demodex mites ivermectin effective treatment ?

Demodex mites ivermectin effective treatment ?

From: “Linda Sy MD”
Date: Fri Dec 1, 2000 11:36 am
Subject: Re: [rosacea] Effective treatment ?

Hello Annie,

Welcome. I have just read your message with interest and am impressed with your enthusiasm to share your treatment with the group. You also seem to be committed to your research, what with all the work required, not to mention the liability. You cannot find a more intelligent group to test your treatment plan. Rosacea is an enigma to me and I am sure, to many colleagues. I for one, would be interested in the outcome of your informal study.

Demodex folliculorum has been mentioned as an aggravating factor to rosaceans for many decades and yet, I have not seen any formal double blind study done on this front. (This supports the wisdom of independent research funding by rosaceans). As you have presented, articles have been published, reporting individuals (a number of whom are immunocompromised) who responded to rx of demodex. The rx’s were not cures but nevertheless, afforded some form of control to otherwise refractory situations. I do not think your hypothesis is without merit. As a matter of fact, at the end of this message, I have copied an article reporting a case rx’d successfully with oral Ivermectin & topical Permethrin. Months ago, I sent a copy of this article to a group member with very resistant case of folliculitis.
However, I’m not sure that it is wise to have someone self- treat without the supervision of an attending physician. Luckily, here in the U.S., 5% Permethrin (Elimite Cream) is only available by prescription. I have given this topical medication to many patients for scabies but not for rosacea. Other than a few cases of contact or irritant dermatitis, I have not seen any serious side effects. However, my patients have only used it no more than 2-3 times at most. I don’t know what the side effects of long-term use are; considering the hypersensitivity, easier penetrability (hence, increased absorption) and vascular lability of inflamed rosacean skin. I personally believe demodex mites are incidental parasites that prey on compromised skin causing secondary symptoms, not unlike bacteria & fungi. They are not the primary cause of rosacea. Therefore, I suspect that not all rosaceans have demodex as a relevant factor.

If I may, I would like to offer some suggestions:

1. Limit participants to those who were unresponsive to all the usual treatments.
2. Ask participants to solicit the cooperation and supervision of their respective dermatologists. By that, I mean - if possible, get a KOH skin scraping (a common procedure in a derm’s office) to establish the presence of florid demodex population. There may be some resistance to this but I believe many physicians will have the interest of their patients at heart and the curiousity to find out if this works.(I know of some colleagues who have given this treatment for rosacea). Thus, if there is any acute reaction, a physician is available and responsible to take care of the problem.
3. Participants try the Permethrin on a small area of face first, to determine if any immediate severe problem exists.

Here is the article which appeared in JAAD:

Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream

JAAD, November 1999, part 1 . Volume 41 . Number 5 Christa Forstinger, MD Harald Kittler, MD Michael Binder, MD Vienna, Austria, and Boston, Massachusetts

A 32-year-old man presented with a chronic rosacea-like dermatitis of the facial skin and the eyelids. The skin disorder had been present for 4 years and was unresponsive to multiple previous treatment attempts. Skin scrapings and a histologic examination of a biopsy specimen from the affected area revealed the presence of numerous Demodex mites. The patient was treated with oral ivermectin and subsequent topical permethrin resulting in complete and rapid clearing of the folliculitis. We believe that this case supports the view that Demodex mites may be pathogenic when they are present in large numbers. Oral treatment with 200 µg/kg ivermectin with subsequent weekly topical permethrin showed impressive treatment efficacy in a case refractory to conventional treatment. (J Am Acad Dermatol 1999;41:775-7.)

Demodex folliculorum, a 0.3-mm long Acarus mite, is the most common ectoparasite of man. Because of its ubiquitous nature, infestation with this organism is recognized as a normal occurrence. However, there have been numerous clinical observations linking the presence of Demodex mites at extremely high-density colonization with various skin disorders. Demodex mites have been suggested as the causative agent in rosacea, perioral granulomatous dermatitis, blepharitis, and pustular folliculitis. Demodicidosis has been associated with AIDS and chemotherapy for malignant diseases.

We describe a patient with the clinical and histologic features of demodicidosis, in whom rapid and complete recovery was achieved by a single oral dose of the antiparasitic agent ivermectin and subsequent treatment with topical permethrin cream.

A 32-year-old white man was seen with a 4-year history of a slowly progressive and pruritic facial eruption. Apart from mild seborrheic dermatitis on the scalp, he had no history of skin disease.

Physical examination revealed a diffuse erythema localized on the cheeks, the nose, the forehead, and the glabella. There were scattered 2 to 3 mm erythematous papules and follicular papulopustules with eczematous lesions and scaling. Blepharitis and 3 external chalazions were noted on the upper eyelids (Fig 1, A and B).

The retroauricular region, neck, and chest were not affected. The rest of the physical examination was within normal limits. The patient noted moderate to severe pruritus in the affected regions.

Laboratory findings including routine blood counts and acute phase proteins revealed no abnormalities. Enzyme-linked immunosorbent assay for HIV was negative. A skin test for recall antigens was positive for several antigens.

A 10% potassium hydroxide preparation of skin scrapings from the cheek showed many Demodex mites but no yeast or fungal elements. Histopathologic examination of a biopsy specimen obtained from the left cheek revealed features of both rosacea and seborrheic dermatitis and enlarged hair follicles containing structures of D folliculorum (Fig 2). Because of the long list of previous unsuccessful treatment attempts the patient received a single oral dose of 200 µg/kg of ivermectin (Mectizan; Merck, Inc, Whitehouse Station, NJ). Topical treatment consisted of applications of a bland oil-in-water preparation and was applied for 1 month after treatment with ivermectin.

Within 2 weeks after initiation of treatment the patient noticed a remarkable reduction of pruritus; within 4 weeks there was noticeable reduction in the size and intensity of the inflammatory response (Fig 1, C and D). Skin scrapings were negative for Demodex mites.

To prevent reinfestation 5% permethrin cream was prescribed for once-weekly use and was initiated 4 weeks after ivermectin treatment. Subsequent examinations during the past year showed excellent control of the disease. Repeated scrapings remained negative for D folliculorum. The patient in this case report presented with an unusual long-lasting history of rosacea-like dermatitis of the face and eyelids. For 4 years his skin condition had been diagnosed as rosacea, seborrheic dermatitis, or an allergic dermatitis of unknown cause. As a consequence, treatment was attempted with topical and oral antibiotics including metronidazole, topical ketoconazole, etretinate, and topical corticosteroids. Finally, the patient decided to treat his skin condition with homeopathy and diet. This attempt was also without success.

Ivermectin is a semisynthetic product from Streptomyces avermitilis, a potent macrocyclic lactone disaccharide antiparasitic agent used to prevent and treat parasitic infestations in man and animals. The compound has activity against internal and external parasites and has been found effective against arthropods, insects, nematodes, filarioidea, platyhelminths, and protozoa. Ivermectin, initially applied extensively to control loiasis and bancroftian filariasis, is increasingly used for the treatment of scabies in immunocompetent and immunocompromised patients. In this case a single oral dose of 200 µg/kg ivermectin effectively led to substantial clinical improvement within 1 month. Repeated skin scrapings remained negative for Demodex mites. The 10-year history of the use of oral ivermectin to control onchocerciasis indicates that it is a safe drug. In our case, neither the patient nor the investigators noted any adverse reaction. Meinking et al recently reported that ivermectin showed no residual activity 2 months after a single dose. To prevent reinfestation with Demodex mites, 5% permethrin cream was prescribed for once-weekly use.

Linda Sy M.D.
Linda Sy Skin Care
http://www.lindasy.com
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