Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Case Report
Editorial
Erratum
Guest Editorial
History
Image
Images in Clinical Practice
Invited Commentary
JSSTD Symposium
Letter to Editor
Letter to the Editor
Letter to the Editor - Study Letter
Net Case
Net Consensus Statement
Net Educational Video for Residents
Net Image
Net Letter
Net Quiz in Dermatology
Obituary
Original Article
Resident’s Page
Review Article
Study Letter
Study Letter Case Series
Symposium
View/Download PDF

Translate this page into:

Net Case
ARTICLE IN PRESS
doi:
10.25259/JSSTD_40_2022

Papulopustular periorbital demodicosis: A diagnosis often overlooked

Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Corresponding author: Megha Merri Alex, Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India. meghamerrialex@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Alex MM, Criton VJ, Mohanan S. Papulopustular periorbital demodicosis: A diagnosis often overlooked. J Skin Sex Transm Dis doi: 10.25259/JSSTD_40_2022.

Abstract

Demodicosis is the term given for cutaneous diseases caused by the human ectoparasitic mites Demodex folliculorum and Demodex brevis which are common commensals of the pilosebaceous units in human beings. We report a 72-year-old female who presented with erythematous papulopustular lesions over both upper and lower eyelids and a few similar lesions on the cheeks of 2 weeks duration with one similar episode in the past. A cyanoacrylate standardized skin surface biopsy showed increased mite density and the patient was successfully treated with acaricides. Demodicosis is often misdiagnosed as contact dermatitis, papulopustular rosacea, or seborrheic dermatitis. A high index of suspicion of demodicosis is needed to arrive at an accurate diagnosis.

Keywords

Demodex
Demodicosis
Papulopustular
Periorbital

INTRODUCTION

Demodex, initially described as a worm by Jacob Henle, and later identified accurately as an obligatory human ectoparasitic mite, has now been implicated in the pathogenesis of many cutaneous diseases.[1] These are collectively called demodicosis.[2] Different clinical manifestations of demodicosis have been described in the literature. In this case report, we present a rare manifestation of the same.

CASE REPORT

A 72-year-old woman presented to the dermatology outpatient department with pruritic, red, raised lesions around both eyes of 2 weeks duration. She had Type 2 diabetes mellitus, hypertension, and bronchial asthma. There was no history of any topical applications (medications or cosmetics) on face. She gave a history of similar lesions a year back, which resolved after 3 months of treatment with oral and topical medications, the details of which were not known.

Examination revealed multiple, firm, discrete, reddish papules with minimal scaling and a few papulopustules on an erythematous background involving the upper and lower eyelids of both eyes. A few similar lesions were noted on the cheeks [Figure 1a]. There were no telangiectasia. Ophthalmology evaluation ruled out ocular involvement. All systems were within normal limits. Our differential diagnoses of sarcoidosis, acne agminata, and granulomatous rosacea were ruled out as the biopsy report showed only dense perivascular and perifollicular infiltrate of lymphocytes and occasional neutrophils with no evidence of granuloma. A differential diagnosis of air-borne contact dermatitis was considered and the patient was given topical steroids for 2 weeks with no improvement. A dermoscopic examination revealed non-specific scales and spiky-whitish, thread-like structures indicating Demodex tails [Figure 2].[3]

Figure 1: (a): Erythematous papules and pustules on the eyelids of a patient with demodicosis; (b): resolution of lesions after 1 month of anti-Demodex treatment.
Figure 2:: Dermoscopy showing spiky-whitish, thread-like structures (black arrows) indicating Demodex tails in a patient with demodicosis (Illuco dermoscope, polarised light, ×10)

A cyanoacrylate standardized skin surface biopsy (SSSB) was performed, which showed viable Demodex mites (with a mite density of more than 5/cm2).[4,5] Patient was treated with topical and oral (400 mg twice a day for one week) metronidazole and single-dose oral ivermectin (12 mg). A repeat SSSB after 1 week of treatment showed decrease in mite density (2/cm2). On follow-up visit after 1 month, the patient showed significant clinical improvement [Figure 1b]. Patient was advised maintenance therapy with 1% topical ivermectin cream for one more month. Clinical, dermoscopic, SSSB findings, and a positive response to anti-Demodex therapy pointed toward a diagnosis of demodicosis in our patient.

DISCUSSION

Demodex is a genus of obligatory human ectoparasitic mites belonging to class Arachnida, family Demodicidae which live in or near pilosebaceous units at a density of ≤5 mites/cm2. The two species which parasitize humans are Demodex folliculorum and Demode brevis.[2,4,6] They have a predilection for high sebum producing areas and are hence, found mainly on the face with maximum numbers on the forehead, cheeks, nose, and nasolabial folds. They are also found on the scalp, external ear, meibomian glands, eyelash follicles, upper chest, nipples, penis, mons veneris, buttocks, and ectopic sebaceous glands in the buccal mucosa.[1] Cutaneous diseases caused by these mites are termed demodicosis.[7] It manifests when the follicles are heavily infested with the mites or when the mites penetrate the dermal tissue. The immune system by various unknown mechanisms maintains Demodex as commensals. An imbalance in the host immunity together with changes in the microenvironment of skin and increased mite density could possibly play a role in the pathogenesis of demodicosis.[8,9]

Human demodicosis has been classified into primary and secondary forms. Primary demodicosis is due to excessive mite density in the absence of pre-existing or concurrent inflammatory dermatoses, whereas secondary demodicosis is associated with an increase in Demodex mites in patients with other known dermatoses or systemic diseases. The dermatoses associated with secondary demodicosis include papulopustular rosacea, seborrheic dermatitis, perioral dermatitis, steroid dermatitis, tumors (eyelid basal cell carcinoma, and mycosis fungoides), and melanocytic naevi. Systemic diseases such as chronic renal failure, can also predispose to secondary demodicosis.[1,7,10,11] The different clinical manifestations of demodicosis include spinulate demodicosis, papulopustular demodicosis, perioral demodicosis, and blepharitis to mention a few.[1,7] Though periorbital demodicosis is often described as a manifestation of demodicosis in literature, it is rarely encountered and reported.[12] We ought to consider demodicosis as one of the differential diagnoses in a patient, who presents with periocular, non-specific, papules. A standardized skin surface biopsy and response to treatment with acaricidal agents (ivermectin, metronidazole, permethrin, or benzyl benzoate) can help to diagnose demodicosis.[13-15]

CONCLUSION

A high index of suspicion is needed to arrive at a prompt diagnosis of demodicosis and gratifying results can be obtained by treatment with acaricides.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , . Arthropods In: Rook's Textbook of Dermatology (9th ed). Hoboken, New Jersey: Wiley-Blackwell; . p. 1124-6.
    [CrossRef] [Google Scholar]
  2. , . Human Demodex mite: The versatile mite of dermatological importance. Indian J Dermatol. 2014;59:60.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , . Usefulness of dermoscopy in the diagnosis and monitoring treatment of demodicidosis. Dermatol Pract Concept. 2017;7:35.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . Density of Demodex folliculorum in rosacea: A case-control study using standardized skin-surface biopsy. Br J Dermatol. 1993;128:650-9.
    [CrossRef] [PubMed] [Google Scholar]
  5. . Comparison of the two techniques for measurement of the density of Demodex folliculorum: Standardized skin surface biopsy and direct microscopic examination. Br J Dermatol. 2010;162:1124-6.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Demodex folliculorum (Simon) and D. brevis akbulatova of man: Redescription and reevaluation. J Parasitol. 1972;58:169-77.
    [CrossRef] [PubMed] [Google Scholar]
  7. , . Human demodicosis: Revisit and a proposed classification. Br J Dermatol. 2014;170:1219-25.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , . Demodex: A skin resident in man and his best friend. J Eur Acad Dermatol Venereol. 2021;35:62-72.
    [CrossRef] [PubMed] [Google Scholar]
  9. , . Which factors influence Demodex proliferation? A retrospective pilot study highlighting a possible role of subtle immune variations and sebaceous gland status. J Dermatol. 2021;48:1210-20.
    [CrossRef] [PubMed] [Google Scholar]
  10. . Demodectic Eruptions (Demodicidosis) in the human: 30 years-experience with 2 commonly unrecognized entities: Pityriasis folliculorum (Demodex) and acne rosacea (Demodex type) Arch Dermatol. 1961;83:816-27.
    [CrossRef] [PubMed] [Google Scholar]
  11. , , , , , , et al. Facial dermatosis associated with Demodex: A case-control study. J Zhejiang Univ Sci B. 2011;12:1008-15.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , . Demodex folliculitis presenting as periocular vesiculopustular rash. Orbit. 2013;32:370-1.
    [CrossRef] [PubMed] [Google Scholar]
  13. , . Effectiveness of benzyl benzoate treatment on clinical symptoms and Demodex density over time in patients with rosacea and demodicosis: A real life retrospective follow-up study comparing low-and high-dose regimens. J Dermatol Treat. 2022;33:456-65.
    [CrossRef] [PubMed] [Google Scholar]
  14. , . The effect of different therapeutic modalities on Demodex densities and clinical symptoms of patients with demodicosis. Acta Med. 2022;53:83-9.
    [CrossRef] [Google Scholar]
  15. , . Comparation of the efficacy of oral ivermectin combined topical metronidazol 1% with oral and topical metronidazol in the treatment of demodicosis. Tạp Chí Liễu Học Việt Nam. 2021;33:30-5.
    [CrossRef] [Google Scholar]
Show Sections