Demodex blepharitis is widely recognised among eyecare professionals as an important cause of chronic lid margin inflammation, dry eye and ocular surface diseases. The characteristic feature for diagnosis is the presence of waxy deposit at the lash bases on slit lamp examination.
Despite being a very common condition, treatment options can vary significantly across different healthcare systems. In this article, we will compare the treatments available for Demodex blepharitis in the US and in the UK.
Figure 1: Right eye with Demodex blepharitis. Cylindrical collarettes encircling the lash bases which represent epithelial debris and Demodex mite waste product.
Figure 2: Left eye with Demodex blepharitis. Cylindrical collarettes encircling the lash bases which represent epithelial debris and Demodex mite waste product.
Clinical features for diagnosis
Slit lamp examination plays a crucial role in the diagnosis of Demodex blepharitis. The pathognomonic sign is the presence of sleeve-like waxy deposits encircling the base of the lashes, typically described as cylindrical collarettes (Figure 1). These collarettes represent a mixture of epithelial debris, sebum and mite waste products that can be visualised with high magnification of the slit lamp. Other characteristic findings include:
- Lid margin erythema and telangiectasia
- Lash misdirection, lashes growing inwards or loss of lashes
- Conjunctival hyperaemia or superficial punctate epithelial erosions secondary to ocular surface inflammation.
Demodex mites can be visualised by epilating a few lashes and viewed under light microscope. However, this is not routinely done in clinical practice. Clinically, collarette identification under slit lamp examination is considered diagnostic. Differential diagnosis for Demodex blepharitis:
- Staphylococcal or seborrhoeic blepharitis
- Meibomian gland dysfunction related posterior blepharitis
- Ocular rosacea or chronic allergic blepharoconjunctivitis.
The coexistence of dry eye, rosacea and meibomian gland dysfunction is common, which can often complicate management.
Management principle for Demodex blepharitis
The management goal is to reduce mite load with the aim to alleviate symptoms resulting from inflammation. Historically, this focuses on two main aspects: (1) lid hygiene and (2) control of secondary infection. Key elements of Demodex blepharitis therapy:
Lid hygiene
- Warm compresses (5–10 minutes) to heat up oil blockages in meibomian glands
- Lid massage to express the liquefied oil blockages
- Cleaning the lid margins using clean flannel, cotton buds or commercially available lid wipes
- Consistent daily routine is key to prevent re-colonisation of mites.
Anti-microbial/anti-inflammatory agents
- Topical antibiotics (e.g. fusidic acid) for secondary bacterial involvement
- Mild topical corticosteroids or topical ciclosporin to reduce inflammation.
Demodex-directed treatments
- Tea tree oil (TTO)- or terpinen-4-ol (T4O)-based lid wipes
- Mechanical exfoliation (BlephEx) or micro-debridement
- Pharmacological options recently approved by the Food & Drug Administration (FDA) in the USA.
Maintenance
- Once the mite burden is controlled, low-intensity lid hygiene is advised to prevent recurrence.
With these principles in mind, the clinical landscape diverges sharply between the UK and the US.
The UK picture: conservative management in the public sector and innovative approach in the private sector
In the UK, Demodex blepharitis is mostly managed conservatively in the NHS. The mainstay of treatment is patient education and lid hygiene advice, aimed at reducing mite load and mechanical debris.
Standard advice includes:
- Warm compresses with clean moist flannel to soften meibomian blockages
- Lid massage along the direction of the meibomian glands and mechanical cleaning of the lash line using moist cotton buds
- Commercial or diluted baby shampoo lid cleansers are advised.
Topical antibiotics or short courses of mild corticosteroids may be prescribed for secondary bacterial infection or inflammation. However, no Medicines and Healthcare products Regulatory Agency (MHRA)-licensed Demodex-specific medication is currently available on the NHS. Patients are often recommended to purchase over the counter TTO/T4O lid wipes as part of their self-care package [1].
UK private sector options
Within private ophthalmology and optometry practices in the UK, a broader range of Demodex-targeted treatments is available:
- TTO and T4O lid wipes such as Blephademodex® and Cliradex® are used widely
- BlephEx/micro-blepharo-exfoliation – a mechanical procedure that removes collarettes and lid biofilm, improving symptoms and tear film stability
- Unlicensed or imported medications – under MHRA and General Medical Council (GMC) guidance, ophthalmologists may prescribe unlicensed ‘specials’ on a named-patient basis when clinically justified. While this route theoretically allows import of lotilaner 0.25% (XDEMVY™), it is not standard NHS practice and involves additional governance, consent and cost.
For now, UK clinicians rely on a pragmatic combination of lid hygiene, TTO/T4O-based lid wipes and in-clinic debridement – with good symptomatic control in most cases but without a pharmacological mite-targeting option.
The US picture: an innovative pharmacological mite-targeting option
In contrast to the UK, lotilaner 0.25% ophthalmic solution (XDEMVY™) gained the world’s first FDA-approved treatment for Demodex blepharitis in the US in 2023 [2]. Lotilaner is a selective GABA-gated chloride channels inhibitor which specifically targets chloride channels in mites, resulting in the paralysis of the organism and death. Randomised clinical trials demonstrated significant reductions in collarettes, mite counts and lid erythema after a six-week twice-daily course, with minimal adverse effects [3].
Access and insurance considerations
Lotilaner 0.25% is available on prescription through ophthalmologists and optometrists in the US. Insurance coverage varies, and patients lacking coverage may decide to pay privately. Private clinics continue to offer adjunctive measures along lotilaner 0.25% – notably BlephEx, in-clinic hygiene procedures, and TTO-based products – mirroring many UK private options.
Evidence and efficacy
Phase 3 randomised vehicle-controlled, multicentre clinical trials demonstrated that there is statistically significant difference in collarette elimination in treatment group using vehicle containing lotilaner 0.25% in comparison to control group using vehicle without lotilaner (56 % vs 12.5%) after six weeks of treatment for twice daily dosing [3]. Additionally, 89% of patients using lotilaner 0.25% had clinically meaningful collarette reduction of 10 collarettes or fewer.
T4O/TTO-based cleansers
Numerous clinical and laboratory studies published from 2012 to 2021 all confirm anti-Demodex efficacy of TTO. This gives a lot of confidence in recommending this conventional treatment for patients with Demodex blepharitis [1,4].
Mechanical approaches (BlephEx, micro-debridement)
These mechanical techniques can remove the biofilm and debris. However, evidence for these approaches is non-conclusive [5]. However, they are valuable adjuncts to other treatments but not standalone parasiticidal treatments.
Clinical implications for UK ophthalmologists
With no licensed pharmaceutical currently available, UK ophthalmologists should continue a staged approach:
- Diagnose confidently with slit lamp examination – identify collarettes for Demodex blepharitis diagnosis.
- Optimise lid hygiene – daily warm compresses and lid cleaning.
- Advise adjunctive measures – TTO/ T4O lid wipes or BlephEx for recalcitrant cases.
- Discuss unlicensed options where appropriate.
Patients are increasingly aware of the lotilaner approval in the US through media and social channels, so it is important to provide informed, balanced explanations about the current UK position.
Future direction
The approval of lotilaner in the US marks a new era of targeted therapy for Demodex blepharitis. MHRA evaluation in the UK will be a welcome development which potentially aligns UK practice with international standards. Until then, the NHS approach remains grounded in conservative management, supplemented by innovation within the private sector.
For UK clinicians, successful treatment for Demodex blepharitis still lies in the fundamentals: recognise, clean, debride and control – while we await the era of licensed, targeted Demodex therapy.
References
1. Koo H, Kim TH, Kim KW, et al. Ocular surface discomfort and Demodex: effect of tea tree oil eyelid scrub in Demodex blepharitis patients. J Korean Med Sci 2012;27(12):1574–9.
2. Abo ZM, Elrosasy A, Abbas AW, et al. Efficacy and safety of lotilaner ophthalmic solution 0.25% in the treatment of Demodex blepharitis: a systematic review and meta-analysis. Ocul Immunol Inflamm 2024;32(10):2494–505.
3. Gaddie IB, Donnenfeld ED, Karpecki P, et al. Lotilaner ophthalmic solution 0.25% for Demodex blepharitis: randomized, vehicle-controlled, multicenter, Phase III trial (Saturn-2). Ophthalmology 2023;130(10):1015–23.
4. Capasso L, Abbinante G, Coppola A, et al. Recent Evidence of Tea Tree Oil Effectiveness in Blepharitis Treatment. Biomed Res Int 2022;2022:9204251.
5. Siegel H, Merz A, Gross N, et al. BlephEx-treatment for blepharitis: a prospective randomized placebo-controlled trial. BMC Ophthalmology 2024;24(1):503.
Declaration of competing interests: None declared.
Below is a response to this article received by Eye News in February 2026
LETTER TO THE EDITOR
Date: 26 February 2026
Regarding: Phong Phan and Andrena McElvanney’s ‘Demodex blepharitis: A transatlantic comparison of treatments available in the UK and US’
In response to the article by Phan and McElvanney on the perceived lack of options for the treatment of demodex blepharitis, I would respectfully suggest that consideration be given to the growing body of evidence as cited below for the use of ivermectin. This cream used nightly on the eye lids for three months has been shown to offer a relatively cheap and straightforward treatment modality demonstrating significant efficacy at reducing the demodex burden by treating the various life cycle phases of the infestation.
In addition, there has also been significant interest in the use of intense pulsed light (IPL) and low-level light therapy (LLLT) in the treatment of dry eye and associated conditions. This primary care-based treatment, which currently is only available privately, has shown to be efficacious in the improvement of ocular symptoms associated with meibomian gland dysfunction and aqueous deficiency however the addition of cycles of blue low level light masks into the treatment regime also reduces the demodex burden.
Based on my own personal experience of prescribing ivermectin and undertaking IPL/LLLT, I can attest to the efficacy in real life practice, my adoption of these treatments was based on the evidence cited below.
Yours sincerely,
Andy Britton, BSc(hons) FCOptom Dip TP(IP) Dip(Glauc), Prof Cert Med Ret MBCLA,
Specialist Optometrist and Senior Lecturer.
Ivermectin citations
1. Smith M, Wolffsohn JS, Chiang JCB. Topical ivermectin 1.0% cream in the treatment of ocular demodicosis. Cont Lens Anterior Eye 2024;47(1):102099.
2. Ivermectin cream effective against demodex blepharitis. Review of Optometry (2023) [Online]:
https://www.reviewofoptometry.com/article/
ivermectin-cream-effective-against-demodex-blepharitis.
3. Valvecchia F, Greco L, Perrone F, et al. Topical ivermectin ointment treatment of demodex blepharitis: a 6-year retrospective study. Graefes Arch Clin Exp Ophthalmol 2024;262(4):1281–8.
4. Choi Y, Eom Y, Yoon EG, et al. Efficacy of topical ivermectin 1% in the treatment of demodex blepharitis. Cornea 2022;41(4):427–34.
5. Saleh N. Topical ivermectin yields favorable outcomes in patients with demodex blepharitis. Optometry Advisor (2022) [Online]:
https://www.optometryadvisor.com/news/
topical-ivermectin-improves-speed-and-staining
-scores-decreases-redness-swelling-eyelid-debris
-telangiectasia-in-patients-with-demodex-blepharitis/
6. Misich F. Eye and mitey: dealing to demodex with ivermectin. New Zealand Optics (2024) [Online]:
https://www.nzoptics.co.nz/live-articles/eye-and
-mitey-dealing-to-demodex-with-ivermectin/
IPL / LLLT citations
1. Farrant S, Giannaccare G, Lim CHL, Coco G. Intense pulsed light combined with low-level blue and red light therapy for Demodex-associated blepharitis. Clin Ophthalmol 2025:19:2575–85.
2. Tumolo J. Assessing combined light therapy for Demodex-associated blepharitis. Physician’s Weekly (2025) [Online]:
https://www.physiciansweekly.com/post/assessing
-combined-light-therapy-for-demodex-associated-blepharitis
3. Combined light therapy shows promise for treating Demodex-associated blepharitis. Ophthalmology 360 [Online]:
https://ophthalmology360.com/dry-eye/
combined-light-therapy-shows-promise-for
-treating-demodex-associated-blepharitis/
4. Garrote M. IPL and LLLT improves signs and symptoms of Demodex-associated blepharitis, study finds. MediaMICE (2026) [Online]:
https://mediamice.com/ipl-and-lllt
-improves-signs-and-symptoms-of-demodex
-associated-blepharitis-study-finds/
5. Effectiveness of low level light therapy and intense pulse light on mite count as adjunctive therapies in demodex blepharitis using artificial intelligent program (Ai-Demodex) (NCT07169461). ClinicalTrials.gov (2025) [Online]:
https://clinicaltrials.gov/study/NCT07169461
6. Low-Level Light Therapy (LLLT). Blepharitis.uk (2025) [Online]:
https://blepharitis.uk/treatments/lllt/
