Demodex Mites: Normal Inhabitants That Can Get Out of Control
Demodex Mites Are Found on Everyone
This is meant to be a nitty gritty review of human Demodex and disease associated with it. It is hard for folks to find information on this issue and I am in the process of writing up a detailed examination of Demodex. In the meantime I have written up this brief review hoping it will be helpful. Let me know what additional data you need.
I should start by saying that demodex is found on 100% of people when they test for DNA of demodex on the human skin. It is considered to be a natural part of our skin microbiome. However, it is also thought by many to get out of control and cause issues in a variety of skin conditions.
Itching May Be Due to Demodex Mites
Is your patient itchy? Do they have acne, acne rosacea, blepharitis (itching of the eyelash area), pityriasis folliculorum, eye brow or hair loss, pustular folliculitis, papulopustular scalp eruptions, perioral dermatitis, seborrheic dermatitis, other types of pustular eruptions? These conditions and others have been associated with a body mite called Demodex. (Also associated with a yeast called Malassezia.) When a person has itching and or skin eruptions their skin should be closely looked at. Demodex can be visually seen with a good 10X magnifying lens. Although you may have to instigate their appearance in the day time as they prefer to only come out in the dark.
Conditions Associated With Demodex Mites
Demodex has been reported to be involved in pityriasis folliculorum (Ayres, 1930), rosacea (Ayres and Ayres, 1961; Bonnar et al., 1993; Forton and Seys, 1993), pustular folliculitis (Dong and Duncan, 2006), papulopustular scalp eruptions (Purcell et al., 1986), perioral dermatitis (Hsu et al., 2009), and blepharitis (Post and Juhlin, 1963; Divani et al., 2009; Zhao et al., 2012). It is also suspected that Demodex infestation may be one of the triggering factors of carcinogenesis in eyelid basal cell carcinomas (Erbagci et al., 2003) and sebaceous adenoma (Dhingra et al., 2009). Moreover, the infestation rate in the immunocompromised population with leuco-cythemia (Damian and Rogers, 2003) or acquired immune deficiency syndrome (AIDS) (Clyti et al., 2005) is remarkably high and pustular eruption or seborrheic dermatitis becomes even more suspicious of demodex in this group of people.
Mites Often Ignored By Practitioners
In my speaking to people with health issues related to mites, I find that often they have been to a physician or dermatologist who has simply visually looked at their skin and they have not used magnification or taken skin scrapings to identify these mite related conditions. This may be due to the fact that many physicians do not realize the relationship between mites and the various skin conditions associated with them. Additionally, physicians have been taught that these mites are a normal inhabitant of our skin and only severely immunocompromised individuals would have an issue with them. Although this was the idea in the recent past by the medical establishment, this is an old idea that has worn thin. There is also a cultural bias against ectoparasites. In our culture, body mites are considered a problem of people who live in unsanitary conditions. No one wants to believe they have mites crawling around on their skin. Neither the patient or the physician want to consider mites. Those brave ophthalmologists/dermatologists who are telling their patients that their blepharitis or acne rosacea is related to bugs in their skin are often met with disbelief by their patients. Some patients will leave them to go get a second opinion. If that second opinion Doc does not know about the mite connection they will think the first Doc is crazy or even incompetent. Therefore some dermatologists are purchasing equipment that allows them to photograph these tiny mites and show them to the patient while the patient is being examined. This usually convinces the patient of the issue.
In China the mite issue is well known. They also think these mites have a relationship to general acne and I agree wtih them. Years ago before opthamologists knew about the connection between mites and blepharitis, I was in conversation with an ophthalmologist in Singapore named Dr. Por Yong Ming who uses a 1% ivermectin cream topically and claimes all his blepharitis patients are cured of their itching in one month. He uses a simple, thorough diagnostic technique that allows him to find mites in all of his patients. This bright physician is getting results with all his blepharitis patients as he has realized what the actual cause is. (I originally wrote this article prior to 1% ivermectin being used in this country. As I go through and update this, I would note that in 2016 as I write this, clinical research is being undergone with 1% ivermectin in the United States.)
Meanwhile in the United States, there are some ophthalmologists who have also caught onto the idea that mites are causing most of the blepharitis they see. Some of them have started experimenting with tea tree oil cut 50% with macadamia nut oil to treat their patients and they are getting good results. This also takes about a month to be effective. (Another 2016 update, many patients with bleparitis are being told to use a 5% tea tree and oil mix that they apply to their eye lids to erradicate or keep mites under control.)
For those who want to investigate how to control mites via making their environment inhospitable or outright killing them, there are some things to consider. First, consider what is necessary for healthy skin. Some of the things we need to incorporate into our diet for healthy skin is adequate levels of vitamin A, vitamin D, E, B vitamins, vitamin C, magnesium, zinc, selenium, omega 3 fatty acids (cod liver oil), sulfur (usually from sulfur containing amino acids. Skin also needs an acid mantle and so much more. When I have time I will write an article on healthy skin. I would add though that a healthy diet and lifestyle will go far to supporting healthy skin.
Mites Life Cycle
The reason it takes a month of any kind of therapy to get results is that these mites are hiding in hair follicles, sebaceous glands and meibomian gland (sebaceaus gland in eyelid). They come out to mate in the dark usually and prefer to hide in the light of day. Their life cycle is about 3 weeks, so it makes sense you would need a month to get rid of them completely. The next thing to know about them is that they are not only around the eyes. Some patients need to treat their whole face and even their whole head.
Whole Body Demodex Infection - Demodicosis
There are also patients who are unlucky enough to have whole body demodex mites. These folks often think they have scabies at first, as do some of their physicians. Indeed they are related to scabies, but, unlike scabies they live under the skin most of the time and are harder to kill. They are also harder to transfer from one person to the other athough they do get around just fine with skin to skin contact. Perhaps, people should rethink shaking hands when they meet strangers. They are also hard to find since they usually come out at night. However, I have figured out that you can tease them out by using straight tea tree oil on an area of skin that you think they are inhabiting (because it itches a lot in that location). You use the tea tree oil, wait 5 minutes and put the tea tree oil on the same area again. Use a 10X lens to view the area 1 minute after each application. Try a third application ten minutes later if they still are not showing. By a third application they will come out if in the area. What you see with the lens is similar but different than a hair on the skin. What is sticking out of the skin is their tiny little tails. If you look around the web, you can find some photos of them doing this. Once you get them to poke their tails out or come out all the way, it is easier to take a scraping to examine for mites. Otherwise, you are simply guessing at where to scrape and may never get a positive scraping for the microscopic exam.
Whole body Demodex infestation has been called demodicosis and has been thought to only happen to folks who are immunocompromised. However, I am finding this to be untrue. There are people who get whole body demodex and do not have indications of being immunodeficient. Some people seem to keep the demodex under control with their lifestyle choices or perhaps genetics while others are over-run by them. If a person has itchiness and sees little pimples form and disappear on their body that look like acne pimples the physician should consider demodex mites. They can also use a tea tree/oil combo on the area a couple days in a row and see if pimples appear. As you kill the mites, they die and release toxins form their bodies which causes pimples to appear. For this reason, when treating them, you may see more pimples appear at the beginning of treatment.
Essential Fatty Acids Relationship to The Mites
Why is it that some folks have mites in low numbers and are not bothered while other people are taken over by them? Is it genetics, diet, or environment? Are there types of Demodex that are more pathogenic? Does something cause the normal Demodex to become more pathogenic such as happens to yeast when they morph into their hyphal form? Probably all of these are factors. Research has shown folks with a mite problem have different types of essential fatty acids in their skin. The research I read on Rosacea sufferers and essential fatty acids lead me to using cod liver oil as a base in 50/50 tea tree oil and I liked this mix better than the macadamia oil mix that some Docs have been using. I think peanut oil would also be a good choice if a good unrefined, organic peanut oil was available on the market. Some types of cod liver oil is a little smelly to folks in which case they may want to use a different oil. I would suggest using a nut oil as a base. I have not yet used castor oil, but it might also be beneficial. The one issue with putting so much oil on the skin is that a yeast called Malassezia which may be a commensal of Demodex loves oil and it too can be pathogenic. I believe Malasezzia may be one of the causes of the crawling sensations and itchiness that is seen with Demodex.
Things A Practitioner Should Consider Regarding Control or Removal Of Mites
We want to target the mites but we also want to target possible commensal organisms that are inside or on the exterior of the mites. As the mites enter and exit our skin they take bacteria and fungus from our outside on top of our skin to the interior, under our skin. Additionally they harbor critters inside their own bodies and these critters are released when they die. It is thought that the mites are unable to release excrement as they have no way to remove by-products (such as we do via urine, feces, sweat, respiration) and the by-products build up inside of the mite until they die at which time it is all released. This includes metabolic by-products as well as any bacteria, fungus, virus etc that is inside of them. One of these bacteria living inside of them is called Bacillus oleronius. This bacteria is implicated in causing inflammatory skin reactions associated with Rosacea. It is thought this is why using antibiotics gives Rosacea people relief but does not cure the Rosacea.
When mites are killed people usually experience an acne erruption in the areas they are treating. It is thought that the acne is due to the debris released from these dead mites into the skin. They live their life with no ability to excrete their wastes into the environment. It is not until they die and that their bodies degrade that their wastes are released around them. For this reason when people first start to treat them and notice an increased skin irritation, many people will think what they are doing is making the condition worse. Actually, it is killing the mites often and the worsening of the skin condition is simply a step toward healthier skin. However, be careful how quick you kill off mites. Many mites can live in a small area. (Check out the freaky electron microscope photos of them all packed into small areas.) You can get some intense skin reactions if you kill them with heavy duty essential oils.
Some people have experienced a few days of relief after killing of the mites only to have an even more debilitating skin eruption appear even though the mites are gone. This skin eruption seems to be due to something else the mites were harboring inside of them and is released when they die or it is something such as the skin yeast Malassezia, which is taking advantage of the breakdown of the protective acid skin mantle.
This skin condition that worsens after the mites are killed can be seen at a low level while the mites are alive but when they die there is an increase in their activity and the skin may be taken over with this new affliction. I suggest testing for Malassezia at this point as it may be your culprit. You can do a skin scraping. If you see any areas on the skin that looks like Pityriasis (Tinea) versicolor, scrape that area and check it out for yeast/hyphae.
The fact is that Demodex mites may be associated with untold bacterial, fungal or other hitchhikers. We just don’t know. Research is currently underway but at a snails pace. Since we know demodex is harboring critters that may be the cause of inflammatory reactions, I have decided it is helpful to include nutrients/herbs in the diet that are immunomodulating and that decrease quorum sensing/biofilm formation to keep bacteria, fungus and viruses in check. At the same time most of the herbs used to quench quorum sensing/biofilm formation are also antioxidants and antinflammatory via other mechanisms. The bacteria Bacillus oleronius which has been isolated from demodex mites is sensitive to antibiotics, however using antibiotics may then unleash a malassezia over-production. Using herbs that are antimicrobial, antifungal and immune supportive seems to be a better alternative than antibiotics.
If your patient has blepharitis or any other skin disease associated with mites consider demodex. They may have itching, crawling sensations on the face, scalp or other parts of the body. The pores on the nose, forehead, chin and cheeks may be visibly larger. There may be a tickling sensation on the lower nose, around the mouth, and forehead. This is especially felt at night. I personally think this tickling may be from the yeast Malassezia that I think is associated with Demodex mites. You may also see pustular papular rosacea with damaged capillaries and thickening of the nose. The person may have thinning of the eyebrows or may be loosing eyelashes. They may have sores on their head or dandruff. They may also be loosing hair if they have had Demodex for awhile. They may have evidence of systemic inflammation such as arthritic symptoms that I believe is a reaction to the mites or commensals of the mites. They may also complain of other inflammatory problems such as digestive problems and even cognitive issues.
If you think you have a patient that has Demodex mites, you can take a deep skin scraping to find them. You an see the mites with a good 10X magnifying glass in the skin if you tease them out with tea tree oil. It usually works best to put some diulted tea tree oil on the skin and wait for 5 minutes and apply again. Wait a couple minutes and look. Be aware it is hard to find them and see them. You have to purchase a high quality hand lens to see them. The one I have is made by Baush and Lomb and is good quality. In the past, the best test to do was to get a deep skin scraping and check it out under a microscope. Some plain oil on the skin and a deep scraping in a really itchy skin area will usually produce the mites. This is best viewed with a traditional microscope under a 40x microscope lens. For more detail use a stronger lens. However, now the new method is to apply a little distilled water to the site and scrape the skin with a scalpel. The skin above the site should be pulled up with one hand and the scalpel edge moved across the edge of the lesion with the other. This is viewed with a 20% potassium hydroxide mount. Recent 2016 article said " Potassium hydroxide preparation of skin scrapings is an effective, time saving and practical technique to detect Demodex mites with accuracy comparable to the standard biopsy method."
Since it is considered normal to have some demodex in the skin, demodicosis is the diagnosis only when the number of mites exceeds 5 individual mites in 1 cm squared of skin surface. This is hard to ID, so you have to account for the test results and clinical symptoms to make a decision.
You usually don't see the mites as they spend all their time in the sebaceous glands or at the base of hairs. However, if you see a new papule (pimple like) on the skin, put tea tree oil on the area and look at it again in 3-5 minutes they will usually stick their tale out. If not, put another dab of tea tree oil on the area and look again in another 5 minutes. Dermatologists look at these mites under slit lamp microscopes and claim the black hair like things that you see coming out of the papules is the tale end of them. They are hard to catch but I have caught site of them. Usually you see one come out and then a second and third may also appear. I have only watched long enough to see an entire body emerge once. If you do a skin scraping you can seen them under the microscope using 40X. Generally, if a person is bothered by them you will find quite a few of them having a party.
My observations have lead me to believe it may be possible for interspecies exchange of mites when people are continually in close quarters with animals that harbor mites. I suggest you ask if they have animals in their house or have farm animals. Sometimes you will find the person has a mangy or super itchy animal at home. Although, it is thought that demodex is species specific there are cases in the literature of animals and humans sharing demodex mites and I have seen it as well as experienced it. I think it is more common than we realize. What we think is not real is often ignored. If they do have a mangy or itchy animal around and the animal is not treated, they may simply get the mites back again.
Dogs will sometimes spontaneously recover from demodex mites and I believe the same can happen with people. The mites are still there but have decreased in number and the person or animal is now able to ignore them or may not even notice them any more.
Support the “elan vital” – the vital energy or inherent vitality of the individual (This is at the basis of all naturopathic medicine.)
Kill Mites and any problem commensal organisms of the mite, Support Acid mantle of skin/skin integrity/normal microflora, Modulate the inflammatory response / Immunomodulation, Enhance the neuroendocrine system, watch for other pathogens as a result of decreased skin integrity or as a result of treatment of mites.
Supporting the microbiome of the gut helps support the skin. Probiotics can restore acidic skin pH, alleviate oxidative stress, attenuate photoaging, improve skin barrier function, and enhance hair quality. (Sharma, Kober, Bowe, 2016)
NEVER GIVE CORTICOSTEROIDS TO THESE PATIENTS. You need to support this persons immune system, not decrease it from working. Check out their stress level. Stress means more cortisol, less immune reaction and means mites can party more.
With both external and internal parasites it is important to consider the environment they are living in. It is important to make it inhospitable to them. This can be done by making sure the person harboring them is in tip-top condition as well as introducing natures building blocks that are inhospitable to them and their activities.
A healthy diet, free of genetically modified food, and all organic, is very important. The diet should consist of a lot of fresh green leafy vegetables and brightly colored vegetables and fruits. It is important to get the nutrients necessary for your body to thrive. Herbs and foods high in polyphenols are useful. It is absolutely necessary to make sure your gut microbes are happy and healthy. They can make or break you. Making sure the person who has mites in in an environment without other stressors such as high EMF load, heavy metal toxicity, mycotoxins, unsafe drinking water, polluted air. All of these things add to a stress load on the body and keep the body so busy dealing with these things that it is hard for it to muster a response to mites or other parasites. So, if any of these stressors are an issue, make sure they are dealt with in the beginning.
You probably know that the immune system is important in keeping mites at bay. The better it functions, the better your body is able to keep mites at bay. However, people with healthy immune systems have also had issues with mites. I would suggest that you support your immune system and make sure any other issues that may effect your immune system negatively are dealt with. The idea is to make yourself as healthy as possible.
Dealing With Mites Head On
If you want to see how hard it is to kill demodex mites, check out vet data on how to kill them in dogs. You will see it is a long drawn out process that uses toxic substances. There is not as much research or case histories on people and demodex as it has not really been acknowledged until recently. In the past people with demodicosis have often been told they are delusional parasitosis and were put on psychotropic drugs. The only cases seen in the literature were of immunocompromised people who had demodicosis and treated with mixes of ivermectin and/permethrin. Now you can find both animal and human cases of non-immunocompromised cases of Demodicosis in the literature. However, there are not many.
To help with itching: Mint generally helps with all itching. However it only helps with inflammatory induced itching. It will not relieve the sensation of movement of the mites or other critters the mites associate with. It will relieve inflammation associated with them. However, menthol in the mint that helps to relieve itching also kills mites which causes increased itching, so be aware of this circular situation.
NF-Kappa B is an inflammatory agent that increases with demodex mite invasion and there are herbs that can lower it. Decreasing this inflammatory agent can help stop an inflammatory cascade that can induce itching and irritation. The herbs and supplements that lower NF-Kappa B are Scutellaria baicalensis, Curcuma long and it's constituent curcumin, Vitamin D, Andrographis paniculata and it's constituent andrograpolide, Withania somnifera and it's constituent withaferin A, Tribulus terestris, Angelica sinensis and it's constituent ligustilide, Salvia miltiorrhiza and its constituent salvianolic acid B, Commiphora mukul and its cosntituent guggulsterone, Camellia sinensis and it's constituent (-)-epigallocatechin-3-gallate, any herb with berberine such as Hydrastis canadensis, Berberis spp., Coptis chinensis.
Tea tree oil & other essential oils: Tea tree essential oil has been used both neet (not mixed with anything) and mixed with a fixed oil. It is usually mixed with a fixed oil 50/50. You will see it used topically for facial/eyelash mites. It has been found that 50% tea tree oil mixed with oil is generally adequate. Additionally, tea tree shampoo is used to wash the hair. See the link below for the specific protocol that is used. The use of tea tree oil is only possible for people with mites localized to the face region as seen in Rosacea. For folks with them on other parts of their body, full body tea tree oil is overwhelming and there is the concern of toxicity. However some have used it full body for one to two weeks. I don't know of anyone using it long enough to kill them off completely as the toxicity stops people from using it. It is notable that some people are sensitive to tea tree oil also and it may not be appropriate for everyone or for long term application. There is good research on the use of tea tree for blepharitis caused by demodex mites. A product containing tea tree oil called Cliradex is on the market now.
This first article is on the incidence of demodex in blepharitis and the following articels are on the use of tea tree oil for ocular demodex infestations. There are many more research articles you can find on pubmed. This is just a few.
Lavender helps and I like to use it for a few days and then use tea tree oil for a few days in hard to treat areas with lots of mites. Lemon grass is good but can burn the skin terribly. It has to be diluted enough to decrease the irritation. All essential oils can be toxic to the nervous system if used to much, so only trained practitioners should use these with their patients. Many essential oils are helpful. You will find a research article below on Salvia and Peppermint use to kill demodex mites.
People have used a lot of things to kill mites and most of them do not work. One of the keys is that whatever is used has to actually get to the mite which is hiding under your skin or you have to stop them from breeding. They live under the skin and come up on top of the skin to breed at night. People have used whole body mustard plasters, whole body cayenne, whole body tea tree, whole body neem etc. Some people claim they have had success getting rid of them by using some of these items relentlessly for a month or more. Unfortunately, essential oils used full body can become neuro-toxic very fast so people can't use them long enough for demodicosis to kill the mites. So, although you might kill mites if you could do it for a few weeks, you may not survive the treatment. I don't suggest using full body tea tree oil ever. Using tea tree oil mixed in a fixed oil on the eyebrows and eyelashes while using tea tree oil shampoo on the scalp and face is one thing. Using a strong tea tree/fixed oil mix full body multiple times per day is just crazy. Unfortunately, feeling bugs crawling on you can make you crazy enough to try such things.You can find the directions for using tea tree oil for facial/head/blepharitis Demodex caused problems in dermatological research on the web. I suggest you consider this for patients with blepharitis and papulopustular Rosacea.
Some people find they can use diluted essential oils in one of the worst areas of their body first such as their face (essential oil diulted with fixed oil) and head (shampoo with essential oil). Then when these areas are under control, they will move downward to the next area. It will usually take them a few weeks to get the first area under control and then they can discontinue that area and move down to neck and back or neck and chest etc. They will usually need to reapply on the head again off and on as maintenance but the mites will be mild compared to what they were before. Some people have been able to get rid of their mites in this slow progressive fashion without causing damage from excessive use of essential oils, however I would warn folks that this can be risky if you do not know what you are doing.
There are a variety of dog related shampoo products for mites and itching that many people end up using with positive results. I would again advise caution and reading the labels very carefully. The Edgar Cayce Foundation has a good Tar shampoo made for people that some folks find useful in conjunction with tea tree shampoo.
Permethrin cream: This has been used topically to kill whole body mites (demodicosis), but so far I don't know of anyone using it by itself that has been able to eradicate them as like the essential oils it is nasty to use long term. It has been used in conjunction with ivermectin internally and this has seemingly eradicated them. Remember they are not on top of the skin. They need a moist environment and can not live for long outside of the body. In labs they find their ability to live off the body is measured in hours, and usually not many hours. They seem to last better if on a wet rag. Permethrin is nasty and not something that is good to put on your body or your animals body.
Ivermectin: Ivermectin used for Demodex is completely off label. This information as with all information on this website is educational only. Ivermectin appears to work when the correct dose and the correct length of time is reached. However, it has the potential to be toxic also. I am not sure if the reactions people are having is due to die off of the mites or the drug itself. It appears to be both. A physician using this is using it off label and better be watching for side effects in their patient. They better know what those side effects are in advance. In my opinion, physicians deciding to use this drug should monitor the patients liver and kidneys for damage from the drug or die off of the mites and their associated pathogens causing a toxin load reaction. There is the possibility for liver damage from ivermectin in the literature. Cases I read about have used anywhere from one single dose of ivermectin to many doses over a 2-3 week period. When used in one dose, it is usually used in conjunction with permethrin which is used externally. I have observed ivermectin clearing demodex when nothing else relieved it. It took 19 days of a staggered course of ivermectin use. The research on how much and when to give ivermectin is not perfect. Additionally, with those patients who relapse months later, you have to wonder if they still had some mites that took awhile to grow out of control or if they were reinnoculated by a family member, or family dog. We really need this researched to understand it better.
There is now1% ivermectin cream available and it is working better than topical metronidazole which has also been used but both metronidazole and ivermectin have a 36 week relapse rate of 62.7% for ivermectin and 68.4% for metronidazole after disconinuing the treatment. . (From 2018 data as I rewrite this)
The oral dose given at http://www.skintherapyletter.com/fp/2008/4.4/3.html for demodex induced folliculitis is to use topical metronidazole or permethrin. Oral ivermectin 0.2mg/kg q.wk. for 2-4 weeks may help in more extensive or resistant cases.
Here is a dosing chart off of medscape for ivermectin which includes use for off label use of ivermectin in blepharitis. This link will only be visible to those Docs who have a medscape account. (It is free, just sign up. You can get free CE here too.)
If you have decided to use Ivermectin on a patient I suggest you not only read the drug insert but also read this article on Ivermectin toxicity in rats.: https://www.jstage.jst.go.jp/article/jvms/73/5/73_10-0424/_pdf
This is a good review article of ivermectin I would suggest you read also.
Besides watching the patient closely and getting labs, giving them milk thistle (1-2 T per day of ground seed) to protect their liver/kidneys and aid general transformation/detox. I also suggest turmeric (2 teaspoons per day or two caps of Meriva by Emerson) which also protects the liver and is a great anti-inflammatory.
When you kill off the mites, remember they harbor other organisms and will release them. Your patient can react to them. I believe that either the mites or other commensal organisms related to them can cause a rheumatoid arthritis picture in people that may disappear upon treatment. I suggest you also read about Malassezia. What many people note when they kill mites is that they get acne in the area where they are killing them. Some people think the acne is a response to the release of toxins from dead mites.
Here is the really sucky part of this. Many people get reinfected while treating themselves or after treatment is over. Many people have mites and shaking the hand of a person with mites or other body contact (Do you get massages?) can give you mites again. Contrary to what mainstream medicine believes, you can get mites from other animals. People with dogs who can't get rid of their mites should try treating the dogs at the same time. There are many shampoos that can be used to keep mites under control in dogs. Sometimes your spouse needs to be treated for mites even if they don't notice any issues. Not everyone reacts to mites. Some people do not react at all while others are driven crazy by them. When you can't seem to get rid of them, look to the people and animals in your environment.
Articles of Interest
Rosacea is a chronic inflammatory skin disease with different phenotypes. There is accumulating evidence that the commensal Demodex mite is linked to papulopustular rosacea. Established treatment options, including topical metronidazole, azelaic acid, and tetracyclines, are thought to work through their anti-inflammatory effects. However, none of these therapies have been shown to be curative and are associated with frequent relapses. Therefore, new and improved treatment options are needed. Topical ivermectin 1.0% cream is a new option having both anti-inflammatory and acaricidal activity against Demodex mites which might pave the way to a more etiologic approach. Its use has now been widely adopted by clinical guidelines. The objective was to review the evidence and clinical guideline recommendations concerning ivermectin 1.0% cream in the treatment of papulopustular rosacea.
METHODS:A systematic review of both medical literature and clinical guideline recommendations was conducted. Numbers needed to treat (NNT) were calculated for relevant dichotomous outcomes (e.g., relapse rate and achieving full lesion clearance) to compare ivermectin with other established treatment options for rosacea.
RESULTS:The search identified three randomized trials, three extension studies, and two meta-analyses. Ivermectin has only been tested in moderate-to-severe papulopustular rosacea. Ivermectin is an effective treatment option for papulopustular rosacea and seems to be more effective than metronidazole (NNT = 10.5) at 12 weeks of treatment. Although ivermectin was numerically more effective than metronidazole at week 36 in preventing relapse (NNT = 17.5), relapse after discontinuation of treatment in both groups was common with 62.7% and 68.4% of patients relapsing. Based on limited generalizability of available evidence, clinical guidelines have yielded different treatment algorithms and, in some areas, conflicting recommendations.
CONCLUSION:Topical ivermectin is an effective option in the treatment of papulopustular rosacea. Although ivermectin seems to be more effective than topical metronidazole, with both treatment options about two-thirds of patient relapsed within 36 weeks after discontinuation of treatment. More research is needed to establish the clinical benefit of ivermectin's acaricidal action in preventing relapse compared to other non-etiologic treatment approaches.
Exp Ther Med. 2015 Apr;9(4):1304-1308. Epub 2015 Feb 6.
Volatile oils of Chinese crude medicines exhibit antiparasitic activity against human Demodex with no adverse effects in vivo.
Liu JX1, Sun YH1, Li CP2.
Demodex is a type of permanent obligatory parasite, which can be found on the human body surface. Currently, drugs targeting Demodex usually result in adverse effects and have a poor therapeutic effect. Thus, the aim of the present study was to investigate the use of Chinese crude medicine volatile oils for targeting and inhibiting Demodex in vitro. The volatile oils of six Chinese crude medicines were investigated, including clove, orange fruit, Manchurian wildginger, cinnamon bark, Rhizome Alpiniae Officinarum and pricklyash peel, which were extracted using a distillation method. The exercise status of Demodex folliculorum and Demodex brevis and the antiparasitic effects of the volatile oils against the two species were observed using microscopy. A skin irritation test was used to examine the irritation intensity of the volatile oils. In addition, an acute toxicity test was utilized to observe the toxicity effects of the volatile oils on the skin. Xin Fumanling ointment was employed as a positive control to identify the therapeutic effects of the volatile oils. The results indicated that all six volatile oils were able to kill Demodex efficiently. In particular, the clove volatile oil was effective in inducing optimized anti-Demodex activity. The lethal times of the volatile oils were significantly decreased compared with the Xin Fumanling ointment (P<0.05). Furthermore, the skin irritation test results indicated that the clove volatile oil did not trigger any irritation (0.2 and 0.3 points for intact and scratched skin, respectively), and had a safety equal to that of distilled water. There were not any adverse effects observed following application of the clove volatile oil on the intact or scratched skin. In conclusion, the volatile oils of Chinese crude medicines, particularly that of clove, demonstrated an evident anti-Demodex activity and were able to kill Demodex effectively and safely in vivo.
Hautarzt. 2015 Mar;66(3):189-94. doi: 10.1007/s00105-015-3595-z.
[Primary human demodicosis. A disease sui generis].
[Article in German]
Hsu CK1, Zink A, Wei KJ, Dzika E, Plewig G, Chen W.
Human Demodex mites (Demodex folliculorum and Demodex brevis) are unique in that they are an obligate human ectoparasite that can inhabit the pilosebaceous unit lifelong without causing obvious host immune response in most cases. The mode of symbiosis between humans and human Demodex mites is unclear, while the pathogenicity of human Demodex mites in many inflammatory skin diseases is now better understood. Primary human demodicosis is a skin disease sui generis not associated with local or systemic immunosuppression. Diagnosis is often underestimated and differentiation from folliculitis, papulopustular rosacea and perioral dermatitis is not always straightforward. Dependent on the morphology and degree of inflammation, the clinical manifestations can be classified into spinulate, papulopustular, nodulocystic, crustic and fulminant demodicosis. Therapy success can be achieved only with acaricides/arachidicides. The effective doses, optimal regimen and antimicrobial resistance remain to be determined.
PMID: 25744530 [PubMed - indexed for MEDLINE]
Journal Bacteriology & Parisitology, 2015, 6:3
Impact of Salvia and Peppermint Oil on the In Vitro Survival of Demodex Mites.
Aleksandra Sedzikowska, et. al.,
Demodicosis is a medical condition caused by presence of Demodex mites. Mites may cause ocular demodicosis with symptoms such as burning and itching of eyelids. Currently, several drugs are available for the treatment of demodicosis. However, their use carries a risk of serious side effects. According to recent studies, substances contained in some plant-derived essential oils kill Demodex mites. Good efficacy of tea tree oil against Demodex sp. has been reported. However, some patients develop allergic reactions and ocular irritation in the course of tea tree oil treatment. Tests with essential oils showed that salvia and peppermint oils rapidly kill Demodex-in 7 and 11 minutes, respectively. Salvia is known as a valuable herb and is used to treat eye disease. Therefore, salvia essential oil could be an alternative treatment for demodicosis.
Article on Open Acess Here
Clin Cosmet Investig Dermatol. 2016; 9: 71–77.
Published online 2016 Mar 18. doi: 10.2147/CCID.S98091
New developments in the treatment of rosacea – role of once-daily ivermectin cream
Leah A Cardwell, Hossein Alinia1 Sara Moradi Tuchayi1 and Steven R Feldman
Rosacea is a chronic dermatological disorder with a variety of clinical manifestations localized largely to the central face. The unclear etiology of rosacea fosters therapeutic difficulty; however, subtle clinical improvement with pharmacologic treatments of various drug categories suggests a multifactorial etiology of the disease. Factors that may contribute to disease pathogenesis include immune abnormality, vascular abnormality, neurogenic dysregulation, presence of cutaneous microorganisms, UV damage, and skin barrier dysfunction. The role of ivermectin in the treatment of rosacea may be as an anti-inflammatory and anti-parasitic agent targeting Demodex mites. In comparing topical ivermectin and metronidazole, ivermectin was more effective; this treatment modality boasted more improved quality of life, reduced lesion counts, and more favorable participant and physician assessment of disease severity. Patients who received ivermectin 1% cream had an acceptable safety profile. Ivermectin is efficacious in decreasing inflammatory lesion counts and erythema.
Parasitology. 2015 Aug;142(9):1152-62. doi: 10.1017/S0031182015000530. Epub 2015 May 25.
Symbiosis in an overlooked microcosm: a systematic review of the bacterial flora of mites.
Chaisiri K1, McGarry JW2, Morand S3, Makepeace BL1.
A dataset of bacterial diversity found in mites was compiled from 193 publications (from 1964 to January 2015). A total of 143 mite species belonging to the 3 orders (Mesostigmata, Sarcoptiformes and Trombidiformes) were recorded and found to be associated with approximately 150 bacteria species (in 85 genera, 51 families, 25 orders and 7 phyla). From the literature, the intracellular symbiont Cardinium, the scrub typhus agent Orientia, and Wolbachia (the most prevalent symbiont of arthropods) were the dominant mite-associated bacteria, with approximately 30 mite species infected each. Moreover, a number of bacteria of medical and veterinary importance were also reported from mites, including species from the genera Rickettsia, Anaplasma, Bartonella, Francisella, Coxiella, Borrelia, Salmonella, Erysipelothrix and Serratia. Significant differences in bacterial infection patterns among mite taxa were identified. These data will not only be useful for raising awareness of the potential for mites to transmit disease, but also enable a deeper understanding of the relationship of symbionts with their arthropod hosts, and may facilitate the development of intervention tools for disease vector control. This review provides a comprehensive overview of mite-associated bacteria and is a valuable reference database for future research on mites of agricultural, veterinary and/or medical importance.
Acari; Cardinium; Rickettsiales; Symbionts; allergy; microbiota
PMID: 26004817 [PubMed - in process]
Vet Parasitol. 2016 Mar 4. pii: S0304-4017(16)30050-4. doi: 10.1016/j.vetpar.2016.02.027. [Epub ahead of print]
Efficacy of sarolaner, a novel oral isoxazoline, against two common mite infestations in dogs: Demodex spp. and Otodectes cynotis.
Six RH1, Becskei C2, Mazaleski MM3, Fourie JJ4, Mahabir SP3, Myers MR3, Slootmans N2.
The efficacy of sarolaner (Simparica™, Zoetis) was evaluated against Demodex spp. in dogs with generalized demodicosis and against Otodectes cynotis (otodectic mange) in dogs with induced infestations. In the first study, 16 dogs with clinical signs of generalized demodicosis and positive for Demodex spp. mites were randomly assigned to treatment with either sarolaner (2mg/kg) orally on Days 0, 30 and 60, or topical imidacloprid (10mg/kg) plus moxidectin (2.5mg/kg) solution every 7 days from Day 0 to Day 81. For sarolaner-treated dogs, pretreatment mite counts were reduced by 97.1% at 14days and 99.8% by 29 days after the first dose, with no live mites detected thereafter. Weekly imidacloprid plus moxidectin resulted in 84.4 and 95.6% reduction at these two time points, respectively, with no mites detected from Day 74 on. All dogs in both groups showed marked improvement in the clinical signs of demodicosis. In the second study, 32 dogs with induced infestations of O. cynotis were randomly assigned (eight per group) to oral sarolaner (2mg/kg) as a single treatment on Day 0 or as a two dose regime (Days 0 and 30), or a placebo group for each of the dose regimes. Sarolaner administered at 2mg/kg as a single oral dose resulted in a 98.2% reduction at Day 30 and two doses of sarolaner, administered one month apart, resulted in a 99.5% reduction in ear mites at Day 60 compared to placebo controls. There were no treatment related adverse events in either study. In these studies, sarolaner at an oral dose of 2mg/kg was highly effective in reducing the live mite counts associated with a natural infestation of Demodex spp. and an induced infestation of O. cynotis. In addition, the Demodex-infested dogs showed a marked improvement in the clinical signs of generalized demodicosis.
Copyright © 2016. Published by Elsevier B.V.
Demodex spp.; Demodicosis; Dog; Ear mites; Mange; Oral; Otoacariasis; Sarolaner
Int J Infect Dis. 2014 Dec;29:176-7. doi: 10.1016/j.ijid.2014.07.021. Epub 2014 Oct 24.
Bartonella quintana detection in Demodex from erythematotelangiectatic rosacea patients.
Murillo N1, Mediannikov O1, Aubert J2, Raoult D3.
We report here the presence of Bartonella quintana in a demodex. Demodex are arthropods associated with acnea. Bartonella quintana was found by broad Spectrum 16rDNA PCR amplification and sequencing, and confirmed by specific PCR. Bartonella quintana may parasite several arthropods and not only lice.
Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Bartonella quintana; Demodex; Rosacea
J Drugs Dermatol. 2016 Mar 1;15(3):325-32.
Over 25 Years of Clinical Experience With Ivermectin: An Overview of Safety for an Increasing Number of Indications.
Kircik LH, Del Rosso JQ, Layton AM, Schauber J.
Although the broad-spectrum anti-parasitic effects of the avermectin derivative ivermectin are well documented, its anti-inflammatory activity has only recently been demonstrated. For over 25 years, ivermectin has been used to treat parasitic infections in mammals, with a good safety profile that may be attributed to its high affinity to invertebrate neuronal ion channels and its inability to cross the blood-brain barrier in humans and other mammals. Numerous studies report low rates of adverse events, as an oral treatment for parasitic infections, scabies and head lice. Ivermectin has been used off-label to treat diseases associated with <em>Demodex</em> mites, such as blepharitis and demodicidosis. New evidence has linked <em>Demodex</em> mites to rosacea, a chronic inflammatory disease. Ivermectin has recently received FDA and EU approval for the treatment of adult patients with inflammatory lesions of rosacea, a disease in which this agent has been shown to be well tolerated. After more than 25 years of use, ivermectin continues to provide a high margin of safety for a growing number of indications based on its anti-parasitic and anti-inflammatory activities. <br /><br /> <em>J Drugs Dermatol. </em>2016;15(3):325-332.
PMID: 26954318 [PubMed - in process]
Indian J Dermatol Venereol Leprol. 2016 Feb 9. doi: 10.4103/0378-6323.174423. [Epub ahead of print]
Skin scrapings versus standardized skin surface biopsy to detect Demodex mites in patients with facial erythema of uncertain cause - a comparative study.
Bunyaratavej S, Rujitharanawong C, Kasemsarn P, Boonchai W, Muanprasert C, Matthapan L, Leeyaphan C1.
Standardized skin surface biopsy (SSSB) is considered to be the gold standard technique to evaluate the density of Demodex mites for the diagnosis of demodicidosis. Potassium hydroxide (KOH) preparation of skin scrapings is a much simpler procedure that can be used to detect pathogens in the superficial skin.
To evaluate the reliability of potassium hydroxide preparation of skin scrapings as compared to the standard skin biopsy technique with regard to capacity to detect Demodex mites, time consumed and technician satisfaction.
One hundred outpatients presenting with facial erythema of uncertain cause were enrolled. Standardized skin surface biopsy and potassium hydroxide preparation of skin scrapings were undertaken in adjacent areas on the patients' right cheek.
Patients with normal facial skin were excluded from the study.
The accuracy of Demodex mite detection by potassium hydroxide preparation of skin-scrapings when compared to the standard procedure is 82%. The sensitivity, specificity, positive and negative predictive values of this method are 75%, 84.2%, 60% and 91.43%, respectively. There was no statistically significant difference between the standard and skin scraping techniques (P = 0.238) with regard to mite detection. Mean preparation time while using the skin scraping technique was 6 times less than that of the standard technique. For interpretation also, skin scraping technique (3.6 min) consumed much less time than the biopsy technique (9.8 min). Moreover, experienced technicians were more satisfied with skin scraping.
Potassium hydroxide preparation of skin scrapings is an effective, time saving and practical technique to detect Demodex mites with accuracy comparable to the standard biopsy method.
J Eur Acad Dermatol Venereol. 2015 Dec 23. doi: 10.1111/jdv.13517. [Epub ahead of print]
Study of Demodex mites: Challenges and Solutions.
Lacey N1, Russell-Hallinan A1, Powell FC1.
Demodex mites are the largest and most complex organisms of the skin microflora. How they interact with the innate and adaptive immune systems is unknown. Their potential to have a pathogenic role in the causation of human skin disorders causes continued speculation. With growing interest in the microflora of human skin and its relevance to cutaneous health, the role of Demodex mites needs to be better understood. The main challenges facing scientists investigating the role of these organisms and possible solutions are reviewed under the following headings: (1) Determining the mite population in skin, (2) Transporting, extracting and imaging live mites, (3) Maintaining mites viable ex vivo and (4) Establishing methods to determine the immune response to Demodex mites and their internal contents.
© 2015 European Academy of Dermatology and Venereology.
Acta Parasitol. 2015 Dec;60(4):777-83. doi: 10.1515/ap-2015-0110.
Demodex mites as potential etiological factor in chalazion - a study in Poland.
Tarkowski W, Owczy?ska M, B?aszczyk-Tyszka A, M?ocicki D.
The aim of the study was to investigate the presence of Demodex in the hair follicles of eyelashes and their potential participation in the aetiology of chalazion in patients in Poland. The study of the correlation between the presence of Demodex spp. and chalazion has never been performed in patients in Europe. There is, therefore, a justified necessity to check whether Demodex mites can be a potential risk factor in the development of chalazion in the European population. The samples were examined by light microscope, using standard parasitological methods. A positive result was assumed in the presence of Demodex spp. Demodex was detected in 91.67% of patients with a chalazion. The presence of Demodex was found in subjects from all examined age groups. The results of statistical analysis unambiguously determined the existence of an interrelationship between the presence of Demodex and chalazion. Our results clearly indicate the existence of a correlation between the occurrence of Demodex spp. and chalazion. Confirmation of the positive correlation between Demodex and chalazion in a European population provides further evidence for the pathogenic role of Demodex in the development of eye diseases.
PMID: 26408604 [PubMed - in process]
Biomed Res Int. 2015;2015:259109. doi: 10.1155/2015/259109. Epub 2015 Jul 21.
Demodex sp. as a Potential Cause of the Abandonment of Soft Contact Lenses by Their Existing Users.
Tarkowski W1, Moneta-Wielgo? J2, M?ocicki D3.
Demodex mites may be a potential etiological factor in the development of various eye and skin disorders. The aim of the study was to investigate the presence of Demodex in the hair follicles of eyelashes and their potential influence on abandoning soft contact lenses which had been previously well tolerated by their users. A group of 62 users of contact lenses (28 with emerging discomfort and 34 without discomfort) were examined. There is a need to check the existence of a relationship between D. folliculorum or/and D. brevis infestation and the emergence of intolerance to the presence of soft contact lenses. The removed lashes were examined under light microscopy, applying standard parasitological methods if demodicosis is suspected. A positive result was assumed if at least one adult stage, larva, protonymph/nymph, or egg of D. folliculorum and/or D. brevis was present. A positive correlation was observed between the presence of Demodex and intolerance to contact lenses by their existing users (p < 0.05), and Demodex sp. infections were observed in 92.86% of patients with intolerance to contact lenses. Our results provide further evidence for the pathogenic role played by the mites in the development of eye diseases.
Drugs. 2015 Jul;75(11):1177-85. doi: 10.1007/s40265-015-0432-8.
Current and Emerging Therapeutic Strategies for the Treatment of Meibomian Gland Dysfunction (MGD).
Thode AR1, Latkany RA.
Meibomian gland (MG) dysfunction (MGD) is a multifactorial, chronic condition of the eyelids, leading to eye irritation, inflammation and ocular surface disease. Initial conservative therapy often includes a combination of warm compresses in addition to baby shampoo or eyelid wipes. The practice of lid hygiene dates back to the 1950s, when selenium sulfide-based shampoo was first used to treat seborrhoeic dermatitis of the eyelids. Today, tear-free baby shampoo has replaced dandruff shampoo for MGD treatment and offers symptom relief in selected patients. However, many will not achieve significant improvement on this therapy alone; some may even develop an allergy to the added dyes and fragrances in these products. Other manual and mechanical techniques to treat MGD include MG expression and massage, MG probing and LipiFlow(®). While potentially effective in patients with moderate MGD, these procedures are more invasive and may be cost prohibitive. Pharmacological treatments are another course of action. Supplements rich in omega-3 fatty acids have been shown to improve both MGD and dry eye symptoms. Tea tree oil, specifically the terpenin-4-ol component, is especially effective in treating MGD associated with Demodex mites. Topical antibiotics, such as azithromycin, or systemic antibiotics, such as doxycycline or azithromycin, can improve MGD symptoms both by altering the ocular flora and through anti-inflammatory mechanisms. Addressing and treating concurrent ocular allergy is integral to symptom management. Topical N-acetylcysteine and topical cyclosporine can both be effective therapeutic adjuncts in patients with concurrent dry eye. A short course of topical steroid may be used in some severe cases, with monitoring for steroid-induced glaucoma and cataracts. While the standard method to treat MGD is simply warm compresses and baby shampoo, a more tailored approach to address the multiple aetiologies of the disease is suggested.
G Ital Dermatol Venereol. 2016 Feb 18. [Epub ahead of print]
Etiopathogenesis of rosacea: a prospective study with a three-year follow-up.
Agnoletti AF1, DE Col E, Parodi A, Schiavetti I, Savarino V, Rebora A, Paolino S, Cozzani E, Drago F.
To assess the role of Demodex folliculorum (DF), Helicobacter pylori (HP) small intestinal bacterial overgrowth (SIBO) in rosacea development and maintenance.
A case-control study including 60 patients with rosacea and 40 healthy controls was performed. All the patients underwent standardised skin surface biopsy to investigate DF, Urea breath test for HP and lactulose breath test and glucose breath test for SIBO. Etiological therapy was started in the following order: acaricidal treatment, antibiotics for SIBO and HP. These exams were repeated after 3 years. Statistical analysis was performed.
As regards the 88 patients who completed the entire follow-up, DF positivity was found in the 47.7%, SIBO in the 25.0% and HP in the 21.6%. SIBO significantly prevailed in papulopustular rosacea, while HP in erythrosis. At the 6-month follow up, the 61% of patients were in remission. After 3 years the 18% dropped out, the remaining patients repeated all the investigations. The majority of patients were still in remission and negative for HP while only 5 were positive for DF and 4 for SIBO.
SIBO was the most relevant factor in papulopustular rosacea. Its treatment was crucial in improvement and in maintaining the clinical remission.
International Ophthalmology pp 1–10
Demodex species in human ocular disease: new clinicopathological aspects
Stephen G. NichollsCarmen L. OakleyEmail authorAndrea TanBrendan J. Vote
Demodex brevis and Demodex folliculorum are likely ubiquitous organisms associated with human eyelashes. However, they have also been implicated in the pathogenesis of external ocular diseases. This article reviews the current literature in regards to life cycle, morphology, pathogenesis and treatment of underlying Demodex spp. infestation and outlines the previously undescribed in vivo behaviour of the mites. Images were obtained from the epilation of lashes from 404 patients seen in clinical practice. Epilated lashes were placed on a microscope slide which had been coated with optically clear hypromellose/carbomer gel (Genteal gel, Novartis pharmaceuticals corporation, East Hanover, New Jersey). Adults were identified with either dark field or standard transmission microscopy at 40–100×. Eggs and other life-cycle stages were examined at 250× magnification, with transmission microscopy giving the best image resolution. The life cycle of the mite has been reviewed and simplified according to clinical observations. Clinical signs suggestive of underlying Demodex spp. infestation have been described, and their pathogenesis was explained based on the micrographic digital images obtained. The problem of symptomatic Demodex spp. disease likely reflects an imbalance in the external ocular ecology; however, the role of Demodex spp. as a commensal should not be overlooked. Treatment should not be aimed at total eradication of the mite but rather restoring the ocular ecology to a balanced state. By revisiting the life cycle of the mite, we can identify areas where possible intervention may be effective.
J Med Microbiol. 2012 Nov;61(Pt 11):1504-10. Epub 2012 Aug 29.
Potential role of Demodex mites and bacteria in the induction of rosacea.
Rosacea is a common dermatological condition that predominantly affects the central regions of the face. Rosacea affects up to 3?% of the world's population and a number of subtypes are recognized. Rosacea can be treated with a variety of antibiotics (e.g. tetracycline or metronidazole) yet no role for bacteria or microbes in its aetiology has been conclusively established. The density of Demodex mites in the skin of rosacea patients is higher than in controls, suggesting a possible role for these mites in the induction of this condition. In addition, Bacillus oleronius, known to be sensitive to the antibiotics used to treat rosacea, has been isolated from a Demodex mite from a patient with papulopustular rosacea and a potential role for this bacterium in the induction of rosacea has been proposed. Staphylococcus epidermidis has been isolated predominantly from the pustules of rosacea patients but not from unaffected skin and may be transported around the face by Demodex mites. These findings raise the possibility that rosacea is fundamentally a bacterial disease resulting from the over-proliferation of Demodex mites living in skin damaged as a result of adverse weathering, age or the production of sebum with an altered fatty acid content. This review surveys the literature relating to the role of Demodex mites and their associated bacteria in the induction and persistence of rosacea and highlights possible therapeutic options.