5 ways to go beyond baby shampoo for lid hygiene

More than 20 years ago, personal computers ran Windows 95, everyone was doing the Macarena, and optometrists were recommending baby shampoo for blepharitis. Lid hygiene has come a long way in two decades-but have all practitioners bought in, or do some still cling to the good ol’ days?

What’s the harm?

First do no harm is fundamental to medical professionals.

Certainly, one would assume that nothing could be safer than a product designed for use with children. Television commercials with smiling, happy babies covered in frothy bubbles imply the product is harmless. Ubiquitous marketing alone creates a subconscious sense of safety for both doctor and patient.

Baby shampoo contains mild detergent due to children’s limited sebum production.¹ 

However, baby shampoos also contain an abundance of other ingredients, some of which are benign and others that have proven to be potentially dangerous. In 2013, Johnson & Johnson removed formaldehype and 1,4-dioxane from its No More Tears baby shampoo.2

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While formaldehyde occurs naturally in many products, there are risks associated with both acute and long-term exposure. Though most risk associated with exposure is caused by inhalation, eye irritation can occur.³ 

Concerns about long-term exposure and mounting public safety concerns prompted the company to revise its popular formulation.²

Similarly, 1,4-dioxane can cause eye irritation as well. However, it may be more difficult to avoid because it is often a manufacturing byproduct.⁴

The updated version of Johnson’s baby shampoo and other similar products continue to contain ingredients like cocamidopropyl betaine (CAPB). CAPB is an amphoteric synthetic detergent used in a variety of hygiene products, including some contact lens cleaners.

Increasing rate of allergic reaction to CAPB, including delayed T-cell mediated type IV hypersensitivity reactions, have been noted.

In 2004, CAPB had the dubious of honor of being named “Allergen of the Year” by The American Contact Dermatitis Society. Prevalence of contact sensitization due to CAPB or manufacturing impurities is between 3 and 7 percent.⁵

Baby shampoos were not designed for application to the eyes nor as lid hygiene products. In an effort to provide patients with an inexpensive mild cleanser, doctors may not only be recommending something less effective but also potentially irritating.

However, lid scrubs with baby shampoo continue to be recognized by the American Optometric Association⁶ and the American Academy of Ophthalmology as a viable lid hygiene option.⁷

Better alternatives

Baby shampoo-along with hot rice in a sock or baked potatoes-are effective for a warm compress, but eyecare practitioners are able to offer more in today’s market of lid cleansers and warming masks. There are a variety of lid hygiene products on the market. Each one offers different benefits. Here are four options.

1. Lid wipes offer a simple alternative to baby shampoo. Reasonable in cost and easy to find, pre-moistened wipes are designed specifically for use around the eyes. They are effective at removing debris and environmental impurities such as pollen. Unlike baby shampoo, these products are formulated to be beneficial to the eyes rather than harm them.

2. Hypocholorous acid solutions mimic the human body’s endogenous response to pathological organisms. Neutorophils naturally release hypochlorous acid when insulted by bacteria. These products not only remove debris, but they also relieve chronic irritation and decrease the body’s own inflammatory mediators.

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3. Tea tree oil (TTO) formulations are useful in the battle against demodecosis. Waxy cylindrical dandruff at the lash base is pervasive and tends to increase significantly with age. TTO has proven to be effective in eliminating demodex and the resulting itch and inflammation.⁸

4. In-office procedures are another viable option. Conventional lid hygiene recommendations are not unlike daily teeth brushing in the dental model. Physical debridement by an implement like a spud can provide a basic removal of debris from the lid margin.

However, microblepharoexfoliation such as BlephEx from RySurg more closely parallels teeth cleaning provided by the dentist. 

5. Warming masks or compresses are widely recommended by eyecare providers and present a compliance challenge for patients. Conventional compresses tend to be messy and lose heat quickly, often leaving patients frustrated and unwilling to continue with regularity.

Using a silicone-beaded mask offers a sustained, moist heat. They can be used over and over without loss of effectivity.

Lid hygiene products offer more benefits

Research suggests that compliance is higher with prescription drug instructions rather than over-the-counter (OTC) recommendations and are often taken more seriously.⁹ While most lid hygiene products are not sold behind the pharmacy counter, “prescribing” a specific OTC regimen rather than baby shampoo may encourage better patient buy-in and compliance.

Offering various lid hygiene products in your practice can build a new revenue stream too. While you’re unlikely to have a bottles of baby shampoo displayed in your office, providing merchandise designed for lid hygiene allows the patient to make an immediate in-office purchase not unlike what takes place in the optical.

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Lid hygiene products have moved out of the ‘90s and out the baby care aisle at the drugstore. Giving patients problem-specific recommendations, detailed direction, and immediate availability serves both patient and practice.

References:

1. D'Souza P,  Rathi SK. Shampoo and Conditioners: What a Dermatologist Should Know? Indian J Dermatol. 2015 May-Jun; 60(3): 248-254.

2. Thomas K. The ‘No More Tears’ Shampoo, Now With No Formaldehyde. NY Times. 2014 Jan 17. Available at: http://www.nytimes.com/2014/01/18/business/johnson-johnson-takes-first-step-in-removal-of-questionable-chemicals-from-products.html?_r=0. Accessed 5/14/16.

3. U.S. Environmental Protection Agency. Facts about formaldehyde. Available at: https://www.epa.gov/formaldehyde/facts-about-formaldehyde. Accessed 5/14/16.

4. Campaign for Safe Cosmetics. 1,4-dioxane. Available at: http://www.safecosmetics.org/get-the-facts/chemicals-of-concern/14-dioxane/. Accessed 5/14/16.

5. Jacob SE, Amini S. Cocamidopropyl betaine. Dermatitis. 2008 May-Jun;19(3):157-60.

6. American Optometric Association. Blepharitis. Available at: http://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/blepharitis?sso=y. 5/14/16.

7. American Academy of Ophthalmology. Blepharitis PPP-2013. Available at: http://www.aao.org/preferred-practice-pattern/blepharitis-ppp--2013. Accessed 5/14/16.

8. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. 2007 Feb;26(2):136-43.

9. Bower AB, Grau SL, Taylor VA. Over-the-counter vs. prescription medications: are consumer perceptions of the consequences of drug instruction non-compliance different? Internat J Consumer Studies. 2013 Mar;37(2):228–233.