If that’s not off-putting enough, studies have demonstrated that formaldehyde releasers “induced cell atrophy, poor adherence, decreased proliferation and death, after 5 days of exposure” to meibomian gland, corneal, and conjunctival epithelial cells with damage starting to occur after only 15-30 minutes of exposure.
Second, when we have blepharitis, it also causes these meibomian glands to produce unhealthy oil. This essentially creates unhealthy fats.
These fats mix with the salt in our tears and produce . . . soap! When somebody has a significant amount of blepharitis, doctors can actually see soapy little bubbles forming along the eyelid margin. So, the recommendation to wash the eyelids with baby shampoo essentially meant we were putting soap on soap. That causes the stripping the eyelids of their own natural oils and certainly does not provide any antimicrobial or anti-inflammatory benefits.
Next came the realization that most of this blepharitis was actually being caused by demodex. Demodex is a mite that acts as a parasite and lives on all of us. There are two types of demodex. Demodex folliculorum lives in hair follicles (this includes the lashes) and demodex brevis lives in oil gland secretions (this includes the meibomian glands). It carries other bacteria such as bacillus oleronius.
So while we all carry demodex, some of us carry demodex in higher percentages than others. Demodex tends to be opportunistic, meaning that anything that affects our body’s immune response also affects our ability to respond to demodex.
For example, it has been proven in studies that people with rosacea have a higher percentage and population of demodex than those without. It makes sense since rosacea essentially compromises our skin’s immune response. It is also currently theorized that rosacea may be a hypersensitivity response to bacillus, which can also live in our gut.
Additionally, 80% of people over age 60 will have demodex blepharitis, and 100% of people over age 70 will have some form of it. This also makes sense considering how our immune systems change with time.
Once we realized how prevalent demodex was, we acknowledged it was going to take a whole lot more than baby shampoo to treat it. In one particularly famous study, they exposed demodex to all sorts of common antimicrobials and antiseptics to include alcohol, betadine and antibiotics only to find that nothing killed this pesky little mite except . . . tea tree oil (TTO)!
What followed was an explosion of tea tree oil eyelid cleansers on the market.
A major issue was getting enough tea tree oil in an ocular product to get a therapeutic benefit, but not so much TTO that it would sting the eye.
Studies tell us we need at least 5% TTO to kill demodex. When I started researching the concentration of TTO in products I found just about all products had concentrations of 1-2%. Only the Cliradex lid wipes came close, having the active ingredient Terpinen-4-ol from TTO at a concentration of 4%. Anyone who used these could tell you that the 4% wipes made the eyes sting significantly. (Sorry about that!)
In December 2020, there was a study published saying that TTO in any amount was potentially damaging to the meibomian glands. Unfortunately this fell during the pandemic when the world was shut down along with regular patient care, so it has taken a while to reconnect with patients and change the treatment protocol. Fortunately, there are newer, more effective treatments with no side effects.
I had had my eye on a few various treatments for the eyelids just prior to the pandemic.
One was photobiomodulation – or light – therapy. This can be in the form of Low Level Light Therapy (LLLT) delivered via medical grade LED masks or Intense Pulsed Light Therapy (IPL) which is when quick pulses of light are delivered to the skin via a handheld device. Both are very effective at treating dry eye, and as it turns out both do an excellent job treating demodex. There are even some very satisfying videos on Youtube of IPL killing demodex on contact! Siepser has been offering both treatments to our patients with much success for over one year now.
The other surprising treatment option for demodex is honey! Certain strains of honey have activity against demodex with a study showing that Manuka Honey is as effective against demodex as 50% TTO! This is significant when you consider that the best TTO eyelid wipe was only able to offer a concentration of 4%. For this reason, we now offer a honey based Eyelid Butter in our practice that has demonstrated remarkable efficacy against demodex with zero ocular irritation or stinging. In fact, we have noticed some enjoyable cosmetic benefits including the fact that the butter also doubles as a moisturizer, makeup primer, and enhances lash growth.
So that is your update on TTO. The bottom line is, we no longer support putting it near your eyes!
If you think you might have issues with demodex blepharitis or any other ocular surface condition, I would love to see you and offer my advice in the Dry Eye Center of Excellence at Siepser Eyecare!