The Effect of Different Therapeutic Modalities on Demodex Densities and Clinical Symptoms of Patients with Demodicosis

Background: Demodicosis represents cutaneous diseases caused by cutaneous overpopulation of Demodex mites. The aim of this study was to evaluate the effect of different treatment options on Demodex densities (Dds) and clinical symptoms of patients with demodicosis. Methods: Patients with high Dds in two consecutive standardized skin surface biopsies (SSSB1>5 D/cm2 or SSSB2>10 D/cm²) and concomitant clinical symptoms were evaluated retrospectively. Measurements of treatment effectiveness included clinical improvement and normalization or reducing of Dds. Results: A total of 21 patients included in the study. Five patients received topical permethrin and crotamiton whereas 16 patients received systemic metronidazole in combination with topical permethrin and/or crotamiton. The treatment was continued with topical ivermectin in 2 patients who had failure with other treatments. The median treatment duration was 3 months (IQR 1-4). Pre- and post-treatment median Dds decreased 30 to 14 D/cm2 on SSSB1 whereas 81 to 80 D/cm 2 on SSSB2, respectively. There was no statistically significant decrease in Dds on SSSB1 and SSSB2 after the treatment (p=0.173 and p=0.134, respectively). Clinical improvement was recorded in a total of 14 patients (66.6%) of whom only 2 patients (9.5%) had normalization on Dds. Additionally, topical ivermectin provided a rapid clinical improvement and normalization on Dds in both 2 patients. Conclusion: Irrespective of the treatment, more than two-thirds of the patients improved clinically without a significant change in Dds. This finding may suggest that the treatment response has been mostly associated with the anti-inflammatory properties of the agents. Topical ivermectin seems to be a more suitable treatment option for demodicosis with positive effects on both clinical findings and Dds.

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[1] Forton F and Seys B. Density of Demodex Folliculorum In Rosacea: A Case-Control Study Using Standardized Skin- Surface Biopsy. Br J Dermatol. 1993;128(6):650-9.
[2] Elston Carly A., Elston Dirk M. Demodex Mites. Clinics in Dermatology 2014 Dec;32(6): 739-43.
[3] Holmes AD. Potential Role Of Microorganisms In The Pathogenesis Of Rosacea. J Am Acad Dermatol. 2013;69(6):1025-32.
[4] Forton FMN, De Maertelaer V. Two Consecutive Standardized Skin Surface Biopsies: An Improved Sampling Method To Evaluate Demodex Density As A Diagnostic Tool For Rosacea And Demodicosis. Acta Derm Venereol. 20178;97(2):242-248.
[5] Ayres S Jr, Ayres S 3rd. Demodectic Eruptions (Demodicidosis) in the Human. 30 Years’ Experience With 2 Commonly Unrecognized Entities: Pityriasis Folliculorum (Demodex) and Acne Rosacea (Demodex Type). Arch Dermatol. 1961;83:816-27.
[6] Zhao YE, Wu LP, Peng Y et al. Retrospective Analysis of the Association Between Demodex Infestation and Rosacea. Arch Dermatol. 2010;146(8):896-902.
[7] Chang YS and Huang YC. Role Of Demodex Mite Infestation In Rosacea: A Systematic Review and Meta-Analysis. J Am Acad Dermatol. 2017;77(3):441-447.e6.
8] Forton F, Germaux M-A, Brasseur T et al. Demodicosis and Rosacea: Epidemiology and Significance In Daily Dermatologic Practice. J Am Acad Dermatol. 2005;52(1):74- 87.
[9] Karincaoglu Y, Bayram N, Aycan O et al. The Clinical Importance of Demodex Folliculorum Presenting with Nonspecific Facial Signs and Symptoms. J Dermatol. 2004;31(8):618-26.
[10] Forton FMN, De Maertelaer V. Papulopustular Rosacea and Rosacea-Like Demodicosis: Two Phenotypes of The Same Disease? J Eur Acad Dermatol Venereol. 2018;32(6):1011- 1016.
[11] Forton FM, Germaux M-A.E, Thibaut SC et al. Demodicosis: Descriptive Classification and Status of Rosacea, in Response to Prior Classification Proposed. J Eur Acad Dermatol Venereol. 2015;29(4):829-32.
[12] Chen W, Plewig G. Human Demodicosis: Revisit and A Proposed Classification. Br J Dermatol. 2014;170(6):1219- 25.
[13] Forton FMN, De Maertelaer V. Rosacea and Demodicosis: Little-Known Diagnostic Signs and Symptoms. Acta Derm Venereol. 2019;99(1):47-52.
[14] Sattler EC, Hoffmann VS, Ruzicka T et al. Reflectance Confocal Microscopy for Monitoring the Density of Demodex Mites in Patients With Rosacea Before and After Treatment. Br J Dermatol. 2015;173(1):69-75.
[15] Truchuelo-Díez MT, Alcántara J, Carrillo R et al. Demodicosis successfully treated with repeated doses of oral ivermectin and permethrin cream. Eur J Dermatol. 2011;21(5):777-8.
[16] Forton FMN, De Maertelaer V. Treatment of rosacea and demodicosis with benzyl benzoate: effects of different doses on Demodex density and clinical symptoms. J Eur Acad Dermatol Venereol. 2020;34(2):365-369.
[17] Forton F, Seys B, Marchal JL et al. Demodex folliculorum and topical treatment: Acaricidal action evaluated by standardized skin surface biopsy. Br J Dermatol. 1998;138(3):461-6.
[18] Jacob S, VanDaele MA, Brown JN. Treatment of Demodex- associated inflammatory skin conditions: A systematic review. Dermatol Ther. 2019;32(6):e13103.
[19] Hsu CK, Hsu MM, Lee JY. Demodicosis: a clinicopathological study. J Am Acad Dermatol. 2009;60(3):453-62.
[20] Luo Y, Sun Y-J, Zhang L et al. Treatment of mites folliculitis with an ornidazole-based sequential therapy : A Randomized Trial. Medicine (Baltimore). 2016;95(27):e4173.
[21] Schaller M, Sander CA, Plewig G. Demodex abscesses: Clinical and therapeutic challenges. J Am Acad Dermatol. 2003;49(5 Suppl):S272-4.
[22] ShelleyWB, Shelley ED, BurmeisterV. Unilateral demodectic rosacea. J Am Acad Dermatol. 1989;20(5 Pt 2):915-7.
[23] Hoekzema R, Hulsebosch HJ, Bos JD. Demodicidosis or rosacea: What did we treat? Br J Dermatol. 1995;133(2):294- 9
[24] Abdel-Badie Salem D., El-Shazly A.,Nabih N et al. Evaluation of the efficacy of oral ivermectin in comparison with ivermectin - metronidazole combined therapy in the treatment of ocular and skin lesions of Demodex folliculorum. Int J Infect Dis. 2013;17(5):e343-7.
[25] Aylesworth R, Vance JC. Demodex folliculorum and Demodex brevis in cutaneous biopsies. J Am Acad Dermatol. 1982;7(5):583-9.
[26] Lacey N, Delaney S, Kavanagh K et al. Mite-related bacterial antigens stimulate inflammatory cells in rosacea. Br J Dermatol. 2007;157(3):474-81.
[27] Lacey N, Russell-Hallinan A, Zouboulis CC et al. Demodex mites modulate sebocyte immune reaction: Possible role in the pathogenesis of rosacea. Br J Dermatol. 2018;179(2):420-430.
[28] Schaller M, Almeida LMC, Bewley A. et al. Rosacea Treatment Update : Recommendations From the Global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471.
[29] Schaller M, Gonser L, Belge K et al. Dual anti-inflammatory and anti-parasitic action of topical ivermectin 1% in papulopustular rosacea. J Eur Acad Dermatol Venereol. 2017;31(11):1907-1911.
[30] Noy ML, Hughes S, Bunker CB. Another face of demodicosis. Clin Exp Dermatol. 2016;41(8):958-959.
[31] Trave I, Merlo G, Cozzani E et al. Real life experience on effectiveness and tolerability of topical ivermectin in papulopustular rosacea and anti-parasitic effect on Demodex mites. Dermatol Ther. 2019;32(6):e13093.
[32] Holzchuh FG, Hida RY, Moscovici BK et al. Clinical treatment of ocular Demodex folliculorum by systemic ivermectin. Am J Ophthalmol. 2011;151(6):1030-1034.e1.
[33] Brown M, Hernández-Martín A, Clement A et al. Severe Demodex folliculorum-associated oculocutaneous rosacea in a girl successfully treated with ivermectin. JAMA Dermatol. 2014;150(1):61-3.