Dry Eye Dx and Tx

Baby Shampoo Revisited

Dry Eye Dx and Tx

Baby Shampoo Revisited


Since 1950, practitioners have been prescribing cleaning care of the lid margin with an ever-evolving list of products. Certainly, we can all remember counseling our patients in the use of diluted “tear-free baby shampoo” in heroic efforts to rid the lid of debris, bacterial toxins, and allergenic matter. Baby shampoo, presumed to be the gentlest and safest product to use around the eyes, was the best we had.

The Good and the Bad

The ingredients used to make shampoo look good, smell nice, and foam easily can be harmful to the delicate environmental balance of the ocular surface. Manufacturers have diligently refined products to remove or limit the concentrations of chemicals that may become toxic with chronic application. As an example, in 2014, Johnson & Johnson re-formulated its baby shampoo, removing quaternium-15, a formaldehyde-releasing preservative (Thomas, 2015). However, concerns remain regarding the safety of the newer formulation that contains other chemicals known to cause allergic dermatitis or other adverse effects.

For instance, cocamidopropyl betaine (CABP), a coconut oil-derived surfactant and lathering agent found in many cosmetic and personal hygiene products, remains in the Johnson’s baby shampoo formula; CABP has been associated with contact dermatitis and eyelid dermatitis (Jacob and Amini, 2008). There are, of course, other dyes and fragrance that may also be taxing/stripping/deleterious to the eyelid/eye surface, particularly with daily application.

Current Offerings

Over the past 30 years, products have come to market that are made specifically for cleaning the eye area. Gentle and hygienic, these products are available in a variety of delivery mechanisms, including scrubs, foams, solutions, and wipes.

With an appreciation of the association of Demodex overpopulation to blepharitis, tea tree oil (TTO)-containing cleaners have became available, most notably products that contain purified 4-terpineol, the clinically active ingredient of tea tree oil. TTO, the essential oil derived from the native Melaleuca alternifolia plant, is characterized by 15 major components (Hart et al, 2000). Studies have shown that 4-terpineol (terpinen-4-ol or T4O), is the most important ingredient found in TTO and has even greater miticidal effects than does TTO itself (Tighe et al, 2013).

Lid hygiene has evolved to now include pure hypochlorous acid solution. Hypochlorous acid is a novel lid hygiene maintenance product. Hypochlorous acid is naturally generated in activated neutrophils, and it contributes to the direct destruction of bacteria, provides a blockade of bacteria-associated inflammatory toxins, and inhibits human cell-produced inflammatory mediators (cytokines) (Michaelis et al, 1992). In solution, it is non-sensitizing and oxidizes quickly after application, making it ideal for debulking a microbial load and the associated biofilms from the eyelash base and lid margins. Hypochlorous acid has been demonstrated to inactivate bacterial lipases (Johnson’s baby shampoo has no effect on lipase activity) (Epstein et al, 2015); lipolysis is thought to contribute to the inflammation characteristic of blepharitis. Intuitively, purity and limited, safe, biocompatible ingredients would be the preferred composition, and you should compare product labels when prescribing these.

With the wide range of commercially prepared lid care products available, both over-the-counter and prescription, what benefit is there to recommending products meant for the hair or body? Are the cost savings worth the price of environmental ocular surface challenge? CLS

For references, please visit and click on document #238.

Dr. Mastrota is Program Chair-Elect of the Anterior Segment Section of the American Academy of Optometry. She is a consultant or advisor to Allergan, B+L, BioTissue, NovaBay Pharmaceuticals, and OcuSoft and is a stock shareholder of TearLab Corporation. Contact her at