Mites and Eye Symptoms

A new study has found there may be a link between ocular rosacea and bacteria associated with Demodex mites, microscopic inhabitants of normal skin that tend to occur in much greater numbers in those with rosacea.

In the recently published study of 59 rosacea patients, Dr. Jianjing Li and colleagues at the Ocular Surface Center in Miami found a significant correlation between facial rosacea, infestation of the eyes with Demodex mites and reaction to certain mite-related organisms previously shown to stimulate an immune response in rosacea sufferers.

Rosacea News covered this paper in April and resulted in a similar summary;

Ocular symptoms match Demodex Bacteria reaction too

This paper is one more small achievement using statistics to try to build a picture of how demodex mites might be involved with rosacea symptoms. We have learnt from recent research that rosacea sufferers are sensitive to 2 particular types of bacteria that have been isolated in demodex mites.

This study further establishes that a reaction to the bacteria correlates to ocular symptoms as well as facial symptoms.

So the small step forward is that for those with rosacea linked to demodex bacteria, ocular symptoms may also be exacerbated by a reaction to the bacteria.

As the NRS Blog notes, more research may help draw out exactly how strongly demodex bacteria and facial and ocular rosacea symptoms are related to each other.

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This study further establishes that a reaction to the bacteria correlates to ocular symptoms as well as facial symptoms.

So the small step forward is that for those with rosacea linked to demodex bacteria, ocular symptoms may also be exacerbated by a reaction to the bacteria.

Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea, Ophthalmology. 2010 Jan 14, Li J, O’Reilly N, Sheha H, Katz R, Raju VK, Kavanagh K, Tseng SC..

PURPOSE: To investigate correlation between ocular Demodex infestation and serum.

DESIGN: A prospective study to correlate clinical findings with laboratory data.

PARTICIPANTS: We consecutively enrolled 59 patients: 34 men and 25 women with a mean age of 60.4+/-17.6 years (range, 17-93).

METHODS: Demodex counting was performed based on lash sampling. Serum immunoreactivity to two 62-kDa and 83-kDa proteins derived from B oleronius was determined by Western blot analysis. Facial rosacea, lid margin, and ocular surface inflammation were documented by photography and graded in a masked fashion.

MAIN OUTCOME MEASURES: Statistical significance based on correlative analyses of clinical and laboratory data.

RESULTS: These 59 patients were age matched, but not gender matched, regarding serum immunoreactivity, ocular Demodex infestation, or facial rosacea. There was a significant correlation between serum immunoreactivity and facial rosacea (P = 0.009), lid margin inflammation (P = 0.040), and ocular Demodex infestation (P = 0.048), but not inferior bulbar conjunctival inflammation (P = 0.573). The Demodex count was significantly higher in patients with positive facial rosacea (6.6+/-9.0 vs. 1.9+/-2.2; P = 0.014). There was a significant correlation of facial rosacea with lid margin inflammation (P = 0.016), but not with inferior bulbar conjunctival inflammation (P = 0.728). Ocular Demodex infestation was less prevalent in patients with aqueous tear-deficiency dry eye than those without (7/38 vs. 12/21; P = 0.002).

CONCLUSIONS: The strong correlation provides a better understanding of comorbidity between Demodex mites and their symbiotic B oleronius in facial rosacea and blepharitis. Treatments directed to both warrant future investigation

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An article published today in the Irish Times takes one more step in the direction of showing an association between demodex mites and rosacea. Readers of Rosacea News will know that a lot of research has tried to find a causative link between the presence of demodex mites and rosacea symptoms.

Some progress towards a link between the two was realised when a particular type of bacteria present in demodex, called Bacillus oleronius was isolated. This bacteria was then analysed and 2 resulting proteins were found to be quite interesting. These proteins were shown to induce an increased inflammatory response specifically in rosacea sufferers.

The Irish Times newspaper article quotes Dr. Kevin Kavanagh from NIU Waynooth (who has received NRS funding for demodex research), who says that a survey of 30 patients found 80% had been exposed to large amounts of 2 demodex bacteria proteins. This appears to me to be a new discovery. Immune tests were performed on the patients to show that the patients had been exposed to Bacillus bacterium inside Demodex mites.

We know from previous studies that “two antigenic proteins of size 62 and 83 kDa” isolated in Bacillus oleronius have the potential to stimulate an inflammatory response in patients with papulopustular rosacea. This is the first time I’ve see mention of a high proportion of rosacea sufferers been shown to been exposed to these 2 proteins.

This short article suggests that an immune response to these 2 proteins is a very common occurrence in rosacea sufferers. So common in fact that it warrants further investigation to see what this really means for rosacea diagnosis and treatment. At the least, a blood test to confirm rosacea seems like a real possibility.

Suggesting that eradicating Bacillus oleronius via antibiotics is the reason for their success in treating rosacea does seem a bit of a stretch. Perhaps interrupting how these proteins induce an inflammatory response is another way of understanding how this all fits together.

As this is just a discussion article in a newspaper, it will be useful to see the full article when it is published later this year. My feeling is that we are still only making baby steps along this path of logic. They are steps that seem to be in the right direction, but it sure takes a long time to get there.

From Study finds cause of rosacea, Tuesday, July 14, 2009, CLAIRE O’CONNELL.

BACTERIA ARE to blame for the inflammatory skin condition rosacea, according to a study involving Irish scientists.

…

Working with the Mater hospital, the researchers previously identified a Bacillus bacterium inside Demodex mites. The bacteria release two proteins that trigger an inflammation in patients with facial rosacea.

…

Immune tests on 30 patients found that 80 per cent had been exposed to large amounts of the two bacterial proteins, said Dr Kavanagh of the study, which is to be published in Ophthalmology later this year.

“Now that we know it’s primarily probably a bacterial disease, we know the proper way to treat it is with antibiotics at a low level over a long period of time,” Dr Kavanagh said, noting that washing the skin with dilute tea tree oil also killed the bacteria.

“The other implication is that we could do a simple blood test to say whether a patient has rosacea or not. That’s something we will investigate in the future.”

The article also mentions a link between demodex bacteria and ocular rosacea.

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Here is a good example of why not to believe everything you read on the internet.

Today the internet news stream has a `release’ titled OCuSOFT(R) Lid Scrub(TM) PLUS Proven to Kill Demodex Mites. In it we read ;

“SYNACON/OCuSOFT(R) a broad based supplier of ophthalmic pharmaceuticals and supplies is pleased to announce the latest findings from a recent study(1). OCuSOFT(R) Lid Scrub(TM) PLUS, in its unique “Leave-On” formulation, was shown to effectively eradicate Demodex mites. Significantly, NO other eyelid cleanser used according to manufacturer’s instructions kills Demodex.” (emphasis added)

This is a pretty big claim, and I felt sure that I had never read this before. The brief product description from ocusoft.com says that Lid Scrub Plus is “An Extra Strength eyelid cleanser utilizing a low-level preservative and moisturizer blend offering a wide range of anti bacterial properties.”.

Further reading will reveal that indeed the only claim that is proven is that OCuSOFT Lid Scrub Plus is able to kill “Staphylococcus epidermidis — the most common bacteria associated with blepharitis. This bacteria is often found on the skin and in mucous membranes.” Note that there is no mention of demodex mites.

So the press release is a fabrication, who would have believed it Sadly the internet is full of inaccuracies about demodex mites.

Another page about OCuSOFT based research, Rid the Lid of Disease, reveals more about how their lid scrubs are used in practice.

I use OcuSoft Lid Scrub Plus for all my blepharitis patients. I recommend patients use a hot compress for 10 minutes and follow with the OcuSoft Lid Scrub Plus formulation once a day for two weeks. The hot compress expands the pores and oil glands. This doesn’t necessarily mean the lids absorb the scrub faster, but the product will at least dissolve the hardened meibum.

So eradicating S. epidermis may help your blepharitis symptoms, but what else do we know about demodex mites and ocular symptoms ? We do know that tea tree oil is effective at eradicating ocular demodex and that this might lead to a reduction in ocular rosacea symptoms.

We also know that demodex mites are resistant to a wide range of antiseptic solutions. Some of the products that are known to kill demodex mites include 100% alcohol, tea tree oil, carraway oil, dill weed oil, ether, benzen and xylol. Be careful with carraway oil and dill weed oil as they are toxic to the eye.

So keep an eye out for what you read and believe, especially these sorts of publicity seeking press releases. There may be truths behind press releases, but sometimes you have to dig deeper to see what information is worth taking home.

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Demodex mites and rosacea seem to be a popular pairing. If you are interested in eliminating demodex mites to see if your rosacea symptoms improve, just how can you kill them ? Demodex mites are tiny, and live naturally in everyone’s skin. They are quite difficult to kill.

Read on if you’d like to know more.

First of all, why would you want to eliminate them ?

There may be some new evidence that proteins from a bacteria that can be isolated from demodex mites cause an immune reaction in rosacea sufferers. I’m still not a believer in the involvement of these critters in rosacea. Just in case more evidence is found in the future, though, demodex mites are worth further understanding.

Demodex mites have a life cycle of 14-18 days.

Killing Demodex Invitro (in the test tube)

We know from the paper In vitro and in vivo killing of ocular Demodex by tea tree oil, that various oils and solutions can kill demodex mites quite quickly.

Note that carraway oil and dill weed oil are toxic to the eye. Studies have also confirmed that ether, xylol, benzene, Danish (sulfur-containing) ointment can kill demodex in a few minutes.

Ivermectin

Ivermectin is used in dermatology against some parasitic infestations in humans. The drug is used in the treatment of patients with different forms of scabies, human body lice, head lice, demodecicosis, et. al. Published literature includes a case study of one patient who was treated with topical permethrin and oral Ivermectin. In another case report of one patient, the papules and pustules of rosacea were difficult to treat until oral ivermectin was included in the treatment regime.

Several rosacea sufferers on the rosacea-support email group report success in treating their rosacea with Ivermectin, but the benefits were only short lived.

Ivermectin (Stromectol, Mectizan, Ivomec, Oramec, Cardomec) has been patented as a treatment for rosacea.

Tea Tree Oil

Tea Tree Oil is sourced from the Melaluca tree which is native to eastern Australia. Tea Tree Oil has been shown to kill demodex mites in as little as 4 minutes. External application of undiluted tea tree oil and/or at inappropriate high doses has been associated with toxicity, including death, in cats and other animals.

There is so much interest in the properties of tea tree oil that a research group has been created within the School of Biomedical, Biomolecular and Chemical Sciences at The University of Western Australia.

In a recent study, TTO was used to eliminate demodex mites living in the eyelashes of ocular rosacea sufferers. Study participants were given weekly lid scrubs with 50% tea tree oil and a daily lid scrub with a tea tree shampoo. After six weeks all 6 participants showed improvement in conjuctival irritation and inflammation.

TTO is not soluble in water, but is soluble in alcohol, but sadly that would be unsuitable for use around the eye. Tea Tree Oil can be diluted 50% in Macadamia nut oil for use around the eyes. Lid scrubs with 50% Tea Tree Oil did produce irritation in the participants but the effect was found to be minimised if care was used to avoid spilling it into the eye.

Full strength tea tree oil should never be used anywhere on the face.

Kwellada/Elimite (Permethrin)

Back in 2000, Annette Anderson advocated using Permethrin 5% on the face to eliminate the mites. Permethrin was originally used to treat scabies. She warned that getting it in your eyes burns terribly and that the instructions mention that you should not use it on your face. A few members of rosacea-support had bad reactions to using permethrin on their face, so use Permethrin with extreme care. In the U.S., 5% Permethrin (Elimite Cream) is only available by prescription.

If you are considering Permethrin in any form it would be wise to consider Dr. Linda Sy’s advice to “solicit the cooperation and supervision of their respective dermatologists, get a KOH skin scraping to establish the presence of florid demodex population … Participants try the Permethrin on a small area of face first, to determine if any immediate severe problem exists”.

Seabuckthorn Oil

Despite claims on various internet sites, I have not been able to find any published evidence that Seabuckthorn oil kills demodex mites. If you know of some evidence, please post in the comments below.

A natural approach

For those interested in a more natural approach to treating rosacea including using Olive Leaf Extract and Tea Tree Oil see Rachelle’s Alternative Treatments for Demodex Mites.

Over to You

Have you tried any treatments to eliminate demodex mites ? Did you have a bad reaction them ? any suceess ? Feel free to leave a comment below.

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Some recent NRS supported research has made more steps towards showing a possible link between demodex mites and rosacea symptoms. Although this Br J Dermatol paper was mentioned by Rosacea News in (see demodex mite bacteria causes the inflammation ?) June last year, I just got hold of the full text this week.

A couple of interesting thoughts arise. The researchers were able to extract 2 proteins from the bacteria cultured from a demodex mite. These 2 proteins more commonly produced an inflammatory response in rosacea sufferers, compared to non-rosacea sufferers.

This is an example of how medical research makes quite small and steady steps. This was, as I can see, the main result of this piece of research – 2 proteins from bacillus eleronius were extracted from a demodex mite from a rosacea sufferer, and these proteins might cause aggravated symptoms in rosacea sufferers.

Now for the bad news – the researchers could only isolate the bacteria from one mite from one sufferer out of 40. The researchers are unsure why this is the case- whether it is their methods or sufferers had taken antibiotics in the last 14 days. So we are still a long way from being able to say that demodex bacteria causes rosacea symptoms.

The paper makes the argument that the relative efficacies of different types of antibiotics in rosacea treatment leads to the suggestion that rosacea is bacterial in origin (b. oleronius is sensitive to tetracycline, doxycycline and minocycline) ;

The mechanism by which antibiotics successfully clear the inflammatory lesions of papulopustular rosacea is unknown. It has been suggested that antibiotics work through anti-inflammatory mechanisms, but other potent anti-inflammatory drugs are ineffective and immunosuppressive agents such as steroids (administered topically or systemically) and tacrolimus can make the inflammatory eruption of rosacea worse.

The fact that only selective antibiotics are effective in rosacea suggested to us the possibility that a bacterial agent may be involved in the pathogenesis of the disease. A D. folliculorum related bacterium sensitive to the antibiotics used in the treatment of rosacea could explain the induction of inflammatory changes in papulopustular rosacea.

The researchers conclude that the significance of finding b. oleronius in association with demodex mites and their biological functions need to be further defined. Other mite related bacteria also need to be investigated.

An enormous amount of research effort has been invested in demodex mites. This paper takes a baby step towards perhaps understanding a possible link.

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This 2007 paper is similar to a 2002 paper, Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream. The 2002 paper is also a case report of a single patient with recalcitrant symptoms.

Note that topical permethrin may well be too harsh for many rosacea sufferers. Back in 2000, a a project that proposed using topical permethrin was suddenly canceled after reports surfaced of strong negative reactions to permethrin.

I would suggest that these results are the exception rather than the rule when approaching how to treat your rosacea.

Recalcitrant papulopustular rosacea in an immunocompetent patient responding to combination therapy with oral ivermectin and topical permethrin

Cutis. 2007 Aug;80(2):149-51., Allen KJ, Davis CL, Billings SD, Mousdicas N. Indiana University School of Medicine, Indianapolis 46202, USA.

A 68-year-old healthy man presented with papulopustular rosacea (PPR) recalcitrant to multiple therapies, including permethrin cream 5%. Histologic examination detected the presence of chronic folliculitis and numerous Demodex organisms. A diagnosis of rosacealike demodicidosis was rendered, and the patient was treated with oral ivermectin and permethrin cream 5%, resulting in resolution of the folliculitis. Demodex infestation should be considered in any patient with rosacealike dermatitis resistant to conventional rosacea therapies. If infestation is demonstrated in these patients, oral ivermectin in combination with topical permethrin is a safe and effective therapeutic option.

Further Extracts

Conclusion

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They highlight a paper presented at this year’s AAD Meeting in Washington DC. Rosacea News mentioned this abstract in February as ;

demodex bacteria – could that be the cause ?

Some more speculation about how rosacea might be linked in some way to demodex mites. So far there is no causative link – that is scientists cannot yet prove that demodex mites cause rosacea. The quest continues to find if there is a good provable link between the mites and rosacea. I remain skeptical until some good research is published.

I also added some more background in June when a similar paper was published in the British Journal of Dermatology – demodex mite bacteria causes the inflammation ?

Personally I hope that the rosacea community doesn’t spend too many resources chasing demodex causes. If only the mites could be discounted once and for all. Sadly, though, I think the fact that a link is hard to find, just means researchers look harder. Maybe I’ll be proved wrong in the future, but I just can’t see demodex and their effects adding much to the rosacea cause research effort.

The rest of this edition of Rosacea Review is the usual light reading.

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This paper is proposing that a particular type of bacteria taken from a demodex mite, called Bacillus oleronius is capable of producing an inflammatory response. As the mite was isolated from a patient with papulopustular rosacea the tempting conclusion is that this bacteria has caused these rosacea symptoms. This part is of course not confirmed, just the fact that it is possible to isolate a bacteria that causes an inflammatory response in humans.

This paper looks to be the publication of a study mentioned in a 2004 press release from the National Rosacea Society – New Study Shows Role for Bacteria in Development of Rosacea Symptoms.

A study from February 2007 (also with NRS funding), mentioned in demodex bacteria – could that be the cause ?, tried a different approach to proving a link. Herer, Burroughs et.al. is suggesting that antibiotics actually affect the intraceluar bacteria in demodex mites – and that is the reason they work in rosacea – not their anti-inflammatory properties.

So here is the abstract of the just-published paper.

Mite-related bacterial antigens stimulate inflammatory cells in rosacea.

Br J Dermatol., 2007 Jun 26, Lacey N, Delaney S, Kavanagh K, Powell FC .

Background: Patients with papulopustular rosacea have a higher density of Demodex folliculorum mites on their faces than normal subjects but the role, if any, of their mites in initiating inflammation is disputed. Selective antibiotics are effective in reducing the inflammatory changes of papulopustular rosacea, but their mode of action is unknown.

Objectives: To investigate whether a D. folliculorum-related bacterium was capable of expressing antigens that could stimulate an inflammatory immune response in patients with rosacea.

Methods: A bacterium (Bacillus oleronius) was isolated from a D. folliculorum mite extracted from the face of a patient with papulopustular rosacea, and was investigated further.

Results: This bacterium produced antigens capable of stimulating peripheral blood mononuclear cells proliferation in 16 of 22 (73%) patients with rosacea but only five of 17 (29%) control subjects (P = 0.0105). This antigenic preparation was fractionated into 70 subfractions and the proteins in each fraction were visualized by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Western blot analysis revealed the presence of two antigenic proteins of size 62 and 83 kDa in fractions when probing with sera from patients with rosacea. No immunoreactivity to these proteins was recorded when probing with sera from control patients. Two-dimensional electrophoretic separation was used to isolate these proteins and matrix-assisted laser desorption/ionization time-of-flight analysis was employed to identify the relevant peptides. The 62-kDa immunoreactive protein shared amino acid sequence homology with an enzyme involved in carbohydrate metabolism and signal transduction while the 83-kDa protein was similar to bacterial heat shock proteins.

Conclusions: Antigenic proteins related to a bacterium (B. oleronius), isolated from a D. folliculorum mite, have the potential to stimulate an inflammatory response in patients with papulopustular rosacea.

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This recently published paper suggests that a variety of ocular symptoms might be caused by demodex infestation. Six patients all having demodex present, and suffering with recalcitrant symptoms (including 4 diagnosed with rosacea) were given tea tree oil for a weekly eyelid scrub and tea tree shampoo for a daily scrub. All patients showed a large decrease in demodex counts and relief from their symptoms.

Other recently published studies are showing that tea tree oil kills demodex. See ;

• Clinical treatment of ocular demodecosis by lid scrub with tea tree oil., Cornea. 2007 Feb;26(2):136-43. Conclusions: Demodex potentially causes ocular surface inflammation, meibomian gland dysfunction, and lash abnormalities. Lid scrub with TTO can effectively eradicate ocular Demodex and result in subjective and objective improvements. This preliminary positive result warrants future prospective investigation of Demodex pathogenicity.
• In vitro and in vivo killing of ocular Demodex by tea tree oil. [full text], Br J Ophthalmol. 2005 Nov;89(11):1468-73 Conclusions: Demodex is resistant to a wide range of antiseptic solutions. Weekly lid scrub with 50% TTO and daily lid scrub with tea tree shampoo is effective in eradicating ocular Demodex.

I have always pushed the line that demodex mites have thus far only been proven to be innocent bystanders in rosacea symptoms. In order to prove that the mites are responsible for some ocular symptoms we now need double blind studies to show 2 things – firstly that killing demodex does lead to a reduction in ocular rosacea symptoms and secondly some studies that show how tea tree oil works. We also now need larger studies that confirm that tea tree oil is a safe therapy for ocular symptoms.

Corneal Manifestations of Ocular Demodex Infestation, Kheirkhah A, Casas V, Li W, Raju VK, Tseng SC., Ocular Surface Center, Miami, Florida. Am J Ophthalmol. 2007 Mar 19

PURPOSE: To report the corneal manifestations in eyes with Demodex infestation of the eyelids.

DESIGN: Noncomparative, interventional case series.

METHODS: This retrospective review included six patients with Demodex blepharitis who also exhibited corneal abnormalities, which led to suspicion of limbal stem cell deficiency in three cases. All patients received weekly lid scrubs with 50% tea tree oil and a daily lid scrubs with tea tree shampoo for a minimum of six weeks. Improvement of symptoms and corneal and conjunctival signs were evaluated.

RESULTS: All six patients exhibited ocular irritation and conjunctival inflammation, while meibomian gland dysfunction (n = 5), rosacea (n = 4), and decreased vision (n = 3) also were noted despite prior treatments with oral tetracycline, topical steroids with antibiotics, and lid scrub with baby shampoo. These patients were proven to have Demodex folliculorum (n = 6) and Demodex brevis (n = 3) by microscopic examination of epilated lashes. Their corneal manifestation included superficial corneal vascularization (six eyes of five cases), marginal corneal infiltration (two eyes of two cases), phlyctenule-like lesion (one eye of one case), superficial corneal opacity (two eyes of two cases), and nodular corneal scar (two eyes of two cases). After treatment, the Demodex count was reduced from 6.8 +/- 2.8 to 1 +/- 0.9 (standard deviation; P = .001). All patients showed dramatic resolution of ocular irritation, conjunctival inflammation, and all inflammatory, but not scarred, corneal signs; three patients showed improved vision.

CONCLUSIONS: A variety of corneal pathologic features together with conjunctival inflammation, commonly noted in rosacea, can be found in patients with Demodex infestation of the eyelids. When conventional treatments for rosacea fail, one may consider lid scrub with tea tree oil to eradicate mites as a new treatment.

Update: For those interested in how to follow the tea tree oil treatments discussed in this paper, here are some related notes from a page titled Demodex treatment options ;

Dr. Safran said Dr. Tseng’s identification of tea tree oil to treat the Demodex is novel, and he has slightly modified the formulation. While physicians can buy tea tree oil from most health food stores, Dr. Safran has also used an ointment Dr. Tseng is working on. If using the heath food store variety, he said to cut the oil to 50% in Macadamia nut oil.

“I apply it with cotton tip applicators after one drop of tetracaine, so there’s no shield required,” he said. “I am very aggressive with trying to get the oil into the lash roots and along the lashes to kill any eggs. I also aggressively treat the eyebrows. I don’t like the applicator dripping wet, but it should be moist enough so I can see the oil getting onto the skin when it’s touched. I treat the brow first, then the lid to get rid of the excess oil where it won’t irritate as much. I’ll do three applications a visit, about 10 minutes apart, and then finish with a tea tree ointment at 20%, which I have mixed for me at a compounding pharmacy. I do this for three visits, each one week apart.”

Dr. Safran warned other physicians not to use full strength tea tree oil. “I tried that on myself, and it was not a pleasant experience,” he said.
The patient must institute hygiene at home, he said, and that includes tea tree shampoo, scrubs and face wash.

As Tea Tree Oil is a strong substance and your eye is such a sensitive organ, these sorts of therapies really are best undertaken with the supervision of a doctor.

This article also mentions that Dr. Tseng has filed a patent on the use of tea tree oil for ocular symptoms.

For further information on eradicating demodex mites I also strongly recommend that you read the related article just how do you kill demodex mites ?.

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