The thought of demodex mites crawling on your face is really unsettling. It’s only on my rosacea journey that I learned that these mites are a completely normal part of our skin ecosystem.
The big question is why do people with rosacea seem to have more of them? And more importantly, do these mites actually cause rosacea, or is their population explosion a symptom of having rosacea?
What Are Demodex Mites Anyway?
Demodex mites are tiny, microscopic organisms that live in or near hair follicles on human skin. There are two types that typically affect humans:
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Demodex folliculorum – found in hair follicles (especially on the face)
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Demodex brevis – lives deeper in sebaceous (oil) glands
They’re a normal part of our skin microbiome. Yes, that means everyone has them! These mites are invisible to the naked eye (about 0.3mm in size) and tend to be most active at night, feeding on sebum and dead skin cells. Their life cycle is only a few weeks, and their presence is usually harmless, unless something goes out of balance.
What’s the Connection Between Demodex and Rosacea?
Several studies have found that people with rosacea often have significantly higher numbers of Demodex mites on their skin, sometimes up to 18 times more than people without rosacea. But here is the big debate: are the mites causing the inflammation, or is the inflamed skin attracting more mites?
There are two main theories:
1. Demodex Mites as a Trigger
This theory suggests that an overgrowth of mites, especially Demodex folliculorum, can irritate the skin, damage the hair follicles, and trigger an inflammatory immune response. The mites may also carry bacteria, such as Bacillus oleronius, which further irritate the skin and cause redness and pustules (similar to acne).
2. Rosacea Attracts More Demodex
Another theory proposes that people with rosacea already have compromised skin barriers and more inflammation, which makes the skin a perfect environment for mites to thrive. The warm, oily, inflamed skin creates the ultimate buffet for Demodex (yuck).
Both theories can actually be true. It’s likely a loop where mites multiply due to inflammation, and their growing population further inflames the skin.
How Do You Know If Demodex Is the Problem?
There’s no easy way to self-diagnose a Demodex overgrowth. Most people who have rosacea will never be told, “You have mites” unless a dermatologist does a skin scraping or uses a microscope to detect them. Not a single dermatologist mentioned demodex mites in any of my appointments. However, this could be because it didn’t look like an overgrowth was an issue for me. Here are some symptoms that suggest that Demodex mites are contributing to your skin issues:
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Persistent itching or crawling sensations, especially at night
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Rosacea-like symptoms that don’t respond to typical rosacea treatments (assuming its not your first appointment)
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Pustules, redness, or scaling primarily around the nose, cheeks, forehead, or eyes
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Blepharitis (eyelid inflammation), which may be related to Demodex brevis in the lash follicles
Still, Demodex is rarely the sole cause, it’s usually part of a larger picture.
Medical Treatments That Target Demodex Mites
Another reason why a dermatologist may not mention demodex mites is because most of the typical creams that are prescribed to rosacea sufferers supposedly address the excessive demodex issue anyway.
1. Topical Ivermectin (Soolantra)
This ivermectin cream is one of the most common and effective treatments. Soolantra (called Rosiver in Canada) is a topical cream specifically designed to reduce Demodex populations and calm inflammation. Many rosacea patients see improvement within 4–8 weeks.
2. Metronidazole
While this antibiotic gel or cream doesn’t directly kill Demodex, it reduces inflammation and has some antiparasitic properties. It’s often prescribed alongside other treatments.
3. Permethrin Cream
This antiparasitic cream usually found in products that treat lice and scabies but can be used to deal with Demodex.
4. Oral Ivermectin
In more severe or stubborn cases, dermatologists may prescribe oral ivermectin to address systemic mite overgrowth.
5. Azelaic Acid (Finecea)
Azelaic acid is anti-inflammatory and has mite-killing properties. Studies show that azelaic acid can reduce demodex mite populations.
Is “Die Off” Real?
This is a common question on the Rosacea subreddit as well. Does it get worse before it gets better when using any of these prescribed topical creams?
I honestly wish I had known of this die off phenomenon 10-12 years ago when I was first prescribed ivermectin cream. I tried it for about three days, only to see my face become more red and inflamed. When I called my dermatologist’s office to tell her this, I was told to discontinue and was then prescribed Finecea instead. I don’t believe my skin got worse before I saw improvement with the Finecea.
The other issue is that many people are taking doxycycline at the same time as using the topical cream. So if they see improvement after a few weeks, that could also be when the antibiotics are starting to become effective as well.
Still, studies show that die-off is real and it may be worth continuing with the treatment for a longer period to see if there is a chance of improving.
Are There Natural or Non-Prescription Ways to Manage Demodex Overgrowth?
There are ways to help kill off excess demodex mites without a prescription. It may not be as fast or as effective but it’s definitely worth trying first. Just like prescription topical creams, there is no guarantee that these natural treatments will work to reduce your rosacea or kill off extra demodex mites. Especially when we now know that there could be multiple factors that are causing your rosacea.
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1. Tea Tree Oil
Demodex mites live in hair follicles and sebaceous glands. They remain hidden there during the day and at night they emerge to mate and lay eggs on the skin’s surface, whether its on the scalp or face. Yes let’s cringe together.
Tea tree oil is one of the most widely studied natural options for Demodex. It has antimicrobial and anti-mite properties. Use tea tree shampoo (this is the one I use) and leave it on your scalp for at least 5 minutes before rinsing. For your face, tea tree oil is too strong to use by itself. It must be diluted with a carrier oil like jojoba oil. Wipe your face, eyelids, eyebrows and up to your hairline. You can also try using tree oil lid wipes like Cliradex or a similar product. I have never used this product but have searched for tea tree oil experiences on the rosacea subreddit and this is a brand that was discussed.
2. Ivermectin Lice Lotion or Horse Paste
Prescription ivermectin creams can be expensive, and unaffordable for some people. Also, if you’re in Canada like I am, there’s also quite a wait time to see a dermatologist to get a prescription. Many people, including influencer dermatologists have mentioned trying lice lotion 0.5% on the face. The main one I’ve seen mentioned are from either Walgreens or the brand Equate which is from Walmart. It may also be at CVS. The horse paste is a higher concentration at 1.87%.
Please use with caution. I have never used either one before but it was on my list to try if I didn’t experience any improvement.
3. Raw Honey Masks
Raw honey, especially manuka honey, has antimicrobial, anti-inflammatory, and healing properties. Using a raw honey mask a few times a week can soothe inflamed skin and create an unfriendly environment for mites.
4. Green Tea Extract
Topical green tea contains EGCG, a potent anti-inflammatory compound that can help soothe rosacea symptoms and reduce redness.
5. Lemongrass Essential Oil
I came across a reddit post in the rosacea subreddit of course, that showed a study that said that lemongrass essential oil was effective in killing demodex mites that were burrowed in hair follicles. So I added several drops of lemongrass essential oil to a handful of jojoba oil and applied it to my scalp for 5 to 10 minutes. There was a tingling sensation that eventually felt a bit like burning. Then I shampooed clean per usual. I did this for a few days in the month. I don’t know whether it was effective or not as I was also in the middle of my new diet plan. But it was a low cost investment that I was willing to try.
6. Azelaic Acid
Non-prescription azelaic acid products are available in several different brands. A popular one is from The Ordinary and has 10% azelaic acid. Prescription is usually 15 – 20%. Azelaic acid has acaricidal (mite-killling) properties and can improve rosacea by reducing the mite population as well as inflammation.
7. Sulfur
Sulfur has antimicrobial and keratolytic (exfoliating) properties that can help reduce inflammation and improve rosacea. Sulfur can be found in soaps, creams and face washes.
Did Anything Work For Me?
I used Finecea azelaic acid prescription cream everyday, twice a day for around ten years. But my rosacea never entirely cleared. Otherwise I wouldn’t have had to use it for so long. I was told there were no long-term side effects from using Finecea, however it ended up depigmenting my skin. Since I have brown-colored skin, it’s clear that my skin has patches of white skin now under the redness.
So either azelaic acid didn’t kill the mites, or mites weren’t what was actually causing the rosacea. I have been using a sulfur cream for a few months and it cleared the perioral dermatitis on around my mouth. I can’t recommend this sulfur cream enough.