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Gets Worse Before It Gets Better

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  1. 1. When you treated your rosacea for demodex mites, did it get worse before it got better?

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demodex.jpg
Image of Demodex Folliculorum courtesy of National Geographic - by Darlyne A. Murawski

Galderma reports that treatment with Soolantra improves rosacea. This is usually the same with treatment using the ZZ cream

There are substantial anecdotal reports that treatment for demodectic rosacea by reducing the number of mites that it gets worse before it gets better. 

The Theory Behind This Logic
The logic behind this is that killing the demodex mites causes a die-off of the mites that takes weeks to accomplish since new eggs are being hatched each day and the "life cycle of demodex mites consists of five phases of development and lasts from 14 to 18 days". [1] Furthermore because the movement of the mites has been shown to be "at a speed of 8-16 mm/h" [2] they may leave the area being treated and return later while planting eggs along the route. During the initial treatment which may take weeks some of the mites are reported to be killed which may cause inflammation and worsen the skin. One explanation of this is the "Jarisch–Herxheimer reaction" (JHR) which has been "traditionally associated with antimicrobial treatment of syphilis." [3] The principle of JHR may indicate a reason why it gets worse before it gets better. One source comments on this by stating, "And while the JHR only technically relates to spirochetal infections (spiral-shaped bacteria) and antibiotics, the concept of symptom-onset or worsening after starting treatment with antimicrobials has been seen to apply more broadly in clinical practice. This is why you’ll often hear practitioners talk about a Herx-reaction, even if it isn’t scientifically accurate. But, what we call ‘die-off symptoms’ is certainly something we see commonly when clients begin addressing bacteria, parasites and yeast pathogens using natural antimicrobials." [4] Most reports indicate that it takes eight to twelve weeks to achieve clearance. 

It is not uncommon in medical treatment that 'it gets worse before it gets better,' such as in treating acne, which the Mayo Clinic states, "With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely," or in immunotherapy, 'it gets worse before it gets better.'  In fact, immunosuppressive treatments may actually increase demodex mites! [11] When treated with isotretinoin for acne, one reports states, "Some patients experience an initial worsening of their acne in the first month of treatment; less commonly, isotretinoin can induce acne fulminans." [13]

One article explains, how this might happen when treatment is for demodex mites: 

"Rosacea often improves with antibacterial drugs that don’t affect the mites, such as tetracyclines. Kavanagh thinks this is because rosacea is caused by a reaction to bacteria in the mite’s faeces." Antibiotics do not kill demodex mites but likely treats the bacteria the mites carry. [5]

Furthermore, there are at least six types of bacteria that have been associated with demodex mites, and bacteria has been implicated for a long time with rosacea. [6] At least one fungus has been associated with rosacea [7]. Viruses have not been ruled out in rosacea. There are very little, if any, clinical studies done on virus and rosacea. Viruses are in bacteria and throughout the human body and comprise more weight in the human body than bacteria by a factor of ten times. [8] For that matter, other microbes haven't been studied either, such as protozoa or archea. There is much to learn about the human microbiome and as more research is done, new insights are learned. 

Ivermectin, the active ingredient in Soolantra and horse paste is an insecticide that kills parasites, including mites. Sulfur in the ZZ cream has been used for decades to treat rosacea and kill the mites as well. [12] 

More study should be done on why treatment for demodectic rosacea seems in many cases to get worse before it gets better.

Nevertheless, reducing demodex density counts in rosacea improves the patient with rosacea. [9] Just think if 10K members of the RRDi each donated one dollar and insisted on supporting a reputable clinician to study what they wanted, supporting their own research, what might be discovered? This can only happen if you want it to happen. Or you can continue to do nothing and let the status quo research continue on. [10]

Rosacea Forum
Severe-die-off-from-zz-after-first-use

In the above thread, Mothinrust had an initial immediate reaction of getting worse and then one month (1/18/2020 post no 35) later posts, "But I do think it helping my skin so much....So I take the vast improvement as a sign of better things to come...."  He posted a total of eleven posts in the thread.

End Notes

[1] Demodex Update
Subheading, The potential role of Demodex folliculorum mites and bacteria in the induction of rosacea, third paragraph 

[2] Russian Study on Demodex Mites and Rosacea Illuminating, (2) The report confirms the size and movement of demodex, second paragraph

[3] Jarisch–Herxheimer reaction, Wikipedia

[4] Pathogen & Parasite Die-Off Symptoms: How to manage detox side-effects, Bella Lindemann, June 24, 2019

[5] Rosacea may be caused by mite faeces in your pores, Debora MacKenzie, New Scientist

[6] Bacteria Associated with Rosacea and Demodex Mites

Bacteria Theory

[7] Candida Albicans

[8] Human Microbiome, Brady Barrows 

[9] Decreasing Demodex Density Count Improves Rosacea

What are the numbers?

[10] Rosacea Research in Perspective of Idiopathic Diseases
Rosacea Research in Perspective of Funding

[11] Immunosuppressive Treatments May Increase Demodex Mites

[12] The Health Benefits of Sulfur, Cathy Wong, VeryWellHealth

[13] Clin Cosmet Investig Dermatol. 2019; 12: 943–951.
Challenges and Solutions in Oral Isotretinoin in Acne: Reflections on 35 Years of Experience
Vincenzo Bettoli, Aurora Guerra-Tapia, Maria Isabel Herane, and Jaime Piquero-Martín

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Very good post. I also have been researching and trying to find out the ways in which mite-bacterial interaction as well as viral interaction in rosacea exacerbate the condition of inflammation.

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