An integrative approach to demodectic mange

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An integrative approach to demodectic mange

Canine demodicosis can be a frustrating disease state to treat in small animal practice. An integrative approach using herbs, nutrition and acupuncture provides faster resolution of the presenting problem, while also addressing underlying imbalances.

Canine demodicosis is a non-contagious parasitic dermatosis commonly seen in small animal practice. It is characterized by excessive proliferation of the commensal mite, Demodex canis, within the hair follicles and sebaceous glands.1 Demodecosis can be localized or generalized, with localized cases being easier to resolve. Generalized demodicosis is typically more difficult to treat and often complicated by secondary bacterial infections.2 However, an integrative approach to treatment that draws on herbs, nutrition and acupuncture can be effective.

How does canine demodicosis arise?

The progression to pathological disease is influenced by many factors, including genetic defects, alteration of the skin’s structure and biochemistry, immunological disorders, immuno-suppressive therapies, hormonal status, breed, age, nutritional status, oxidative stress, length of hair coat, stage of oestrus cycle, parturition, endoparasitism and the presence of debilitating diseases.1,3 Typically, the number of mites is kept low by the dog’s immune system, but overpopulation of host-specific follicular Demodex mites results in demodicosis, with the cutaneous microenvironment playing a role in the development of disease.3

There are typically multiple reasons why the Demodex mites are able to multiply beyond the control of these patients’ immune systems. Many are under extreme stress, experiencing relocation to a foster home or shelter after having been shipped and sterilized the same day, while simultaneously adjusting to new diets, routines, caregivers and environments. Other patients have an underlying disease such as cancer, hypothyroidism or hyperadrenocorticism. An integrative approach to demodicosis should address as many of these predisposing factors as possible, as well as environmental stressors.

Conventional treatments lead to frustration

Practitioners are often frustrated when it comes to treating canine demodicosis, since current therapeutic treatment options are of variable efficacy, none has been deemed most effective, and they’re often are associated with potentially severe side effects.4,5 A recent (2019) detailed search of the literature recommends not using Amitraz topical, since it is backed by only a single study. Moxidectin has a 37% chance of severe side effects, and the oral use of Afoxolane also has only one research reference.5 A common conventional treatment, oral Ivermectin, which is known to have potential neurotoxicity side effects, is often used alongside a benzoyl peroxide shampoo, followed by topical Amitraz. Treatment may go on for months in severe cases, leading to frustrated owners and suffering patients.

To effectively treat the current condition as well as resolve the predisposing factors, holistic modalities including herbal medicine, nutrition and acupuncture should be utilized.

Herbal medicine

When formulating an herbal combination for demodicosis, pre-existing conditions of immunodeficiency, poor gut health, secondary bacterial infections, circulation to the integument, stress and allergies should be addressed.

Immuno-modulation

The inclusion of herbal immuno-modulators such as ashwagandha (Withania somnifera), punarnava (Boerhaavia diffusa), aloe vera, turmeric (Curcuma longa) and tulsi (Ocimum sanctum) resolved demodicosis in four weeks when combined with conventional treatments, as compared to eight weeks to using Ivermectin and Amitraz alone.1

Demodex canis mites have the ability to down-regulate CD4+ T cells, with increased apoptosis of peripheral leukocytes, contributing to the progression of clinical disease manifestation. Olive leaf extract (Olea Europaea) is an example of an herb known to modulate CD4+ T cells and increase the production of leukocytes .6 Eleuthero root (Eleutherococcus senticosus) increases T lymphocytes, especially helper T cells,  as well as cytotoxic and natural killer cells.7 Cat’s claw (Uncaria tomentosa) is an immune stimulant that normalizes lymphocytes, possibly with cytokine modulation, and stimulates the transition of  immature CD4+ and CD8+ T cells into mature CD4+ helper lymphocytes.8

Mites also elevate Tumor Growth Factor beta (TGF-β) and inhibit Tumor Necrosis Factor alpha (TNF alpha) mRNA expression.3 TNF alpha is an inflammatory cytokine produced by macrophages/monocytes during acute inflammation, and is responsible for a diverse range of signaling events within cells, leading to necrosis or apoptosis. The protein is also important for resistance to infection and cancers.9 Olive leaf extract modulates TGF-β and TNF-α mRNA expression.Maitake (Grifola frondosa) supports TNF production while enhancing T-4, T-8 and NK function.10

It has been hypothesized that elevated IL-10 levels account for the occurrence and recurrence of demodicosis in dogs.3 Olive leaf extract has been found to decrease levels of IL-10, which serves to maintain the equilibrium between IL-10 and IL-17, an important factor in the prevention of chronic inflammatory, autoimmune and allergic diseases.6,11 Other immune-modulating herbs helpful in these cases include astragalus (Astragalus membranaceus), Asian ginseng (Panax ginseng), reishi (Ganoderma lucidum), maitake (Grifola frondosa), shitake (Lentinus edodes), turkey tail (Trametes versicolor), cordyceps (Cordyceps sinensis), and Echinacea (Echinacea purpurea).

Addressing secondary infections and supporting the liver

When utilizing integrative therapeutic approaches, it is important to address secondary infections as well as provide gut and liver support, especially in cases where pharmaceuticals are also being used. Secondary bacterial infections can be addressed with Echinacea (Echinacea purpurea), Oregon grape (Mahonia aquifolium) and Pau d’Arco (Tabebuia spp.). The liver can be supported with a combination of calendula (Calendula officinalis), milk thistle (Silybum marianum), dandelion leaf (Taraxacum officinale), cleavers (Galium aparine), gotu kola (Centella asiatica), cat’s claw (Uncaria tomentosa) and red clover (Trifolium pretense).

Adaptogenic herbs and managing stress

The author has seen many cases of demodicosis in puppies from stressful housing situations, as well as in older dogs with underlying disease causing emotional and physical strain. Adaptogenic herbs are essential in these cases to address the underlying psychological stress from chronic disease as well as environmental stressors.

An adaptogen acts by increasing the animal’s resistance to a broad spectrum of adverse biological, chemical and physical factors, while regulating his organ and system function.  Ashwagandha (Withania somnifera), which not only helps modulate the HPA axis, but also has been found to have a strong anti-inflammatory effect, assists in integument healing. Other useful adaptogens include Korean ginseng (Panax ginseng) and eleuthero root (Eleutherococcus senticosus). In cases where the dog has a TCVM diagnosis of Blood deficiency, the formula Xiao Yao San (XYS) is indicated. XYS is a traditional Chinese medicine formulation that relieves depression and nourishes the liver. Its active ingredients can raise the expression of the glucocorticoid receptor and recover the negative feedback of the HPA axis to relieve stress and illness.12

Topical herbal treatments

Topical treatment with crude extracts of ginger (Zingiber officinale) and lemon, juiced, mixed, diluted in water and applied to affected areas, resulted in faster recovery when combined with Ivermectin, than when Ivermectin was used alone.4 Topical neem (Azadirachta indica) on affected areas can suppress mite numbers along with diluted essential oils of lavender and eucalyptus.13,14 A rinse of calendula tea improves healing time of the skin with its vulnerary and anti-inflammatory properties, as its flowers are rich in flavonoids and carotenoids.15

Nutrition

Improving the plane of nutrition is another essential step in assisting these cases. A poor quality diet will play a role in the development of disease and the propagation and perpetuation of demodicosis. A fresh food diet, either cooked or raw, is the gold standard; multiple pro-inflammatory factors are associated with kibble diets (including the Maillard reaction).16 The more bioavailable the nutrients are, the better patients are able to absorb and use them in all systems.17

Nutritional supplements such as glutamine will repair and improve intestinal barrier function as well as the immune system and general overall health. Improving gut health also entails microbiome restoration, since 80% of the immune system is in the gut. A non-processed diet will support the gut microbiome as well as the skin microbiome.                  ` Probiotic supplementation activates dendritic cells, macrophages and monocytes to provoke specific helper T cell responses that elicit immuno-modulatory effects on not only the intestinal but also the systemic immune system.18 Leaky gut syndrome can be addressed with colostrum, fecal transplants, probiotic supplementation and non-processed diets.

Acupuncture

From a TCVM perspective, acupuncture decreases inflammation and improves the immune system, blood flow to the integument, HPA axis balance, and thyroid and thymus function. Patients with demodicosis are often characterized as Blood deficient, with secondary Wind and accompanying pruritus. A secondary bacterial infection may also lead to Damp Heat. Acupuncture points should be chosen based on the patient and his tongue and pulse diagnosis.

Points that can be helpful for Damp Heat are BL17, ST40 and SP10. Acupuncture up-regulates NK cell activity. Studies have shown that electroacupuncture (EA) stimulation of the acupuncture point ST36 induces secretion of β-endorphins and increases levels of IFN-γ, which enhance splenic NK cell activity. ST36 also suppresses the increase of Th2 cytokines, especially IL-4.19 A number of brain imaging studies in animals have shown that EA treatment activates the hypothalamus, a primary center for neuroendocrine-immune modulation, and regulates activities of the autonomic nervous system. Another point that would be helpful for immune modulation is LI4.

Conclusion

Demodicosis can be a frustrating condition to treat, but a cohesive integrative approach will help patients heal faster, while also decreasing pharmaceutical side effects and treating underlying predisposing and secondary factors.

References

1Kachhawa JP, AP Singh, A Ahuja, A Sharma, S Kachhawaha, M Srivastava. “Clinical Management of Canine Demodicosis with Acaricides and Herbal Immunomodulator”. Intas Polivet 17 (1), 2016:188-190.

2Kuznetsova E, Bettenay S, Nikolaeva L, Majzoub M, Mueller R. “Influence of systemic antibiotics on the treatment of dogs with generalized demodicosis”. Vet. Parasitol. 188 (1–2), 2012, 148–155.

3Singh SK, Umesh D. “The immune-pathological conversions of canine demodicosis”. Veterinary Parasitology 203: 1-5, 2014.

4Roy S, M Roy, T Ottalwar. “Therapeutic Management of Demodicosis in Canines”. Intas Polivet 17, 2016 (1): 186-187.

5Perego R,. et. al. “Critically appraised topic for the most effective and safe treatment for canine generalized demodicosis”. BMC Veterinary Research; 15-17, 2019.

6Magrone T, et. al. “Olive Leaf Extracts Act as Modulators of the Human Immune Response”. Endocrine, Metabolic & Immune Disorders – Drug Targets, 2018, 18: 85-93.

7Bohn B, CT Nebe, C Birr. “Flow-cytometric studies with eleutherococcus senticosus extract as an immunomodulatory agent”. Arzneimittelforschung. Oct;37(10):1193-6, 1987.

8Domingues A, et al. “Uncaria tomentosa Aqueous‐ethanol Extract Triggers an Immunomodulation toward a Th2 Cytokine Profile”. Phytother. Res.25: 1229–1235, 2011.

9Idriss HT, JH Naismith. “TNF alpha and the TNF receptor superfamily: structure-function relationship(s)”. Microsc Res Tech. 2000 Aug 1;50(3):184-95.

10 Wu SJ, Lu TM, et al, “Immunomodulatory Activities of Medicinal Mushroom Grifola frondosa Extract and its Bioactive Constituent”. Am J Chin Med, 2013;41(1):131-44.

11Kim HW, et al. “Dietary Lutein stimulants immune response in canine”. 2000. Vet Immunol, 74(3-4):315-327.

12Lu J, Fu L, Qin G, Shi P, Fu W. “The regulatory effect of Xiao Yao San on glucocorticoid receptors under the condition of chronic stress”. Cell Mol Biol (Noisy-le-grand). 2018 May 15;64(6):103-109.

13Mulla MS, Su T. “Activity and biological effects of neem products against arthropods of medical and veterinary importance”. J Am Mosq Control Assoc 15(2):133-152, 1999.

14O’Brien DJ. “Treatment of psoroptic mange with reference to epidemiology and history”. Vet Parasitol 83 (3-4): 177-185, 1999.

15Preethi KC, Kuttan R.,” Wound Healing Activity of Flower Extract of Calendula officinalis”. J Basic Clin Physiol Pharmacol., 2009;20(1):73-9.

16Van Rooijen C, Bosch G, Van Der Poel AFB, Hendriks WH, Wierenga PA. “The Maillard reaction and pet food processing: Effects on nutritive value and pet health”. Nutrition Research Reviews, v26 n2 (2013 01 01): 130-148.

17Girodon F, et al. “Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients”.

18Fong FLShah NPKirjavainen PEl-Nezami H. “Mechanism of Action of Probiotic Bacteria on Intestinal and Systemic Immunities and Antigen-Presenting Cells”. Int Rev Immunol. 2016 May 3;35(3):179-88.

19Sun Kwang Kim, Hyunsu Bae. “Acupuncture and immune modulation”. Autonomic Neuroscience: Basic and Clinical 157:38-41, 2010.

This article has been peer reviewed.