CHALLENGE: If the patient's other health problems aren't identified and treated, cases of demodicosis may not improve, or may improve
and then reoccur.
SOLUTION: Use the patient history, physical exam, clinical signs, and diagnostic testing results to identify any other health problems.
Demodex mites can lead to secondary pyoderma. Superficial staphylococcal pyoderma is treated empirically by using a beta-lactamase-stable
antibiotic for a minimum of four weeks. In dogs with unresponsive superficial pyoderma or deep pyoderma, or when rod-shaped
bacteria are identified on cytologic examination, a bacterial culture and antimicrobial sensitivity testing is strongly recommended
to help select an antibiotic. Continue antibiotic therapy until the pyoderma is clinically and cytologically resolved. Deep
pyodermas may need several weeks of antibiotic therapy. Topical therapy with a shampoo containing an antibacterial active
ingredient (benzoyl peroxide, chlorhexidine, or ethyl lactate) can also help treat the pyoderma.
Cases of adult-onset demodicosis usually have an underlying cause. Ask clients about any medications that the pet is receiving,
as certain medications, such as glucocorticoids, can contribute to the development of demodicosis. I question clients about
their use of topical and over-the-counter medications. I've found that some clients don't consider these "medications" even
though topical and over-the-counter glucocorticoids can also contribute to the development of demodicosis, especially if applied
frequently. Adult-onset demodicosis can be a sign of an underlying systemic condition such as Cushing's disease, hypothyroidism,
diabetes mellitus, or heartworm disease. A complete blood count, serum chemistry profile, urinalysis, and heartworm test are
useful to explore predisposing conditions. With the history and any other findings from the physical examination, this minimum
database may lead to other diagnostic testing such as hormonal assays and stimulation studies. In cases with an underlying
systemic condition, resolution of the demodicosis may not occur until the pet's other health problems are well controlled.
CHALLENGE: There are several options for treating demodicosis. Which one should you choose?
SOLUTION: Educate yourself and your client on the treatment options for demodicosis so that you select the appropriate therapy for
Most of the various treatments for canine demodicosis fall into two categories of medication. Amitraz is a monoamine oxidase
inhibitor (MAOI), prostaglandin synthesis inhibitor, and an alpha2-adrenergic agonist. It is available in the United States as a liquid concentrate (Mitaban—Pfizer Animal Health) to be used
as diluted dip and as a spot-on with metaflumizone (ProMeris for dogs, Fort Dodge Animal Health). Ivermectin, milbemycin oxime,
and moxidectin are all macrocyclic lactones.
When dosed appropriately, both amitraz and the macrocyclic lactones are effective therapies for demodicosis. Each therapy
has its benefits and drawbacks. It's important to evaluate each dog with demodicosis on a case-by-case basis and educate clients
about the different miticidal options.
Amitraz is the only active ingredient approved by the U.S. government for treatment of Demodex mites. It is an especially important miticidal option in dogs that are sensitive to macrocyclic lactones. Drawbacks of amitraz
dips include the need to apply the treatment topically and potential side effects such as lethargy, hypothermia, bradycardia,
and hyperglycemia. The spot-on formulation of amitraz recently became approved for the treatment of demodicosis and is more
convenient to apply; however, it potentially has the same side effects of amitraz dip. More studies are currently being performed
on this product that will give us more information on how to use it for the treatment of demodicosis.
The two most commonly used macrocyclic lactones for the treatment of demodicosis are milbemycin oxime and ivermectin. Both
are given orally once daily at 1.5 to 2 μg/kg for milbemycin oxime and 300 to 600 μg/kg for ivermectin. Milbemycin oxime is
more expensive than ivermectin, but for some clients, its tablet form may be easier to administer than liquid ivermectin.
Dogs should test negative for heartworm disease before starting macrocyclic lactone therapy. Side effects can include lethargy,
mydriasis, muscle tremors, ataxia, blindness, and seizures. When using macrocyclic lactones for generalized demodicosis, clients
should understand their extra-label use and potential for side effects. To identify ivermectin-sensitve dogs, a test to screen
dogs for a genetic mutation that causes ivermectin sensitivity is available at the Washington State University Veterinary
Clinical Pharmacology Laboratory (
http://www.vetmed.wsu.edu/vcpl). I also recommend starting dogs on a low dose (50 μg/kg) of ivermectin once a day and incrementally increasing the dose
by 50 μg/kg during the first days of treatment until the target dose is achieved.
In my experience, one of the most common reasons for a seemingly resistant case of demodicosis is the premature discontinuation
of treatment. Any miticidal treatment for canine demodicosis should continue until two consecutive negative skin scrapings
are obtained two to four weeks apart. Client compliance can be an issue because cases of canine demodicosis may look clinically
normal to the client before they are truly mite-free, tempting clients to stop the use of the miticide early. A client handout
on the need to continue the miticide as directed can be very helpful.
A patient with demodicosis may respond better to one miticide than another. A good rule of thumb is to give each treatment
plan several weeks to demonstrate an effect. If the number of eggs, immature mites, or total mites do not decrease significantly
in four to eight weeks, consider altering the dose of the the given treatment before switching active ingredients.