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Dr. Koetting
This is CE on ReachMD, and I'm Dr. Cecilia Koetting, and I'm here today with Dr. Douglas Devries, and we're going to review evidence-based treatment strategies for Demodex blepharitis. Right? This is a really good topic, and I think that it’s hopefully very helpful for you.

So Doug, can you review the therapeutic options currently that we have for Demodex blepharitis? 

Dr. Devries: 
Yeah, absolutely. And boy, has this evolved. I mean, back before there was anything that was even over the counter, I would have to order compounded tea tree oil and have the patient pick it up and come in and put it on the lashes. You weren't practicing yet, I'll just say. And what's this evolvement? And then comes along treatments like IPL, because we know that that lessens the load of that. Lid scrubs have been used for years and years to take care of what we saw, which was collarettes, which is pathognomonic for Demodex, but really didn't do anything to take care of the mites that are down in the lash follicles. 

Dr. Koetting: 
No, it didn't, and it would be cyclical, right? And that was the first thing I noticed was great, so we took care of it. I'll see you back in 3 to 4 months when the seasons change and we'll do it again. 

Dr. Devries: 
Yeah, yeah, exactly. And I think with the advent of lotilaner having the first FDA approved treatment for Demodex, it really changed the landscape. Because not only did we have something that a 6-week treatment could really reduce that load and make patients more comfortable, but we had something that was a beginning and an end. And with our ocular surface patients we typically are not used to that. Patients are used to giving a prescription for a lifetime, right? And along with that education said here's how you find it. And the whole look down, kick up the magnification, look at the base of the lash, looking for that collarette, it's 100% pathognomonic of Demodex blepharitis. So I think the treatments really have—the landscape has changed dramatically. 

Dr. Koetting: 
It has. And I think even within the cleaner, because we didn't throw out the baby with the bath water, right? We still want the lid hygiene. We still want to make sure that we're controlling the environment, the bacteria, the food. I have personally gravitated more towards an okra and then also a Manuka honey cleaner that have also shown in some studies to work well.

Are you tea tree oil or what are you reaching for?

Dr. Devries: 
Well, and there's so many different forms of tea tree oil that we have.

Dr. Koetting:
There are. There are.

Dr. Devries:
Initially, I think the initial tea tree oil that hit the market was so strong and it was in a scrub and so patients scrub their lids with that and caused a lot of irritation, inflammation. They said hey now you are throwing the baby out with the bath water because you're creating more inflammation. I think the okra-based treatments. And what I really use that for, if a patient can get lotilaner, I'm using that for more maintenance.

Dr. Koetting: 
Oh yeah, 100% absolutely. Get started on this. Let's get you the lotilaner. And then once that's finished, I’m going to have you continue to clean just to decrease the risk of recurrence. 

Dr. Devries: 
I think we've all really been looking for different maintenance that we can have with our patients. And one school of thought is taking care of the biofilm. So you take away a monosaccharide food source sometimes. And something that is ineffective on Demodex would be some of the sprays that you're going to use, a hypochlorous acid. But it's not to say that that can't reduce the bacterial load and reduce the load of the biofilm. So I think there's some good. And I think we're all still searching for what exactly do we use, because I try a lot of different things. 

Dr. Koetting: 
Yeah, and I do too. And we know that companies are continuously coming out with things as far as OTC for hygiene. And what I might do for 3 months might change a little bit for the next 3 months if I'm like oh what is this going to look like so I can figure it out.

But I think you're right. I think it's not necessarily is there a particular one thing to continue with the lid hygiene along with the lotilaner, right? It's what is working for that patient. What is financially available. What is physically available.

Dr. Devries: 
And one of the things that I've found in my practice is combining these therapies is okay. Using lotilaner before you do thermal expression, lotilaner before you do IPL. I mean, there's no reason you can't combine this, because if we can reduce some of the Demodex load in the meibomian glands and then we're trying to free it up. So essentially it really gives when somebody has Demodex blepharitis and MGD it now gives us a medical treatment but doesn't mean we can't still do the physical treatments of removing the obstruction as well with heat and with IPL. 

Dr. Koetting: 
Absolutely, absolutely. It’s an ‘and,’ you're correct. I'm with you.

Dr. Koetting:
And so thank you, Doug. This was a great discussion. Hopefully everybody got a little bit of pearls out of this. Thank you to our audience for joining us and we'll see you next time.

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