Demodex Mites: Ivermectin Effective Treatment ?

Written by on August 30, 2007 with 47 Comments

Linda Sy MD,
Date: Fri Dec 1, 2000

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

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About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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47 Reader Comments

  1. ruthoftheearth says:

    My ivermectin weekly lotion:

    topical:
    1/2 horse tube ivermectin gel (apple flavor>NOT the white paste)
    add 3 oz +/- of Dollar Store Green Aloe Gel (this brand mixes the best) and mix it up together. Makes about 1/3 cup of lotion. Note: Wmart brand does not mix well, it breaks apart when applying ~ not as absorbent but will work and can be used in a pinch.

    Rub on a thin layer all over body, especially folds, ie arm pits, waist, butt or wherever you have problem areas. Leave on for at least an hour, or overnight to get great sleep if you’re itchy. I do this once a week.

    I have used 3x this amount on awful days with no adverse affect.

    I have not used this on my face though. Seabuckthorn lotions and sulfur lotions are best for face. I wash with sulfur soap or the dead sea salt soaps. Yes, its a constant battle but it gets way better than the meanie bites in the early stages.

    I would like ideas to mix with shampoo, since I find the ivermectin gel as well as the paste do not mix great with shampoo, it just stays in lumps. Any ideas?

  2. j says:

    My suggestions, not a doctor, just what I have done on myself:

    Make your own version of this:

    Just came out Sklice for lice. Ivermection is for scabies and demodex, as I have been reading on many forums. Main ingredients are Ivermectin and olive oil. Read insert of product. http://www.sklice.com/

    Says to leave on 10 minutes. I would go 30 personally or more as scalp itching is insane.

    Ivomec injectible 1% for cattle and swine would work. You get it at farm supply or animal feed stores or even online at Amazon. Petclub carries it. Brown box, the top is hard to get off, had to pry it off, since not using as it is intended with a needle. Be careful not to spill it as it is $42.00 Don’t inject it, just use the liquid mixed with warmed olive oil like a hot oil treatment, mix it with the warm olive oil and then just use a needleless syringe to to suck it out of your mixing bowl, then squirt it onto scalp locations then rub in really well into scalp with fingertips.

    If you do not get the Ivomec, it is way more money, just use the cheap $5.00 gel/apple flavor horse paste that is 1.87%. I have used it orally as well as on my eylahes and eylelids and eyebrows, I am still alive and no side effects. All my reading has told me Ivermectin is a verysafe drug and they test drugs for animals as good or better than the human tests. The human prescrition just cost way more and hard to get a prescription and or refillls. Nu_stock sulfur cream for $13.00 was also used on my body instead of Premetrin. Got at the feed store as well and also on Amazon.

    http://www.sklice.com/

    • Olivia says:

      Hi. I took iveemectin 3 weeks ago for major demodex infestation. I noticed I have fewer mites on ny bosy and the ones u can roll between fingers r much softer rather than tiny razors but now it seems to have warn off. Can someone who has been cured contact me please. Life us very hard. I often want to give up. I spend about 7-14 hrs a day washing and spraying bug sprays on me and rubbing tea trea and lemongrass oils all over. I cant work, cant spend time with my kids as not to pass the demodex mites to them. They live w their dad. My bf has been taking care of me thru it but its put a huge strain on our relationship. My # is 831 428 1945. Pls text b4 calling. I dont answer most calls. Thank u!

  3. Eduardo says:

    I suffer from this little bastards as well. This happened to me right after I was given a pure bred white bull terrier. I couldn’t help the little guy until I took him to at least 10 vets and one of them told me to change his diet to raw chicken. About 6 months after he was cured I began with these red bumps on my left and right checks. I ive started using selsun blue as well as sulfur soap and have seen an improvement of about 75 % but the bastards wont give up on my left check can someone please help!!!!!!!!!!!casillaseduardo@rocketmail.com

  4. Elaine says:

    If your skin and/or eye problems are caused by demodex mites, there is an oral treatment that was quite effective for me. It was published in the International Journal of Infectious disease in 2013. Treatment takes 2 weeks. Oral Ivermectin and Oral Metronidazole. Insurance copay was just $13.03 (Uninsured retail about $52 USD.

    Paper is here: https://www.sciencedirect.com/science/article/pii/S120197121201315X

    Treatment (from paper) based on body weight for the oral Ivernectin:
    1. Two does of oral Ivermectin one week apart 200 micrograms Ivermectin per kilogram of body weight. Worked out to 12 mg for me. Take on an empty stomach with a large glass of water.
    2. Oral Metronidazole, 250 mg. three times a day for two weeks.

    As always, it is best to discuss this treatment with your doctor. These are prescription drugs. My family doctor was most helpful.

    I had demodicosis caused by demodex mites. Onset at age 11.5 after a severe bout of German Measles and possibly the flu. Immune system was at rock bottom allowing the mites to become infested in spite of good hygiene. It got worse with every bout of the flu after that.

    After being misdiagnosed with “allergic conjuctivitis” and acne vulgaris (bacterial origin) for 51 years, it advanced into blepharitis demodex (ocular rosacea) – painfully gritty, dry eyes with eyelashes falling out, etc. Over the years, 4 board certified dermatologists prescribed about 8 different antibiotics, retin A, micro-retin A, benzoyl peroxide, etc. None of the expensive treatment worked. They never checked for demodex mites.

    Demodicosis can be confused for “Hormonal acne” due to the fact that the mites live 2-3 weeks and may indeed be tuned in to the hormonal cycles of the body. The mites eat oil. When your hormones are causing more oil to be generated, there is more for the mites to eat. Any drug that levels out or reduces the oil in your skin can temporarily control the mites by controlling their food source.

    In other studies, the topical version of Metronidazol has not been found to be effective but the oral version is. Oral metronidazol is believed to work indirectly by changing something the mites are consuming or changing the environment so that they die.

    • Soolantra is a topical cream containing Ivermectin. I was prescribed if for my Papulopustular Rosacea and it has worked wonders, after over 15 years I am off the antibiotics and my skin is clearing fast after just 2 weeks using the Soolantra. The patient leaflet says to avoid the eyes but I have been applying it liberally across my eyelids and the blepharitis is clearing up. My eyelids are no longer red, my eyes have stopped watering, and yesterday for the first day in about 2 years I had no irritation wearing my contact lenses for most of the day. I will carry on with the cream for now but I’m interested to know whether the oral Ivermectin is more effective as I have read that in some cases it can eliminate the problem without having to continue treatment. Has anyone got experience of this ?

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