Likely the best treatment is the most natural that does not affect a patient’s gut flora. For this reason we often recommend diluted Tea tree oil applications/scrubs on closed eyelids or hypochlorous acid.
There are now many products over the counter that have hypochlorous acid, such as Avenova and Accycin.
Some papers of advocated using metronidazole with azelaic acid and doxycycline. However, at the doses recommended, metronidazole and high dose doxy can affect the gut flora with potential acute and long term negative side effects.
Therefore, I recommend trying topical treatment for Demadex along the eyelids and lashes first.
We also use and offer BlephEX or BlephScrub does decrease the Demadex load to help patients keep on top of Demodex loads
My last resort is oral antibiotics. The majority of patients do not need them
Sandra Lora Cremers, MD, FACS