Treatment
Localized demodicosis
Systemic antiparasitic therapy is not appropriate for localized demodicosis. There is no evidence that failure to treat localized cases results in generalized ones and in fact this treatment may fail to identify the patients that become generalized. That is not to say that there are no treatments. In juvenile dogs with localized demodicosis, it is essential to ensure a “stress-free” lifestyle. Poor nutrition will certainly play a role in the pet’s immune competence, and close evaluation of the diet and proper dietary recommendations are important factors; I typically recommend balanced, high quality, commercial diets from reputable companies. Fecal evaluation and appropriate deworming is also important. Products containing benzoyl peroxide are often recommended by dermatologists as they are said to aid “follicular flushing” – although the owner should be advised that manipulation of the lesion could initially increase loss of hairs that were about to be shed. Benzoyl peroxide does dry the skin and should be followed with a moisturizer.
Generalized demodicosis
The owner must be aware that once treatment for generalized demodicosis is commenced, the pet should be monitored by repeat scraping every 4 weeks. The life stages and numbers of parasites should be recorded to monitor progress, and advise the owners that treatment will continue for two months after a negative scrape – typically 3-7 months in total. If one form of treatment is unsuccessful, try a different one, but some patients are “control versus cure” (especially the adult onset cases).
Amitraz is licensed in many countries for the treatment of demodicosis. There is good evidence of efficacy using the drug at 250-500 ppm every 7-14 days (possibly better with shorter time intervals) 16. Long- and medium-haired dogs should be clipped before application, and treatment should only be performed in a well-ventilated area (respiratory problems have been observed in humans) by veterinary personnel wearing protective clothing; dogs should remain in the veterinary hospital until dry and should not become wet between rinses. Treated animals should not be subjected to stress for a period of at least 24 hours post-treatment 1617. Amitraz is a monoamine oxidase (MAO) inhibitor and it is important to remember the potential for drug interactions; as an α2-adrenergic agonist, side effects can be treated (pre- or post-treatment) with yohimbine or atipamezole.
Avermectins (ivermectin, doramectin) are macrocyclic lactones. They bind selectively and with high affinity to glutamate-gated chloride channels resulting in increased cell permeability and neuromuscular blocking resulting in paralysis and death of the parasite. They interact with gamma-aminobutyric acid (GABA) sites 17. GABA is a CNS neurotransmitter and these drugs are kept out of the nervous system by the P-glycoprotein pumps of the brain capillary endothelial cells (blood-brain barrier). It is important to remind the owners that using such products at the doses recommended for demodicosis is considered off-label use.
Numerous breeds have members that are homozygous mutants for the MDR1 (multi-drug resistant) gene which are very sensitive to the effects of ivermectin. Although Collies have the highest allelic frequency for the mutant, other affected breeds include the Longhaired Whippet, Shetland Sheepdog, Miniature Australian Shepherd, Silken Windhound, McNab, Australian Shepherd, Wäller, White Swiss Shepherd, Old English Sheepdog, English Shepherd, German Shepherd and Border Collie 18. Since this genetic defect has been identified in many mixed breed dogs testing could be recommended in all dogs before using an avermectin.
Remember that some other drugs (e.g., ketoconazole, erythromycin) can also tie up P-glycoprotein and increase risk of neurotoxicosis when co-administered with a macrocyclic lactone.
Ivermectin (the injectable product given orally) is the most common treatment for generalized demodicosis used in my practice. I routinely recommend a slowly increasing dosage protocol with the drug given with food. A suggested schedule is to start at a trial dose of 0.05 mg/kg daily, then increase to 0.1 mg/kg for the next week. If all is well, increase to 0.2 mg/kg the next day, and 0.3 mg/kg the following day, and finally maintain on 0.4 mg/kg daily, although some patients may require doses as high as 0.6 mg/kg. Continue treatment for two months past negative scrapings. Advise the owner to discontinue immediately if there is evidence of toxicosis (especially lethargy, ataxia, mydriasis and gastrointestinal signs); in this situation, I will usually revert to a lower dose – typically 0.3 mg/kg – on an alternate day treatment schedule (if the dog does not show adverse signs at this dose), while monitoring closely for adverse events.
Note that ivermectin has a relatively long half-life and with daily administration serum concentrations continue to increase for weeks before reaching equilibrium; adverse effects have been reported as long as 10 weeks following institution of treatment 17. Neurotoxicosis can be induced in “normal” (i.e., MDR1(-/-)) dogs after administration of ivermectin or doramectin equal to or greater than 100 μg/kg 18. Clinical signs are dose-dependent and can range from mild depression and ataxia, as well as disorientation and mydriasis within 12 hours of dosing (at 0.1-0.12 mg/kg), to more severe ataxia, stupor, recumbency, head bobbing, apparent blindness, facial twitches, hypersalivation, episodes of hyperventilation and bradycardia (at doses up to 0.17 mg/ kg). Severe neurotoxicosis signs can be seen with doses around 0.2-0.25 mg/kg or more, and include depression, ataxia and apparent blindness as early onset symptoms, as well as vomiting, paddling movements, tremor and excessive salivation, followed by stupor, feeble attempts to crawl, recumbency, and finally non-responsiveness and coma within 30-50 hours after application, often resulting in death 18.
Doramectin has been recommended with apparent efficacy for the treatment of demodicosis in MDR1 (+/+) dogs at weekly subcutaneous injections of 0.6 mg/kg 14, although the author has no personal experience with this product and further investigation has been recommended 17.
Milbemycins can be successful in treating demodicosis. Milbemycin oxime given orally (0.5-2 mg/kg q24H) is reported, with a better success rate at the higher dose 1718. I usually do not suggest “step-up” dosing of these cases but there will be the rare “sensitive” patient that develops neurological adverse effects. Moxidectin has also been evaluated for canine generalized demodicosis (0.2-0.5 mg/kg q24H PO) and again careful monitoring is recommended 19. Moxidectin is available in some countries as a 2.5% spot-on formulation (in combination with 10% imidacloprid) and can be used to treat demodicosis when applied weekly; the spot-on formulation has a markedly higher success rate in dogs with milder disease.
Lime sulfur dips (2%) used weekly for 4-6 weeks can be useful in treating feline demodicosis 6. They are very safe, and may be used as a parasiticide response trial to rule out D. gatoi in a pruritic cat; most affected cats will improve after three treatments. All in-contact cats should be treated when following this regime, and owners must be cautioned that this product can turn white cats yellow and may discolor jewelry; they should also be warned about the odor associated with treatment. A protective collar should be applied to the cat until it is dry, as many cats will vomit if allowed to groom while the product is wet.
Finally, follicular demodicosis is associated with bacterial furunculosis, and I have significantly reduced the population of Demodex using benzoyl peroxide (BPO) shampoos (followed by a conditioner) and antibiotics without antiparasitic drugs. Clipping the animal may improve contact with the shampoo. It is important to treat concurrent pyoderma/furunculosis as bacteria have been implicated in the immunosuppression of affected patients; however, the infection is considered secondary. Recent studies have shown that the use of systemic antibiotics did not change the treatment duration of dogs with generalized demodicosis when administered in addition to oral ivermectin and BPO shampoo; there was no significant difference in duration until the first negative scraping. One can presume that antibiotics can be discontinued once the pyoderma is clinically resolved 20.
In summary, one can conclude that with appropriate diagnostic skills and aggressive therapy, the success rate for this most challenging disease can be quite good. The response to treatment can be dramatic and very satisfying (Figure 10).