Dr. Bikowski

In the last two years, however, Joseph Bikowski, M.D., director of the Bikowski Skin Care Center in Sewickley, Pa., and clinical assistant professor of dermatology, Ohio State University, Columbus, Ohio, has come to realize that a large number of those patients do not have rosacea or seborrheic dermatitis.

"There is a third entity called 'Demodex dermatitis,'" Dr. Bikowski tells Dermatology Times. "Demodex is a little mite that has been recognized for years, and in fact, at one time was thought to be the cause of rosacea. In reality, I believe that it's a separate diagnosis ... and that's based on empirical observations and therapy."

A patient with Demodex dermatitis at baseline [a] and demonstrating 50 percent clearing [b] after using crotamiton cream twice daily for two weeks, and 100 percent clearing [c] after four weeks.

Treatment

As a case in point, Dr. Bikowski explains a situation from two years ago. A patient presented with a red, scaly face that he had treated unsuccessfully for rosacea and seborrheic dermatitis for two years prior. The condition continued to worsen.

He then performed a KOH (potassium hydroxide) preparation of the scales and found Demodex mites, at which point he empirically treated the patient with topical Eurax (crotamiton, Ranbaxy). Within two weeks, the patient was clear and has stayed clear for the last two years.

"Since then, I have treated more than 100 patients," Dr. Bikowski says, "and I've reported about 60 of those cases recently in an article. The patients I have clinically diagnosed with Demodex dermatitis were given a therapeutic trial of crotamiton, and within two to four weeks, were clear and stayed clear," he says.

Dr. Bikowski is convinced that there is a large subset of patients who appear to have classic rosacea, are red and scaly, and may or may not have papules and pustules or seborrheic dermatitis, but who in reality have an increased reaction to the Demodex mite.

"At times," he says, "rosacea and seborrheic dermatitis and Demodex dermatitis may all be together; or rosacea and seborrheic dermatitis may be together; or seborrheic dermatitis and Demodex dermatitis may be together. They can overlap, and two or three can exist in one person.

"But I believe it's best to treat empirically with crotamiton — cream or lotion — twice a day for two to four weeks," Dr. Bikowski says.

"If the patient clears, then it's most likely Demodex, and you don't have to do anything else. If the patient doesn't clear, then you know that the patient is a candidate for long-term therapy," he says.

In addition, Dr. Bikowski says that patients with red, scaly faces that have not responded to any of the medications for rosacea or seborrheic dermatitis should also be empirically treated for Demodex dermatitis.

"The medications that can be effective are either crotamiton, Elimite (permethrin, Allergan), or ivermectin (tablet)," he says. "I prefer crotamiton, because it's a cream or lotion, and the patient has a choice of one of the two vehicles. That's the one I clinically use most successfully."

Drug safety

The safety of medications such as ivermectin — a pill taken by mouth — has been upheld for decades, and in fact, is provided free of charge by its manufacturer to treat river blindness in Africa, according to Dr. Bikowski. Crotamiton and permethrin have been in use for more than 30 years as treatment for scabies, and work well for mites.

"Rarely do we see a reaction from these topical medicines, and I've never seen an allergic reaction to ivermectin," he says.

"Everything that's been done in my observations in the clinic is anecdotal at this time, which is a large body of work. The beauty is that after diagnosis and proper treatment, these patients are essentially 'cured,'" Dr. Bikowski says.

He adds that he has not seen recurrence over one to two years for many of his patients.

As for quality of life, "patients with Demodex dermatitis can look better, so they will have a better self-image. They feel better, because their skin is back to normal again — it's a dramatic improvement," he says.

Dr. Bikowski's recommendation is simple: "When you see a red, scaly face, think rosacea, seborrheic dermatitis and, most importantly, Demodex dermatitis. Treat empirically for Demodex with crotamiton twice a day for two to four weeks."

Disclosure: Dr. Bikowski is a consultant to Ranbaxy.