Please note: In my book, Rosacea 101, I wrote a chapter on demodex mites and rosacea and you can read this chapter in my book entitled "Demodectic Rosacea - A Rosacea Variant" on page 28. I have listed in Appendix K - Research Articles on Demodex and Rosacea on page 189 a comprehensive list of pubMed and other articles on demodex and rosacea. The following article below was the basis for the chapter in my new book on Demodectic Rosacea:
I want to propose a new rosacea variant - Demodectic Rosacea since if you look at the list of rosacea subtypes and variants it is not even mentioned. Mind-boggling isn't it? Yet research grants have been going on for years studying Demodex Folliculorum in Rosacea. Why hasn't anyone done this? Well, I just did. And this isn't something new. I have found research papers connecting demodex folliculorum with rosacea going back to 1932! Since so much research mentions either demodex mites or demodicosis with rosacea, at the very least, Demodectic Rosacea should be listed as a variant of rosacea. Apparently I am not the first one to propose this. A paper written by Samuel Ayres, Jr., M.D. in 1963 proposed a similar term 'rosacea-like demodicidosis,' and I quote the article for your reading pleasure here:
"As early as 1932 Ayres and Anderson called attention to a type of rosacea which they felt was caused in large part by extraordinarily heavy infestation by the mite, Demodex folliculorum, and it was pointed out that the demodex type of rosacea was a further development or complication of an entity that had been described and named by the present author two years previously under the title 'Pityriasis Folliculorum (Demodex) .' Since that time a number of publications have appeared on the subject as well as an exhibit at the thirteenth annual meeting of the American Academy of Dermatology and Syphilology in 1954....
...A more recent publication concerning the pathogenic role of Demodex in the production of pityriasis folliculorum (Demodex) and acne rosacea was Ayres and Ayres' summary of 30 years' experience with these two commonly unrecognized entities. Both conditions were referred to as demodicidosis. Inasmuch as the authors' attempts to describe and segregate a particular type of acne rosacea as being caused wholly or in large part by Demodex has led to confusion and to the erroneous statement that the authors have claimed that all cases of rosacea are caused by Demodex, it was felt that a new term should be coined and that rosacea of the Demodex type should henceforth be referred to as 'rosacea-like demodicidosis.' " California Medicine, June 1963 source
I am not the one who came up with the term, Demodectic Rosacea. It was due to an email I received from Gerg Plewig, M.D. which you can read about at this link. I was trying to understand why demodicosis has never been listed as a variant or subtype of rosacea and finally got a response explaining how Demodectic Rosacea is the preferred term. I am still attempting to understand if this is a variant of rosacea or not from the professionals in the RRDi MAC. This is a slow process, but I am patient. Dr. Plewig explained that demodicosis is a skin disease all on its own. According to Dr. Plewig, it is only when demodex mites are in increased numbers on pre-existing rosacea that the term demodectic rosacea is used.
It has been generally understood that "demodicoses are thought to be rare, occurring mainly for patients with immunosuppression." However, a study released in January 2005 had the objective "to demonstrate the high frequency of demodicoses and the overlapping with papulopustular rosacea (PPR) ." What did the study reveal?
"RESULTS: In all, 4372 diagnoses, in which 115 were demodicoses, were collected among 3213 patients. Demodicosis was the 9th most frequent diagnosis (13th new). Each dermatologist observed an average of 2.4 demodicoses a week (1.2 new). The proportion of demodicoses varied greatly according to the dermatologist. The general status was good in 110 patients; only 3 had known immunodeficiency. The most frequent symptoms were follicular scales (71%) and telangiectasia (63%). The mean Dd was higher in pityriasis folliculorum (m = 61 D/cm 2 ) than in PPR (m = 36 D/cm 2 ; P = .04); 42 patients with PPR had a high Dd, 6 had a low Dd. CONCLUSION: Demodicoses are frequent and occur among patients who are immunocompetent. PPR with normal Dd are rare." Jan 2005 source
One report in August 2005 says, "Although there are several clinical variants of this disease, a clear classification is missing." The report further says: "We suggest that demodicosis be divided into both primary and secondary types." source
In 2005 one study concluded that "MMP-9 may be a further explanatory link between the presence of D. folliculorum and the clinical expression of certain cases of rosacea." Journal of the European Academy of Dermatology & Venereology, Volume 19 Issue 5 Page 646 - September 2005 source
Geoffrey Nase, Ph.D., says that "Now there is "real" evidence, so I support a role of demodex, their bacteria and lipase in the aggravation of some rosacea symptoms; NOT the cause, but one aggravating factor. I did not support this four years ago because the science and clinical studies did not support this role." He further states that "several excellent studies have been performed using state-of-the-art biomedical research to show a cause and effect of demodex, their passenger bacteria, and the irritating enzyme, lipase." "Recent studies have clearly shown that demodex mites and their accompanying bacteria and lipase production can exacerbate rosacea..." source
"...Although Demodex mites do not seem to be the cause of rosacea, they may represent an important cofactor, especially in papulopustular rosacea. Immunohistochemical findings suggest that a delayed hypersensitivity reaction, possibly triggered by antigens of follicular origin, probably related to D. folliculorum, may occur, stimulating progression of the affection to the papulopustular stage..." September 2001 source
"...Although usually considered a non-pathogenic parasite in parasitological textbooks, Demodex folliculorum has been implicated as a causative agent for some dermatological conditions, such as rosacea-like eruptions and some types of blepharitis. Several anecdotal reports have demonstrated unequivocal tissue damage directly related to the presence of the parasite..." May/June 2000 source
While there is evidence that demodicosis is a "condition distinct from common rosacea," further research should be done to determine whether to classify demodicosis as variant of rosacea. March/April 2004 source
One report says since oral metronidazole was used to treat demodicosis without results and topical crotamiton was successful in clearing demodicosis that this was evidence demodicosis is a different condition distinct from rosacea. The report concluded: "This observation provides further evidence that demodicidosis is a condition distinct from common rosacea." April/May 1998 source
However, this should be further investigated since there is now evidence that oral metronidazole does indeed help demodicosis. A report in 2003 states: "Oral metronidazole seems to work in the management of this chronic mite infestation." November 2003 source
Another report in 2004 said: "The daily topical application of 1/3 diluted camphor oil with glycerol and 500 mg metronidazole orally were given for fifteen days. The results were very successful with no clinical side effects." This was in a Demodex folliculorum infestation. source
In one report, Demodicidosis revisited, states that demodex "have been identified and have been implied to play a role in at least three facial conditions: pityriasis folliculorum, rosacea-like demodicidosis and so-called "demodicidosis gravis." 2002 source
One research paper in 2004 said the following:
"Considering clinical similarities of demodicosis, rosacea and some mycotic infections, direct examination to confirm the etiological agent is highly recommended prior to treatment." source
One study in 2000 said this interesting statement:
"Diseases of seborrhoic origin include rosacea, acne, gram-negative folliculitis, demodex-folliculorum, perioral dermatitis as well as seborrhoic dermatitis. An important prerequisite for adequate therapy is the knowledge of these different diseases." source
It has been suggested that demodicosis is a disease that effects primarily people in developing countries and is not prevalent in developed countries. However, since it is simple to test for demodex density and there has been clinically proven results for treating demodicosis rosaceans should insist for tests for demodex to rule out this factor. Demodicosis has been found in developed countries.
Demodex Folliculorum is the name of a type of mite, while Demodex Brevis is another type. Demodicosis is the name of the disease or conditon. I am merely proposing that demodicosis be listed as a variant of rosacea. No one knows what the cause of rosacea is (more info). However, research papers continue to list demodex folliculorum as one of the possible factors in rosacea. A typical paper says the following:
"The cause of rosacea remains somewhat of a mystery. Several hypotheses have been documented in the literature and include potential roles for vascular abnormalities, dermal matrix degeneration, environmental factors, and microorganisms such as Demodex folliculorum and Helicobacter pylori." 2004 source
Whatever criteria is used to determine rosacea demodicosis could be used to add this is the list of variants of rosacea. What I have been told is that a clinical test is administered to check the mite density by a microscopic examination. My understanding is that whatever is the underlying cause, the demodex factor is an aggravating element and has been the focus of many rosacea research grants for years. One of the variants of rosacea is Steriod-Induced. Steroids don't cause rosacea but surely aggravates the conditon, hence is classified as a variant. Why not Demodicosis? Whatever of the cause, there should be some mention of demodicosis in the list of variants since it keeps coming up in clinical studies or whenever the subject of rosacea is discussed.
"The features of demodecidosis are often similar to those of rosacea." May 2005 source
There is evidence that IPL kills demodex mites. 2005source
Another report on IPL said, "...At 1-week, Demodex organisms appeared coagulated....Some esthetic improvement may be secondary to clearing of Demodex organisms and reduction of associated lymphocytic infiltrate." 2002 source
An expert committee assembled by the National Rosacea Society explicitly defined and classified rosacea in April 2002 into 4 different subtypes based upon specific clinical signs and symptoms. This was an important step in the treatment of rosacea. Currently, the therapeutics of rosacea empirically target the signs and symptoms of the disease because investigators do not understand the details of its pathophysiology. Therefore, this classification system aides clinicians in treatment by highlighting the preponderance of one or more of the clustering signs of presentation and, thus, helps to specify which therapeutic approach to initiate.
The diagnosis of rosacea is a clinical diagnosis. Skin biopsy may be necessary to exclude other disease states that mimic the clinical presentation of rosacea. For example, the clinician must exclude polycythemia vera, connective tissue diseases (eg, lupus erythematous, dermatomyositis, mixed connective tissue disease), photosensitivity, carcinoid mastocytosis, long-term application of topical steroids, contact dermatitis, and photosensitivity before making the diagnosis of rosacea. Rosacea is defined by persistent erythema of the central portion of the face lasting for at least 3 months. Supporting criteria include flushing, papules, pustules, and telangiectasias on the convex surfaces. Secondary characteristics are burning and stinging, edema, plaques, a dry appearance, ocular manifestations, and phymatous changes. The prevalence of these findings designates the subclassification of the presentation and, additionally, the therapeutic options."
source > http://www.emedicine.com/derm/topic377.htm
This same article says further down the page,
"Microbial organisms
Demodex species (mites that normally inhabit human hair follicles) may play a role in the pathogenesis of rosacea. Support suggests that Demodex prefers skin regions that are affected in rosacea, such as the nose and cheeks. Studies also support that an immune response of helper-inducer T cell infiltrates occurs, surrounding the Demodex antigens in patients with rosacea. Yet, conflicting evidence indicates that Demodex does not induce an inflammatory response in patients with rosacea. Moreover, Demodex is found in large numbers of healthy individuals without rosacea. More studies need to be performed to determine whether Demodex truly is pathogenic."
Statements like the above keep appearing in rosacea articles and papers and I am only proposing that either a variant or subtype be listed along with the others that includes demodex. The secondary characteristics should also include findings on demodex so that, as it says above, "the prevalence of these findings [including demodex findings] designates the subclassification of the presentation and, additionally, the therapeutic options." As I have repeated, it could be classified as a variant of rosacea.
For years the medical researchers have been studying demodex folliculorum and rosacea, yet have said that the demodex mite plays only a small part in the etiology of rosacea. Hence, the treatments offered for rosacea rarely took into account the demodex mite. However, due to continuing research on this subject demodicosis should be recognized as a variant of rosacea. Why this has been neglected is only conjecture. I hope this editorial will at least get the attention of some rosaceans even if the medical community continues to play down the demodex factor in rosacea.
There is evidence of a relationship between Demodex and bacteria infection in rosacea. Feb. 2004 source
"The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not." 2002 source
Fresh skin scrapings viewed under a microscope can reveal the mites which feed on dead cells and skin fats.
However, there are 'limitations of standardized skin surface biopsy in measurement of the density of Demodex folliculorum,' whatever that means? 1998 source
The prevalence of this mite in people with rosacea has been recorded as significantly higher than people without rosacea:
• an infestation of 51% in rosacea;
• an infestation of 28% in eczema;
• an infestation of 31% in lupus discoides. [source]
The following report is of interest:
"A leading theory suggests a vascular basis; however, clinical observations and histopathologic studies suggest that inflammation of the pilosebaceous follicle may be central to the pathogenesis of rosacea. Demodex folliculorum is a frequently seen commensal in the follicles of facial skin. According to evidence from biopsies of the skin surface, individuals with rosacea have a higher density of this parasite. This increased mite density may play a role in the pathophysiology of rosacea by triggering inflammatory or specific immune reactions, mechanically blocking the follicles, or acting as a vector for bacteria. Ongoing research has shown that bacteria from patients with rosacea may behave differently at the higher skin temperature that may be present in patients with rosacea. Another group has isolated bacteria from the Demodex mites; these bacteria may play a pathogenic role in papulopustular rosacea by facilitating follicular-based inflammatory changes." 2004 source
2007:
"Conclusions Antigenic proteins related to a bacterium (B. oleronius), isolated from a D. folliculorum mite, have the potential to stimulate an inflammatory response in patients with papulopustular rosacea." source
"Demodex species (mites that normally inhabit human hair follicles) may play a role in the pathogenesis of rosacea. Support suggests that Demodex prefers skin regions that are affected in rosacea, such as the nose and cheeks. Studies also support that an immune response of helper-inducer T cell infiltrates occurs, surrounding the Demodex antigens in patients with rosacea. Yet, conflicting evidence indicates that Demodex does not induce an inflammatory response in patients with rosacea. Moreover, Demodex is found in large numbers of healthy individuals without rosacea. More studies need to be performed to determine whether Demodex truly is pathogenic." source
"A total of 197 patients (117 with rosacea, 29 with akne vulgaris, and 51 with allergic diseases) were examined using the standardized skin surface biopsy (SSSB) and 97 out of 197 (49.23%) cases were found to be positive..." source
"Could the effects of antibiotics in rosacea be caused by their actions on intracellular bacteria of Demodex, rather than to a postulated anti-inflammatory mechanism? We believe so, and will demonstrate this in a first-of-its-kind poster." Source >
Electronmicroscopic investigation into the possible etiology of rosacea and the implication for treatment
Journal of the American Academy of Dermatology
February 2007 (Vol. 56, Issue 2 (Supplement 2), Page AB44)
Richard Burroughs, MD, National Capital Consortium (Walter Reed Army Medical Center), Washington, DC, United States; Kurt Maggio, MD, Walter Reed Army Medical Center, Washington, DC, United States
2006:
"This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea," Dr. Kavanagh said.
The researchers located the bacteria in Demodex folliculorum, which are normal inhabitants of human skin. Because these microorganisms often occur in much greater numbers in patients with rosacea, researchers have long theorized that they may play a part in the development of the disorder." source
In 2005 the NRS paid a grant of $23,600 for rosacea research to study among other items and access "the size of the oil glands and the presence of Demodex mites, normal inhabitants of human skin that have been observed in greater numbers in rosacea patients." source
The Role of HLA A2 and Cw2 in the Pathogenesis of Human Demodicosis
Kosta Y. Mumcuoglua Oleg E. Akilovb
Department of Parasitology, Hebrew University-Hadassah Medical School, Jerusalem, Israel;
Department of Dermatology, Cosmetology Hospital ‘Aesthetics’, Ekaterinburg, Russian Federation
Dr. Kevin Kavanagh was awarded $25,000 from the NRS to pursue further research on the potential role of bacterial antigens in papulopustular (subtype 2) rosacea. In an earlier NRS-funded study, he and his colleagues succeeded in isolating a bacterium from Demodex folliculorum, microscopic mites that are a common inhabitant of facial skin. The bacteria produced antigens that induced an inflammatory response in significantly more rosacea patients than controls. In the new study, they will determine whether the presence of the antigens is predictive of the onset of rosacea, in order to establish whether they play a significant role. source
The NRS awarded $22,500 to Drs. Kavanagh and Powell to expand on an earlier study involving Demodex mites. They will examine whether these bacteria produce antigens that may cause papules and pustules in rosacea patients. The report said, "This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea," Dr. Kavanagh said.
The researchers located the bacteria in Demodex folliculorum, which are normal inhabitants of human skin. Because these microorganisms often occur in much greater numbers in patients with rosacea, researchers have long theorized that they may play a part in the development of the disorder.
The researchers offered several possibilities that may explain how Demodex and bacteria interact to cause inflammation in rosacea. The Demodex mites may carry the pathogenic bacteria into areas of the face susceptible to the changes of rosacea, so that the increased mite density in rosacea patients may result in a higher density of bacteria that produce the papules and pustules. Alternatively, Demodex mites may be attracted to an area of facial skin rich in these bacteria and increase in numbers in this "fertile territory."
Another possibility is that the mites in rosacea patients are infected with these bacteria, which in turn produce stimulatory antigens that trigger the disorder in susceptible patients." source
The NRS also awarded a grant in 2002 that said "The researchers were awarded $12,250 to test Demodex from rosacea patients for the presence of bacteria, and analyze data for a possible statistical or clinical link between the bacteria and the presence of rosacea. They hypothesize that the cutaneous changes of rosacea may be due to an inflammatory response to bacteria within Demodex rather than the mite itself." source
Demodicidosis revisited.
Baima B, Sticherling M.
Department of Dermatology, University of Leipzig, Germany.
The management of rosacea.
Rebora A.
Department of Endocrinological and Metabolic Diseases, Section of Dermatology, University of Genoa, Genoa, Italy
2001:
Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. source
2000:
The NRS awarded $24,700 to Dr. Kavanagh to study whether bacteria associated with the Demodex mite may trigger the disorder directly by their presence or indirectly by stimulating the immune system. source
A Canadian physician, Annette Anderson, B.A., M.D., posted a treatment for her rosacea using Kwellada shampoo, Kwellada lotion (5% Permethrin), and Sulfacet face cream or equivalent antibiotic cream at r-s. She wanted testers to fill in questionnaires, and said she hoped to publish a summary of results in a GP's magazine and you can read about this by clicking here. An RS member named Rachelle (P & Ps, broken blood vessels) tried the treatment and wasn't happy. In addition to a slight flare, she had a break-out that took four days to control, aggravation to her seb derm, and the anti-mite spray severely irritated her sinuses. The doctor apologised but said the problem might be that Rachelle had seb derm as well as rosacea. Also, Rachelle was highly sensitive. Rachelle then posted a list of gentler treatments to kill mites: taking Olive Leaf Extract, and using soap, cream and shampoo containing Tea Tree Oil. The doctor said "natural treatments are always preferable" and left the group the very next day.
"...On the basis of histological, immunological and therapeutic arguments, it has been postulated that D. folliculorum was involved in the pathogenesis of rosacea, notably in its granulomatous form. In particular, several cases of granuloma containing the acarid in its core have been reported. However, the significance of such findings remains uncertain..." source
1984:
"...The predominance of helper-inducer T-cell subsets in the dermal infiltrates of acne rosacea lesions in frequent association with Demodex supports the hypothesis that a cell-mediated immune response plays an important role in the pathogenesis of rosacea..." source
"...In 20 patients with rosacea and rosacea-like eruptions Demodex folliculorum mites were found in high numbers within lesional skin..." source
1980:
This paper spoke about 'the role of Demodex mites in the pathogenesis of rosacea.' source
1976:
Demodecidosis and rosaceiform dermatitis: "The authors refer those dermatoses called "Rosacea like" or "Rosaceiform Dermatitis" that always offer differential diagnosis with Rosacea." source
1974
"This increased mite density may play a role in the pathophysiology of rosacea by triggering inflammatory or specific immune reactions, mechanically blocking the follicles, or acting as a vector for bacteria. Ongoing research has shown that bacteria from patients with rosacea may behave differently at the higher skin temperature that may be present in patients with rosacea." source
"Rosacea-like demodicidosis is an entity resembling acne rosacea which is caused by infestation with an abnormally large number of the mite Demodex folliculorum, usually in association with improper cleansing of the face." source
The first research paper I read about this subject that interested me said in April 1997 which struck me the most:
"...Light and scanning electron microscopy revealed that all mites were pointing in one direction. Some of them were containing bacteria inside their gut and on their skin. After treatment 3 cases (18.75%) were completely cured, 10 cases (62.5%) gave moderate response while 3 cases (18.75) have no response. In conclusion, this study supports the pathogenic role of D. folliculorum in rosacea. (see article below)
I have always envisioned these little mites all standing at attention saluting some higher authority in doing their little dirty work on my face!
"Undoubtedly, infestation with D. folliculorum particularly in large number causes rosacea." source
"Our results suggest that Demodex mites may play a role in the inflammatory reaction in acne rosacea." source
Apparently the Chinese have known about the demodex mite for some time and Professor Zhao Zhongzhou has been working on a medicine to eliminate the little creatures which is reported to help rosaceans. (see article below) Professor Zhao Zhongzhou says, "“That means 130 million Chinese people are suffering from acarodermatitis – 30 million of them have red noses.” source
You may be interested in some clinical reports on the Zhongzhou cream.
Another paper in June 1998 said,
"We suggest that a certain mite density is not an appropriate criterion in the diagnosis of the disease; nevertheless, large numbers of D. folliculorum may have an important role in the pathogenesis of rosacea, together with other triggering factors." source
These 'other triggering factors' may be an immune system dysfunction according to this study,
"It seems likely that Demodex infestation does not manifest unless local or systemic immune function is altered, leading to the proliferation of the organism and subsequent disease." source
"...infestations with Demodex folliculorum and environmental stimuli are considered to be involved in the inflammatory process...These results indicate that MNA(+) might be a useful agent for treating rosacea." source
What I have noticed is that when I began using the Zhongzhou Medical Ointment my rosacea has significantly improved within ten days! (see my diary on the results)
It is still not clearly established what is causing rosacea but the evidence is pointi
