Do Mites in the Pores Cause Rosacea?

Do Demodex mites cause rosacea? The pores on your skin are home to many microscopic inhabitants including bacteria, yeast, and – yes – mites. The rosacea puzzle is taking form and microscopic Demodex mites may well play an important role in the skin problems of rosacea! The mites are Demodex. Mammals, including humans, have Demodex on their skin. Demodex mites primarily live in our pores and oil glands.

• They prefer the oiliest parts of our face such as the "T-zone".
• They eat dead skin cells and sebum (skin oil).
• They're shy! The mites rarely venture out of the pores where they live, lay their eggs, and die.

People with rosacea have more mites in their pores.

We've known that rosacea prone complexions have a greater number of mites in the pores. We haven’t understood what, if any, the connection is between mites and rosacea, until now.

Scientific studies connecting mites and rosacea have been popcorning out in medical journals and conferences over the past few years. Researchers are gathering evidence that bacteria on human demodex mites may trigger a complex cascade of events that lead to the skin problems of rosacea.

A paper just published in the August Journal of Medical Microbiology surveyed the scientific literature looking for all of the scientific studies examining the mite/rosacea connection. The authors found a number of papers linking the skin problems of rosacea to the presence of the bacteria on demodex mites.

What rosacea skin problems are linked to Demodex mites?

1. skin barrier fragility (sensitive skin),
2. flushing,
3. permanent "broken" facial capillaries,
4. sebaceous hyperplasia (enlargement of oil glands), and
5. the red rash and pustules of rosacea.

Bacteria on Demodex mites may be the cause of rosacea skin problems.

There are two bacteria that may be to blame, Bacillus oleronius and Staphylococcus epidermidis. Interestingly, these microbes are sensitive to the antibiotics that we dermatologists have used for years to treat rosacea. It may have been the mite's bacteria that we've been treating all along. Conclusions haven't been reached but it's fascinating, surprising, and just a little creepy.

What are the facts about demodex mites on our skin?

Demodex mites live in the pores on places of the human body where there is a lot of oil (T-zone, chest, ear canal, and groin). Only rarely can they get through the lining of the pore and into the second layer of the skin called the dermis. When they do, they may cause severe inflammation such as large inflammatory pustules (pimples). It may be this entrance into the skin that is responsible for some of the worst inflammatory aspects of rosacea.

 FAQ about Demodex mites living in your pores

• Demodex mites live for less than 3 weeks and their eggs hatch in less than 3 days.
• They have to be in a pore to survive; they can’t live outside the pore. They only come out of the pore at night to mate, traveling at most ½ inch away from their home for dating purposes! When done, they scramble back down into their pore to lay their eggs. Click here to see the best (and grossest) pictures that I could find of Demodex mites stuffed into human pores head first (which is how they like it): Shootingparrots.co.uk .
• Human babies are born with no mites, and then their pores slowly become inhabited by them. Every race in all parts of the world has Demodex mites – sorry to break the news but none of us are spared!
• As we age, we become more likely to have a lot of mites in our pores. In fact, 100% of the elderly have Demodex mites in their pores. It may be the quality of sebum (oil) not the quantity that makes the pores hospitable for the mites since the elderly outpace teens in skin mite density. There may also be some element of immune underperformance on the part of our skin that allows the mites to thrive.
• There are two types of mites; they live in different parts of the pores and cause different manifestations of rosacea.
• Demodex folliculorum lives in the main portion of the pore and it's more likely to cause scaling redness and sensitive skin.
• Demodex brevis lives deeper in the sebaceous glands (which comes off the pore) and is more likely to cause the papulopustular eruption (rosacea pimples), the symmetrical rashes, and other skin problems arising on the background of a pre-existing rosacea.
• The B. oleronius bacteria are found on the Demodex mites that colonize human skin. It may actually be a protein on the B. oleronius bacterium that is capable of leading to the inflammatory cascade seen in rosacea including ocular rosacea.
• The bacterium S. epidermidis is a normal skin bacterium, but it is found to be more prevalent in the facial pustules and inflamed eyelash line of rosacea blepharitis.

Demodex rosacea treatment for the mite misadventure!

At this point, the care guidelines are evolving and the one topical approved treatment is really expensive and often not covered by insurance. So, patients and physicians are left to figure this out on their own. Some of the options I discuss with my rosacea patients include:

• The possibility of trying to treat the mites with oral ivermectin. The mites may come back easily, so repeated treatments over time may be necessary to control Demodex.
• Now we have topical Soolantra, an ivermectin cream that can treat demodex mites.
• In my practice, I've prescribed permethrin cream nightly for a week. I have my patients repeat this as necessary. However, it is totally an off-label treatment.

Does benzoyl peroxide kill Demodex mites?

Several years ago, I attended an American Academy of Dermatology lecture given by a physician practicing in Israel where they use benzoyl peroxide for Demodex. Permethrin is not available there and this physician said she gets good control of facial Demodex infestation and rosacea pustules with benzoyl peroxide.

I reviewed the Demodex treatment in the veterinary literature to see if benzoyl peroxide is used and has been studied for the Demodex found in dogs and cats. I could only find it mentioned to benefit for it "follicular flushing activity", which I presume means it keeps the pores clear so the mites can tuck in as well. 

Benzoyl peroxide can be irritating to sensitive rosacea-prone skin however. My alcohol-free Benzoyl Peroxide Cream is the one I use for complexions suffering from rosacea. Another option is Foaming Benzoyl Peroxide Cleanser. This gentle pH balanced cleanser has a full 10% benzoyl peroxide. Sensitive skin rosacea-prone complexions may not tolerate benzoyl peroxide so care must be taken. 

Do antibiotics kill Demodex?

No, antibiotics are not antiparasitic medicines. But topical and oral antibiotics that have been the mainstay of rosacea therapy for years still have a role, and it may be that their target is the bacteria on the mite.

Can you get rid of Demodex naturally?

Some essential oils appear to kill Demodex but at the concentrations used, these oils would be irritating to rosacea. Tea tree, sage and peppermint were the most effective in a small study, though all oils ultimately killed Demodex including sea buckthorn, which is a soothing oil that helps calm skin inflammation. My Omega Enriched Face Booster Oil incorporates sea buckthorn with other botanical healing oils such as borage, kakui nut, argan oil, pomegranate oil, cypress and others to sooth and support sensitive skin. I think there is a role for daily botanical oil use to help control the Demodex recolonization of rosacea-prone skin. I personally apply my Omega Oil at bedtime on top of my other nighttime treatment products. 

Does pyrithione zinc kill Demodex mites?

I find zinc pyrithione in my Calming Zinc ® Soap helpful for rosacea. Whether it helps slow down mites, or their bacteria, or is just working on Pityrosporum yeast, I don't know, but I always recommend it. I keep my eyes open for a study looking at pyrithione zinc and Demodex and so far, there is none. Mites are on the radar so I expect this will be looked at soon.

I also use the Green Tea Antioxidant Skin Therapy to reload the skin's antioxidant reserve to help fight inflammation.  Both of these products are in my Facial Redness Relief Kit.
I also recommend that most of my rosacea patients use a sonic skin cleansing brush such as the Clarisonic or Foreo unless their skin is too sensitive for the brush oscillations. 

The bottom line is that we may be getting closer to understanding rosacea. I expect to see more targeted treatments being developed, and maybe even a cure, as the research continues. For now, the new focus on mites is gross, but fascinating. As a final note the authors of this paper state,

The pathogenic role of Demodex mites, as well as B. oleronius and S. epidermidis, in the induction and persistence of rosacea remains an unresolved issue.

So, until then, we patients and physicians have to be creative at trying to reign in the inflammation and skin problems of rosacea.

How do I as a dermatologist use this information about the Demodex mites' bacteria producing a protein that may cause rosacea in my dermatology practice?

I create a skin care routine that helps rosacea-prone skin resist inflammation and mite overgrowth. That's a routine that:

• fights inflammation with antioxidants from green tea,
• includes ingredients that may fight mites and bacteria such as benzoyl peroxide and sea buckthorn,
• incorporates zinc pyrithione to fight skin yeast that we have long known contribute to facial redness from rosacea,
• supports the fragile skin barrier to heal with a lipid replenishing facial moisturizer and,
• prevents UV ray exposure that can trigger rosacea using a non-irritating zinc oxide sunscreen. 

I build a holistic Complete Skin Care Routine with synergistic and rosacea-friendly products for the 4 essential skin care steps of CLEANSE, CORRECT, HYDRATE and PROTECT. 

I've put this routine together and taken the guesswork out of it with my Rosacea Therapy Kit. Add the Omega Enriched Face Oil and Benzoyl Peroxide Cream if these latter two products fit your complexion. 

 A Rosacea Complete Skin Care Routine™ looks like this:

CLEANSE skin with Calming Zinc Soap once or twice a day. Sensitive complexions do best using Calming Zinc in the morning alternating with pH balanced Extremely Gentle Foaming Facial Cleanser at night. If possible, a Clarisonic Sonic Brush is used at night with the Extremely Gentle Cleanser. 

CORRECT rosacea with Green Tea Antioxidant Skin Therapy applied to the entire face twice daily. If tolerated, Benzoyl Peroxide Cream can be applied to active areas with rosacea pustules and inflammation once or twice a day.

HYDRATE using Omega Enriched Face Oil applied directly or a few drops added to the Daily Face Cream twice a day. Most people prefer to use the Booster Oil in the evening. 

PROTECT using one of my Sheer Strength Pure Physical Sunscreen applied during the day - every day - to prevent UV triggering of rosacea. 

It's that simple! All of the main factors that cause rosacea, trigger rosacea or are the consequences of rosacea are covered by this non-prescription, dermatologist's Complete Skin Care Routine.  

What medical treatments do dermatologist's use to treat demodex mites in rosacea?

My prescription medical treatments include oral or topical miticides to frustrate the demodex (such as permethrin or ivermectin). Permethrin is off label for demodex, ivermectin is available in Soolantra.

IPL (intense pulsed light) also helps reduce the mite population. It also diminishes the blood vessel capillaries and, in my experience, helps reduce skin inflammation in rosacea.

Oral and topical antibiotics are often used by doctors to target bacteria. This may include the bacterium mentioned above. 

My Rosacea Therapy Kit takes the guesswork out of finding a skin care routine that let's your rosacea heal.   

Reference:

The potential role of Demodex folliculorum mites and bacteria in the induction of rosacea.  Stanisław Jarmuda, Niamh O’Reilly, Ryszard Żaba, Oliwia Jakubowicz, Andrzej Szkaradkiewicz and Kevin Kavanagh Journal of Medical Microbiology Papers in Press. Published August 29, 2012

Author: Dr. Cynthia Bailey M.D. is a Board Certified dermatologist practicing dermatology since 1987. She has done well over 200,000 skin exams during her career and authors the longest running physician written skin health blog in the world.