Table 2.

Descriptive characteristics of included interventional and observational Demodex studies (n = 38).

Study Setting	Study Design	Study Participant	Intervention Description	Outcome Measure(s)	Treatment Outcome(s)	Quality Score
RCTs (n = 14)
Ebneyamin et al., 2019 [74], Iran	Randomized double-blind, placebo-controlled trial	Rosacea patients with Demodex (age = not reported, n = 47)	Test (n = 35 right side faces): Received permethrin (2.5%) with TTO (100%) gel, applied on the skin BID (Twice daily) for 12 weeks Control (n = 35 left side faces): Received placebo gel	Demodex mite density (DMD/cm2) after 12 weeks AEs occurrence	DMD (Mean): 528.8 (BL (baseline):1346) in Test vs. 650.9 (BL:1407.1) in Control (p = 0.001) AEs: No allergic reactions and no major AEs observed but skin dryness (n = 21, 60.0% moderate and 37.1% mild), burning and stinging (n = 7, 20%), erosion (n = 7, 20%) and erythema (n = 3, 8.6%)	5 (High)
Epstein et al., 2020 [108], USA	Randomized double-blind, placebo-controlled trial	Blepharitis patients with Demodex (Mean age: 71.0 ± 6 5.8 years in Test and 75.6 ± 5.0 years in Control groups, n = 50)	Test (n = 26): Received microblepharoexfoliation (MBE, one application at baseline) plus Cliradex® eyelid scrubs (T4O, no concentration reported) applied BID for 1 month. Control (n = 24): Received MBE (one application at baseline) plus sham scrubs (no medication, content not reported) applied BID for 1 month. After 1 month, both test and control groups received MBE (one time application) plus Cliradex® eyelid scrubs BID for 1 month	Demodex mite count (DMC, per four epilated lashes) after 1 month DMC after 2 months Ocular Surface Disease Index (OSDI) score after 1 month:1–100 scale OSDI score after 2 months:1–100 scale AEs occurrence	DMC (Mean ± SD) after 1 month: 3.6 ± 1.5 (BL:4.7 ± 1.5) in Test group (p = 0.266) vs. 3.0 ± 1.0 (BL:5.1 ± 1.4) in Control group (p = 0.015) DMC (Mean ± SD) after 2 months: 2.6 ± 1.2 (BL:4.7 ± 1.5) in Test group (p = 0.026) vs. 2.5 ± 0.9 (BL:5.1 ± 1.4) in Control group (p = 0.005) OSDI score (Mean ± SD) after 1 month: 15.1 ± 8.9 (BL: 19.1 ± 8.5) in Test group (p = 0.505) vs. 17.2 ± 8.5 (BL: 16.9 ± 7.9) in Control group (p = 0.962) OSDI score (Mean ± SD) after 2 months: 16.6 ± 7.9 (BL: 19.1 ± 8.5) in Test group (p = 0.660) vs. 7.7 ± 5.4 (BL: 16.9 ± 7.9) in Control group (p = 0.074) AEs: Both treatments were well tolerated and burning, or irritation symptoms reported by few patients (no specific number reported) dissipating in minutes or less.	5 (High)
Ergun et al., 2020 [56], Turkey	Randomized double-blind, placebo-controlled trial	Blepharitis patients with Demodex (Mean age: 48.80 ± 13.22 years in Test and 53.16 ± 9.59 in Control groups, n = 49)	Test (n = 25): Received advanced cleansing gel formulation containing 3% (w/w) TTO plus < 5% (w/w) calendula oil, borage oil, vitamin E, vitamin B5 BID for 1 month Control (n = 24): Received basic cleansing gel formulation containing 3% (w/w) TTO BID for 1 month	Demodex Eradication rate (DER) after 1 month Ocular Surface Disease Index (OSDI) score after 1 month AEs occurrence	DER (%): 20.6% (BL:54.2%) in advanced gel (p = 0.004) vs. 27.8% (BL:42.0%) in Basic cleansing gel (p = 0.302) OSDI score (Mean ± SD): 24.0 ± 16.1 (BL:44.3 ± 22.5) in Advanced gel (p = 0.001) vs. 18.7 ± 15.0 (BL:36.5 ± 17.8) in Basic cleansing gel (p = 0.001) AEs: No AEs were observed in both groups	4 (High)
Karakurt and Zeytun, 2018 [62], Turkey	Randomised single-blinded controlled trial	Blepharitis patients with Demodex (Mean age: 56.5 ± 14.1, n = 135)	Test (n = 75): Received TTO (7.5%) eyelash shampoo applied BID for 4 weeks Control (n = 60): Received TTO-free eyelash shampoo applied BID for 4 weeks	Demodex mite count (DMC) after 1 month DER Ocular symptoms (itching, burning, foreign body sensation, redness, and cylindrical dandruff) score: 0–3 AEs occurrence	DMC (Mean): 0 (BL: 6.3) in 36% (27/75) (p < 0.001) and 4.2 (BL:12.5 per eyelash) in 64% (48/75) of patients (p < 0.001) in TTO group vs. 0 (BL:2.0) in 11.7% (7/60) (p = 0.017) and 7.9 (BL: 12.0 per eyelash) in 89.3% (53/60) of patients (p = 0.024) in Control group DER (%): 36% (27/75) in TTO group vs. 11.7% (7/60) in Control group Ocular symptoms score (Mean): Decreased in Test (p < 0.001) vs. Remained the same in Control group (p > 0.05) AEs: No irritation or other side effect complaints for both groups	2 (Low)
Koo et al., 2012 [77], South Korea	Randomized controlled trial	Blepharitis patients with Demodex (Mean age: 55.7 ± 12.4 years, n = 281)	Test (n = 141): Received TTO (50%) lid scrub weekly followed by TTO (10%) lid scrub daily applied for 1 month Control (n = 140): Received eyelid scrub with saline	DMC (per eight epilated lashes) after 1 month DER after 1 month OSDI score after 1 month Patient compliance (for TTO group): good (> 10 times scrubbing/week); moderate 5–9 times/week) and poor (< 5 times scrubbing/week) AEs occurrence	DMC (mean ± SD): 3.2 ± 2.3 (BL:4.0 ± 2.5) in TTO group (p = 0.001) vs. 4.2 ± 2.5 (BL:4.3 ± 2.7) in Control group (p = 0.27) (p = 0.004) DER (%): 23.6% (25/106) in TTO group vs. 7% (4/54) in Control group OSDI score (mean ± SD): 24.1 ± 11.9 (BL:34.5 ± 10.7) in TTO group (p = 0.004) vs. 27.5 ± 12.8 (BL:35.3 ± 11.6) in Control group (p = 0.04) Patient compliance: 37.7% (40/106) with good vs. 34% (36/106) with moderate vs. 28.3% (30/106) with poor compliance (no report on patient compliance for control) AEs: 4.7% (5/106) reported ocular irritation but disappeared following patient’s education on the proper scrubbing method	2 (Low)
Liu and Gong, 2021 [92], China	Randomized controlled trial	Blepharitis patients with Demodex (Mean age: 46.2 ± 13.0years, n = 52)	Test (n = 27): Received okra eyelid patch (no concertation reported) applied every night for 3 months Control (n = 25): Received TTO eye care patch (no concertation reported) applied every night for 3 months	DMC (per four epilated lashes) after 3 months DER after 3 months OSDI score (0–100) after 3 months AEs occurrence	DMC (mean ± SD): 1.3 ± 1.4 (BL:10.2 ± 4.5) in Test group vs. 1.9 ± 0.2 (BL: 11.2 ± 5.9) in Control group (p = 0.716) DER (%): 40.74% (11/27,) in Test group vs. 48% (12/25) in Control group OSDI score (mean ± SD): 23.7 ± 10.7 (BL: 40.5 ± 10.9) in Test group vs. 18.4 ± 3.3 (BL: 35.9 ± 12.8) in Control group (p = 0.873) AEs: 3.7% (1/27, ocular pruritus and discomfort) in Test group vs. 16% (4/25, slight to moderate irritation with conjunctival congestion) in Control group	3 (High)
Mergen et al., 2021 [72], Turkey	Randomised double-blind, active comparator-controlled trial	Seborrheic blepharitis patients with Demodex (Mean age: 28.4 ± 65.2years in Test and 31.8 ± 61.1years in Control groups, n = 52)	Test (n = 26): Received TTO (7.5%) and chamomile oil (no concentration reported) swabs applied BID for 2 months and followed by a month of treatment withdrawal period Control (n = 26): Received Johnson’s Baby Shampoo (BS) applied BID for 2 months followed by a month of treatment withdrawal period	DMC (per four epilated lashes) after 2 months DER after 2 months OSDI score after 2 months Blepharitis Symptom measure (BLISS) score after 2 months AEs occurrence	DMC (mean ± SD): 0.0 ± 0.1 (BL: 1.5 ± 1.1) (p < 0.001) in Test group vs. 0.0 ± 0.1 (BL:1.2 ± 1.0) (p < 0.001) in Control group (p = 0.930) DER (%): 95.5% (21/22) in Test group vs. 95.7% (22/23) in Control group (no p value reported) OSDI score (mean ± SD): 7.7 ± 7.2 (BL: 16.5 ± 16.0) (p < 0.001) in Test group vs. 12.3 ± 11.0 (BL: 13.0 ± 8.8) (p = 0.143) in Control group (p = 0.186) BLISS score: (mean ± SD): 1.1 ± 2.8 (BL: 10.0 ± 4.0) (p < 0.001) in Test group vs. 6.6 ± 6.7 (BL: 9.6 ± 4.4) (p = 0.01) in Control group (p < 0.001) AEs: No patients reported AEs in both groups	5 (High)
Messaoud et al., 2019 [121], Tunisia	Randomized open level-controlled trial	Blepharitis patients with Demodex (Mean age: 52.0 ± 16.2 in Test group I and 56.5 ± 15.1 in Test group II, n = 48)	Test I (n = 24): Received T4O (2.5%) plus hyaluronic acid (0.2%, moisturizing agent) sterile wipe (Blephademodex®) once daily for 29 days Test II (n = 24): Received T4O (2.5%) plus hyaluronic acid (0.2%, moisturizing agent) sterile wipe (Blephademodex®) BID for 29 days Control: None	Reduction in overall ocular discomfort on Day 29 (0–10 points) Improvement in ocular symptoms score (itching, burning/stinging and foreign body sensation) on Day 29 (0–5 points) Patient satisfaction (Day 29) AEs occurrence (Day 29)	Reduction in overall ocular discomfort (mean ± SD): 1.1 ± 1.0 (BL: 6.4 ± 1.4, p < 0.0001) Test group I vs. 0.2 ± 0.8 (BL: 7.0 ± 1.5, p < 0.0001) in Test group II (p = 0.718) Improvement in overall ocular symptoms: satisfactory or very satisfactory in 95.7% in Test group I vs. 100% in Test group II Patient satisfaction: 100% for both groups AEs: 1/24 (moderate burning sensation after application which resolved after 3s) in Test group I vs. 2/24 (visual acuity) in Test group II	2 (Low)
Mohammadpour et al., 2020 [93], Iran	Randomised triple-blinded controlled trial	Patients with dry-eye symptoms after cataract surgery (Mean age: 66.4 ± 8.8 years, n = 62, of these n = 43 with Demodex: n = 23 in the Test and n = 18 in the Control groups)	Test (n = 33): Received eyesol shampoos with TTO (5%), artificial tears, and topical steroid TID for 1 month Control (n = 29): Received eyesol shampoos without TTO, artificial tears and betamethasone (1%) drops TID for 1 month	DMC (per four epilated lashes) after 1 months OSDI score after 1 months	DMC (mean ± SD): 0.9 ± 2.3 (BL: 2.4 ± 2.9) (p < 0.001) in Test group vs. 2.7 ± 3.3 (BL:2.7 ± 3.9) (p = 0.916) in Control group (p = 0.024) OSDI score (mean ± SD): 21.9 ± 19.1 (BL: 42.5 ± 25.1) (p < 0.001) in Test group vs. 31.5 ± 22.6 (BL: 41.1 ± 26.4) (p < 0.05) in Control group (p < 0.05)	4 (High)
Murphy et al., 2018 [63], Ireland	Randomised controlled trial	Blepharitis patients with Demodex (Mean age: 49.6 ± 17.1 years in TTFW, 49.6 ± 16.9 in OLSP and 49.86 ± 19.7 in BlephEx™ groups, n = 69, n = 17 participants with no Demodex mites)	Test (n = 22): Received TTO containing 38% T4O (Dr Organic Tea Tree Face Wash™, TTFW) lid scrub daily (night-time) for 4 weeks Test II (n = 24): Received OcuSoft Lid Scrub Plus (OLSP) wipes (Active ingredient: 0.5%1, 2-Octanediol) daily (night-time) for 4 weeks Test III (n = 23): Used BlephEx™ exfoliation device once at initial visit and received OLSP wipes at home nightly for 4 weeks	DMC after 4 weeks DER after 4 weeks OSDI score after 4 weeks	DMC (median [range]): 1.9 (0–8) (BL:4.9[0–21]) (p = 0.001) in TTFW group vs. 1.9(0–7) (BL:3.8[0–11]) (p = 0.005) in OLSP group vs. 2.7 (0–9) (BL:6.5[1–25]) (p = 0.001) in BlephEx™ group (p = 0.498) DER (%): 40.9 % (9/22) in TTFW group vs. 45.8% (11/24) in OLSP group vs. 39.1% (9/23) in BlephEx™ group OSDI score (mean ± SD): 16.2 ± 15.2 (BL:27.4 ± 16.7) in TTFW group vs. 13.6 ± 17.1 (BL:28.6 ± 23.6) in OLSP group vs. 12.8 ± 12.8 (BL:30.1 ± 19.8) in BlephEx™ group (p = 0.646)	2 (Low)
Tseng S. (NCT 01647217), 2017 [107], USA	Randomised controlled trial	Chronic blepharitis patients with Demodex (Mean age: 48.8 ± 19.1 years, n = 17)	Test (n = 8): Received T4O (Cliradex®) lid scrub (no concentration reported) once or twice per day for 1 month Control (n = 9): Received placebo lid scrub once or twice per day for 1 month	DMC after 6 weeks Lid Margin Redness and Bulbar Conjunctival Hyperemia: 0 (none)- 6 (severe) after 6 weeks AEs occurrences	DMC (Mean change ± SD): -3 ± 3.1 in Test group vs. -0.4 ± 3.6 in Control group Lid Margin Redness and Bulbar Conjunctival Hyperemia (Mean change ± SD): -2.3 ± 1.4 in Test group vs. -3.1 ± 1.9 in Control group AEs: 0% (0/8) in Test group vs. 0% (0/9) in Control group (no p-value is reported)	NA as this is only trial registry record
Wang et al., 2020 [88], China	Randomised controlled trial	Blepharitis patients with Demodex (Mean age: 37 ± 14 years, n = 32 with 64 eyes)	Test (n = 16, 32 eyes): Received TTO eye patch (concertation not reported) BID combined with daily (night-time) eyelid margin deep cleaning in one eye for 3 months Control (n = 16, 32 eyes): Received TTO eye patch (concertation not reported) BID in the other eye for 3 months	DMC after 3 months DER after 3 months OSDI score after 3 months (Only the outcomes with clinical significance are considered for this study)	DMC (median [range]): 1 (0–2) (BL:6 [4–9], [p < 0.01]) in Test group vs. 2 (0–2) (BL:6 [5–11] [p < 0.01]) in Control group (p = 0.022) DER (%): 37.5% (12/32 eyes) in Test group vs. 28.1% (9/32 eyes) in Control group OSDI score (median (range)): 54.5 (27.1–65.0) Pre-treatment vs. 28.1 [16.3–52.7] Post-treatment in both groups (p < 0.001)	3 (High)
Wong et al., 2019 [120], Australia	Randomised single blinded (R vs. L eye) controlled pilot trial	Blepharitis patients with Demodex (Median age: 63.5 (range 48–76)) years, n = 20)	Test (n = 20 eyes): Received TTO and coconut oil (Blephadex™ concentrations not reported) Eyelid Wipes in one eye once daily for 1 month Control (n = 20 eyes): The contralateral eye was left untreated	DMC after 1 month DER (DMC reduction to 0) after 1 month OSDI (1–100) after 1 month AEs occurrence	DMC (Median ± IQR): 0 ± 2 (BL:2 ± 3) in Test vs. 2 ± 4 (BL:3 ± 5) in Control group (p = 0.04) DER (%): 50% in Test vs. 29% in Control group OSDI (Median ± IQR): 9 ± 14 (BL:9 ± 15) in Test vs. 9 ± 14 (BL:9 ± 15) in Control group (p = 0.15) AEs: No AEs observed and product well tolerated by participants	3 (High)
Zhang et al., 2019 [85], China	Randomized controlled trial	Blepharitis patients with Demodex (Mean age: 38.3 ± 12.3 years in IPL and 39.2 ± 11.0 in TTO groups, n = 40)	Test (n = 20): Received intense pulsed light (Lumenis® M22TM) treatments three times in 3 months Control (n = 20): Received TTO (5%) ointment 15 min lid massage daily for 3 months	DMC (per eight epilated lashes) after 3 months DER after 3 months OSDI score after 3 months	DMC (mean ± SD): −13.1 ± 8.5 (BL:13.1 ± 8.5) in Test vs. −11.1 ± 6.9 (BL:12.9 ± 6.5) in Control (p = 0.780) DER (%): 100% (20/20) in Test vs. 75% (15/20) in Control OSDI score (mean ± SD): −25.6 ± 31.0 (BL:30.5 ± 30.5) in Test vs. −15.6 ± 27.8 (BL:33.5 ± 29) in Control (p < 0.01)	2 (Low)
Non-RCTs (n = 24)
Alver et al., 2017 [52], Turkey	Cohort study	Blepharitis (chronic and treatment-resistant) patients with Demodex (mean age = 54.1 ± 15.4 years, n = 39)	Test (n = 28): Received TTO (10%) eyelash shampoo with TTO (4%) eyelid gel, both applied on the eyelids BID for 1 month Control: None	DER, % after 1 month OSDI score after 1 month Improvement in symptoms (%) AEs occurrence	DER (%): 82.1% (23/28) (no p-value is reported) Improvement in symptoms: 89.2% (25/28) (no p-value is reported) OSDI score (Mean ± SD, n = 12): 33.0 ± 2.7 (BL:39.6 ± 10.1) (p = 0.002) AEs: No patient complained of the TTO use	5 (Medium)
Evren Kemer et al., 2020 [69], Turkey	Case series	Cylindrical dandruff (CD) patients with Demodex (Mean age: 52.8 ± 15.8 years, n = 30)	Test (n = 30): Received eye warm compressed at 43–45 °C for 5 min followed by cleaning eyelids with T4O (0.1%) plus sodium hyaluronate (moisturiser) wipes (Blefastop plus®) BID for 2 weeks (first cycle treatment). After 7–10-days washout period, the same treatment repeated (second cycle treatment) Control: None	DER after 2weeks and 1 year OSDI score after first cycle treatment (3 weeks), second cycle treatment (6 weeks) and 1 year Treatment compliance (Only the outcomes with clinical significance are considered for this study)	First cycle: OSDI score (Mean ± SD): 34.3 ± 13.4 (BL: 48.0 ± 19.8) (p = 0.001) Second cycle DER (%): 86.7% (27/30) (no p-value is reported) OSDI score (Mean ± SD): 40.1 ± 21.1 (BL:48.0 ± 19.8) (p = 0.001) After 1 year, DER: 86.7% (27/30) (no p-value is reported) OSDI score (Mean ± SD): 41.3 ± 14.6 (BL:48.0 ± 19.8) (p = 0.001) Treatment compliance: 86.7% (27/30)	8 (High)
Galea et al., 2014 [58], UK	Case study	A blepharitis patient with Demodex (age = 60 years, n = 1)	Test (n = 1): Received TTO (5%) ointment and tea tree lid scrub (50%) for 3 months Control: None	DER after 3 months Blepharitis improvement	DER (%):100% or complete eradication of the mites Symptom improvement Significant improvement of blepharitis (no p-value is reported)	7 (High)
Gao et al., 2005 [97], USA	Cohort study	Cylindrical dandruff (CD) patients with Demodex (mean age = 59.9 ± 8.7, n = 16)	Test (n = 9): Received weekly (three-time application) of TTO (50%) lid scrub at the office plus daily (two times) application of 0.5 mL tea tree shampoo (TTO < 10 %) lid scrub for 1 month and then once daily thereafter at home Control (Conventional treatment, n = 7): Received daily lid hygiene with baby shampoo	DMC from epilated lashes with CD after 1 month DER after 1 month AEs occurrence	DMC (Mean ± SD):0 in 7 patients (BL:7.9 ± 4.1) in 4 weeks in Test vs. Never zero in 50 weeks in Control DER (%): 77.8% in Test vs. 0% in Control AEs: TTO (50%) generated irritation in some patients (no data is reported) (no p-value is reported)	9 (High)
Gao et al., 2007 [98], USA	Case series	Ocular demodicosis patients with Demodex (Mean age: 60.2 ± 11.6 years, n = 11)	Test (n = 11): Received TTO (50%) office lid scrub weekly and 0.5 mL Tea Tree shampoo lid scrub BID for 1 month Control: None	DMC (per eight lashes) after 1 month DER after 1 month Improvement in symptoms (inflammation) after 1 month AEs occurrence after 1 month	DMC: 5 (BL:120) in all patients and 0 (BL:17 ± 5.2) in 8 patients DER (%): 72.2% (8/11) Symptom improvement: 81. 8% (9/11) patients showed 50–100% improvement in symptoms AEs: TTO (50%) office lid scrub caused mild irritation in 3 and moderate irritation in 6 participants (no p-value is reported)	8 (High)
Gao et al., 2012 [99], USA	Cohort study	Ocular demodicosis patients (Mean age: 37.2 ± 15.6 years, n = 24)	Test (n = 24): Received TTO (5%) ointment lid massage BID for 1 month Control: None	DMC (per eight epilated lashes) after 1 month DER after 1 month Itching grades: Grades 1 (mild), 2 (moderate), and 3 (severe) AEs occurrence	Mean DMC: 0.7 ± 0.8 (BL:4.6 ± 1.8) (p < 0.01, n = 24) and 0 (n = 11 patients) DER (%): 45.8% (11/24) Itching: 66.7% (16/24) no itching while 7 subjects (BL:6) Grade 1 vs. 1 (BL:14) Grade 2 vs. 0 (BL:4) Grade 3 (p < 0.01) AEs: Mild ocular irritation in 2 participants	7 (High)
Gunnarsdóttir et al., 2016 [59], Iceland	Case study	Meibomian gland dysfunction (MGD) patients with Demodex (Age: 35 and 72 years, n = 2)	Test (n = 2): Applied Tea Tree wet wipes (TTO concentration not stated) on eyelashes, eyebrows, and face BID for 10 weeks Control: None	DMC (mites/eye) after 10 weeks OSDI after 10 weeks AEs occurrence	DMC: 2–4 mites (BL:8–12 mites per eyes) in both patients Or Reduction in DMC:66.7–75.8% OSDI score: 16.7 (BL:35.4) in both patients AEs: no side effects in both patients (no p-value is reported)	8 (High)
Hirsch-Hoffmann et al., 2015 [61], Switzerland	Cohort study	Blepharitis patients with Demodex mites (age = not reported, n = 96)	Test: Received daily lid hygiene plus TTO (5%) ointment applied once daily (n = 6); TTO (0.02%) cleansing foam applied once daily (n = 38); metronidazole (MTZ, 2%) ointment applied once daily (n = 5); Ivermectin tablets (IVM, 6 mg given po at Days 1 and 14) (n = 27); MTZ (500 mg po BID for 10 days) Control: None	DMC (10 epilated lashes) after 2 months DER after 2 months Symptom improvement Treatment preference AEs occurrence	DMC: 13.3 for TTO ointment vs. 12.0 for TTO foam vs. 9.4 for MTZ ointment vs. 12.8 for IVM (oral) vs. 22.0 for MTZ (oral) (no baseline data and p-value are reported) DER (%): 0% for TTO ointment vs. 6% for TTO foam vs. 0% for MTZ ointment vs. 6% for IVM (oral) vs. 0% for MTZ (oral) (no p-value is reported) Symptom improvement (%):20% for TTO ointment vs. 40.5% for TTO foam vs. 20% for Metronidazole ointment vs. 35% for IVM (oral) vs. 20% for MTZ (oral) Treatment preference: 2/96 (2.1%) for daily lid hygiene vs. 7/96 (7.3%) for TTO ointment vs. 45/96 (46.9%) for TTO foam vs. 5/96 (5.2%) for MTZ ointment vs. 32/96 (33.3%) for oral IVM vs. 5/96 (5.2%) for oral MTZ AEs: no AEs for systemic drugs but AEs not reported for topical treatments	3 (Low)
Huo et al., 2021 [89], China	Case study	Patients with Phthirus pubis and Demodex co-infestation (Age: 48 years, n = 1)	Test: Received TTO (25%) daily lid scrubs and applied for 2 months Control: None	DMC (12 epilated lashes) after 2 months DER after 2 months	DMC: 0 (BL:19 mites) DER (%): 100% (2/2 eyes) (no p-value is reported)	7 (High)
Jacobi et al., 2021 [73], Germany	Cohort study	Blepharitis patients with Demodex (Mean age: 60.9 ± 18.7 years, n = 50)	Test (n = 6): Received T4O (2.5%) plus hyaluronic acid (0.2%, moisturiser) eyelid wipes (Blephademodex®) every evening for 28 days Control: None	DMC (10 epilated lashes) after 28 days Global discomfort scale (GDS) after 28 days:0 (no)–10 (worst) scale Total ocular symptom score (TOSS): 0 (none)- 4 (all the time) The symptom assessment in dry eye (SANDE) score: very mild–very severe Patient satisfaction after 28 days Treatment compliance after 28 days AEs (tolerability) occurrence after 28 days	Results are for mean changes from 0 to 28 days (only initial treatment phase) DMC (Mean change ± SD): −1.5 ± 1.7 (p < 0.0001) GDS (Mean change ± SD): −1.9 ± 1.9 (p < 0.0001) TOSS (Mean change ± SD): −18.7 ± 16.2 (p < 0.0001) SANDE (Mean change ± SD): −1.9 ± 2.2 (p < 0.0001) Patient satisfaction: 66 % (42% satisfied and 24% very satisfied) Treatment compliance: all patients were regarded as compliant AEs: 86% of participants rated the T4O-wipes tolerable and no AEs were reported during the study period	8 (High)
Kheirkhah et al., 2007 [101], USA	Case series	Blepharitis patients with Demodex (Mean age: 49.3 ± 17 years, n = 6)	Test (n = 6): Received TTO (50%) weekly lid scrubs and daily tea tree shampoo lid scrubs applied for 6 weeks Control: None	DMC (per eight lashes) after 6 weeks Improvement of symptoms after 6 weeks	DMC (Mean ± SD): 1 ± 0.9 (BL:6.8 ± 2.8) (p = 0.001) Symptom improvement: Dramatic resolution of ocular irritation and inflammatory signs in all participants	7 (High)
Kim et al., 2011 [75], South Korea	Cohort study	Blepharitis patients with Demodex (Mean age: 48.3 ± 18.9 years, n = 10 and 13 eyes)	Test (n = 10): Received TTO (50%) weekly lid scrub and TTO (10%) shampoo lid scrub BID for 1 month Control: None	DMC (per eye) after 1 month DER after 1 month Improvement in symptoms (bulbar conjunctival injection, conjunctival papillary hypertrophy corneal erosions and infiltrations)	DMC (Mean ± SD): 0.2 ± 0.4 (BL:3.8 ± 2.2 per eye) (p = 0.001) DER (%): 76.9% (10/13 eyes) Symptom improvement: 53–100% improvements in ocular symptoms in all patients	7 (High)
Kojima et al., 2011 [76], Japan	Cohort study	Blepharitis patients with Demodex (Mean age: 62.9 ± 9 years, n = 15)	Test (n = 15): Received TTO (50%) weekly lid scrubs and tea tree shampoo (10%) daily lid scrubs applied for 6 weeks (n = 15 eyes) Control: None	DMC (per epilated lash) after 6 weeks Improvement in symptoms VAS score (itchiness and foreign body sensation) after 6 weeks: 0–100 scale	DMC (Mean ± SD): 0.5 ± 0.5 (BL:4.0 ± 0.5) (p < 0.05) Symptoms’ improvement VAS Scores Itchiness VAS Score: 15 ± 5.5 (BL: 92 ± 2.5) Foreign Body Sensation VAS Score: 1.0 ± 1.0 (BL: 96.5 ± 6) Ocular symptoms improved post-treatment (p < 0.05)	7 (High)
Liang et al., 2010 [102], USA	Case series	Paediatric blepharoconjunctivitis patients with Demodex (Age range:2.5–11 years, n = 12)	Test (n = 12): Six patients received TTO (50%) eyelid scrubs 3 times/week for 4–6 weeks and the other six (who were not cooperative to the TTO eyelid scrub) received TTO (5%) ointment eyelid massages BID for 4–6 weeks Control: None	DMC (per four epilated lashes) after 6 weeks Improvement in ocular symptoms (surface irritation and reactions, eyelid margin swelling and conjunctival redness)	DMC: Reduced to 0–1 in 4/11 (BL:26 mites for 11 patients) (no DMC report on the n = 7 participants) Improvement in ocular symptoms: Dramatic resolution of ocular irritation and inflammation in 2 weeks in all patients (no p-value is reported)	6 (Medium)
Liang et al., 2018 [78], China	Cohort study	Ocular demodicosis patients (Mean age: 19.1 ± 7.5 years, n = 60 involved and 48 received treatment)	Test (n = 48): Received T4O (Cliradex®, no concentration reported) lid scrub BID for 3 months Control: None	DMC after 3 months Improvement in ocular symptoms (surface inflammation)	DMC (Mean ± SD): 0.5 ± 0.7 (BL:5.6 ± 3.5) (p < 0.001) Improvement in ocular symptoms: Rapidly resolved within 2–3 weeks	8 (High)
Lyu et al., 2021 [90], China	Quasi-experimental	Blepharitis patients with Demodex (Mean age: 43.8 ± 11.5 years in OPT group; 44.2 ± 11.1 in TTO group and 44.9 ± 10.7 in OPT + TTO group, n = 283)	Test I: Received optimal pulse technology (OPT) 3 times/2 weeks for 6 weeks (n = 94) Test II: Received a combination of OPT 3 times/2 weeks and TTO cleansing eye patch daily (night-time) for 6 weeks (n = 96) Test III: Received TTO cleansing eye patch daily (night-time) for 6 weeks (n = 96)	DMC (per 12 epilated lashes) after 6 weeks Improvement in symptoms (itchiness, burning eyes, and foreign body sensation) after 6 weeks: 0–24 score (Only the outcomes with clinical significance are considered for this study)	DMC (Mean ± SD): 1.3 ± 1.9 (BL:8.3 ± 6.1, p < 0.05) in OPT + TTO group vs. 2.4 ± 2.2 (BL:9.3 ± 8.3, p < 0.05) in TTO group vs. 5.3 ± 4.1 (BL:9.0 ± 5.5, p < 0.05) in OPT group (p < 0.01) Improvement in ocular symptoms score (Mean ± SD): 2.8 ± 2.0 (BL:13.4 ± 2.5, p < 0.05) in OPT + TTO group vs. 4.8 ± 2.3 (BL:12.8 ± 3.2, p < 0.05) in TTO group vs. 4.3 ± 2.3 (BL:13.1 ± 3.3, p < 0.05) in OPT group (p < 0.01)	9 (High)
Maher 2018 [79], United Arab Emirates	Quasi-experimental	Blepharitis and meibomian gland dysfunction (MGD) patients with Demodex (Mean age: 51.5 ± 9.2 years in TTO group and 52.9 ± 9.3 years in Massage group, n = 40)	Test (n = 20): Received TTO (0.02%) eyelid (Naviblef™) scrub foam BID for 1 month Control (n = 20): Performed eyelid massage for 5 min QID plus cleansing the lid margins with mild (baby) shampoo QID	Decrease in OSDI score after 1 month Improvement in ocular/lid symptoms (reported by patients) after 1 month AEs occurrence	OSDI score (Mean ± SD): 8.7 ± 4.0 (BL:47.8 ± 8.4) in Test (p < 0.001) vs. 30.1 ± 8.9 (BL: 44.3 ± 6.8) (p = 0.03) in Control Improvement in ocular symptoms: 100% (20/20) in Test (p < 0.001) vs. 25% (5/20) (no p-value) in Control AEs: 1 (contact dermatitis) in Test vs. 1 (eye irritation) in Control	9 (High)
Nicholls et al. 2016 [117], Australia	Cohort study	External ocular diseases patients with Demodex (Mean age: 62 years, n = 333)	Test (n = 333): Received TTO (5%) ointment daily (night-time) for 3 months Control: None	Improvement in symptoms (anterior blepharitis, chronic primary conjunctivitis dry eye disease, MG disease and allergic conjunctivitis) after 3 months: 0 (no symptom) –5 (severe) scale	Improvement in symptoms: 91.4% (213/233) some improvement; 10.3% (24/233) complete resolution; 16.8% (40/233) very little problem; 28.9% (67/233) much better; 26.7% (62/233) somewhat better; 8.6% (20/233) just a little better; 8.6% (20/233) no change in the symptoms (no p-value is reported)	5 (Medium)
Patel et al. 2020 [91], India	Case series	Blepharokeratoconjunctivitis patients with Demodex (Mean age: 19.1 ± 7.5 years, n = 14 and 26 eyes)	Test: Received TTO (50%) twice-daily lid scrubs for 3 months and two doses of oral ivermectin (200 µg/kg, 1 week apart) (n = 15 eyes) Control: None	Improvement in symptoms (ocular surface inflammation such as congestion and corneal vascularization) after 3 months	Improvement in symptoms: Clinical improvement in sign and symptoms in all patients (no p-value is reported)	6 (Medium)
Tighe et al., 2013 [81], China	Case study	A blepharitis patient with Demodex (Age: 60 years, n = 1)	Test (n = 1): Received T4O lid scrub (Cliradex® lid wipes) BID for 8 weeks Control: None	DMC after 8 weeks DER after 8 weeks Improvement in symptoms after 8 weeks	DMC: 0 (BL:22) DER (%): 100% (0/22) Improvement in symptoms: Marked resolution of symptoms and clearer lashes (no p-value is reported)	6 (Medium)
Wu et al., 2019 [87], Chania	Quasi-experimental	Meibomian gland dysfunction (MGD) patients with Demodex (Mean age: 60.5 ± 13.6 years, n = 38 with 76 eyes)	Test (n = 13, 26 eyes): Received both 0.02% flurometholone eye drops (anti-inflammatory) TID and TTO wipes (concertation not reported) BID for 4 weeks Control I (n = 13, 26 eyes): Received TTO wipes (concertation not reported) BID for 4 weeks Control II (n = 12, 24 eyes): Received 0.02% flurometholone eye drops TID for 4 weeks	DMC after 4 weeks Improvement in ocular symptoms (pain, redness, itching, burning/stinging and foreign body sensation) after 4 weeks (0–10 points) AEs occurrence (Day 29) (Only the outcomes with clinical significance are considered for this study)	DMC (mean ± SD): 0.5 ± 0.4 (BL:6.1 ± 4.8) in Test vs. 1.2 ± 1.5 (BL:6.7 ± 3.0) in TTO vs. 4.3 ± 2.7 (BL:5.6 ± 2.9) in Flurometholone groups (p < 0.01) Improvement in ocular symptoms score (mean ± SD): 3.3 ± 2.2 (BL:5.3 ± 2.0) in Test vs. 2.8 ± 2.0 (BL:4.3 ± 2.0) in TTO vs. 2.0 ± 2.2 (BL:4.3 ± 2.9) in Flurometholone groups (p = 0.0836) AEs: No AEs observed in all groups	9 (High)
Yam et al., 2014 [82], China	Case series	Recurrent chalazion patient with Demodex (Mean age: 39.1 ± 10.2 years, n = 30 with 48 eyes)	Test (n = 16, 31 eyes): Received TTO (50%) weekly lid scrub and 0.5 mL tea tree shampoo lid scrub BID for 3 weeks Control: None	Success/cure rate in preventing recurrent chalazion after 6 months follow-up AEs occurrence	Success/cure rate: 96.8% after treatment (p = 0.002) AEs: No AEs observed	10 (High)
Yin et al., 2021 [109], USA	Case study	An ocular Blepharitis patient with Demodex (Age: 72 years, n = 1)	Test (n = 1): Received T4O (Cliradex®) lid wipes (no frequency and duration of treatment reported) Control: None	DMC after 8 months OSDI score after 8 months	DMC: 0 (BL:31 mites) DER (%): 100% (2/2 eyes) OSDI score: 15 (BL:37) (no p-value is reported)	6 (Medium)
Zhong et al., 2021 [94], China	Quasi-experimental	Blepharitis patients with Demodex (Mean age: 47.4 ± 7.5 years in Test group; 46.6 ± 6.7 years in Control group, n = 56)	Test (n = 28, 56 eyes): Received meibomian glands comparison massage weekly followed by eyelid cleansing with cotton swab soaked with TTO (no concertation reported) daily for 2 months Control (n = 28, 56 eyes): Received meibomian glands comparison massage weekly followed by cotton swab soaked with normal saline eyelid cleansing daily for 2 months	DER after 2 months The OSDI score after 2 months	DER (%): 78.6% (44/56) in the Test vs. 10.7 % (2/56) in control groups (p < 0.001) OSDI score (Mean ± SD): 19.6 ± 4.2 (BL: 25.6 ± 6.8) in Test vs. 23.8 ± 5.2 (BL: 25.8 ± 6.9) Control groups (p < 0.001)	9 (High)