Demodex folliculitis B88.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Acne rosacea demodes; Demodex folliculitis; Demodex Folliculitis; Demodex folliculorum folliculitis; Demodicidosis; Demodicitis; Demodicosis

History
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Ayres 1930

Definition
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Rare chronic clinical picture with grouped, follicularly bound papules in saprophytic colonization of the sebaceous gland follicles with the about 0.03 cm large Demodex folliculorum and other Demodex species (e.g. Demodex brevis). These pathogens are found exclusively in humans and cannot be transmitted to other mammalian species.

Manifestation
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  • Advanced adulthood (50-70 years)
  • Also in younger HIV infected persons (30-40 years)
  • Occasionally also with immunocompetent adolescents and young adults

Localization
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Especially face, cheeks, eyelids, eyelid margins.

Clinical features
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Chronic, red, chronic plaques persisting for months, usually unilateral, with mostly disseminated, 0.1-0.2 cm large, follicular, red or red-brown nodules and pustules; often scaling and crust formation. In the case of prolonged existence, extensive reddening of the affected areas. Furuncoloid nodules are rarer, so that the clinical picture may remind of acne conglobata (Demodex folliculits conglobata). Pityriasiform scaling of the affected areas.

Occasionally accompanied by itching.

In the case of infestation of the eyelids (demodex-blepharitis, infestation of the Meibomian glands): incrustations and eczema of the eyelid margin, photophobia and foreign body sensation.

To what extent the frequent occurrence of the demodex mite plays a role in the pathogenesis or aggravation of rosacea is still unclear.

Childhood demodex folliculitis is observed in acute lymphocytic leukemia.

Histology
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3-5 or even more mites in a dilated follicle; perifollicularly arranged, inflammatory, partially epitheloid-cell infiltrate, spongiotic follicular epithelium; possibly perifollicular, granulomatous inflammation with rupture of the follicular epithelium.

Diagnosis
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Histology and clinic. Mites are very conspicuously detectable in the follicles with all stains!

For direct mite detection, a special horny layer tear-off with a cyanoacrylate quick adhesive is suitable. This is placed on a glass object carrier and pressed directly onto the cheek skin. After a short time (60 seconds) the slide can be carefully unrolled. This allows the follicle filaments with the mites to be pulled out of the sebaceous gland openings. They can be assessed microscopically (Melnik B 2018).

An alternative would be a confocal laser microscopy examination.

20-MHz sonography is also a suitable method for displaying follicular structures.

Differential diagnosis
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Rosacea

Bacterial folliculitis

perioral dermatitis

facial tinea

Remember! In case of unilateral skin changes and if the response to "classic rosacea therapy" is poor, think of demodicosis!

General therapy
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The treatment is usually long and difficult; it is similar to the therapy of rosacea in many respects.

External therapy
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Therapy with 10% crotamiton emulsions (e.g. Eraxil Lotio). Treatment on 2 consecutive days, then 1 week therapy break, renewed treatment cycle.

Alternatively permethrin cream, benzyl benzoate (e.g. Antiscabiosum 10% emulsion), allethrin (e.g. Jacutin N spray) or ivermectin (1.0-2.0%) in a cream base (available as finished drug "Soolantra®").

Otherwise 1-2% metronidazole creams e.g. as a formulation - hydrophilic metronidazole cream, or gels (as finished drug e.g. Metrogel® or as a formulation - 2% hydrophilic metronidazole gel ) s.a. rosacea.

  • Mites can be partially mechanically expressed at the edge of the eyelid.

Notice! External glucocorticoid applications are strictly prohibited!

Internal therapy
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If local therapy is not sufficient, metronidazole (e.g. Clont 3x 250-300mg/day for 1-2 weeks - not helpful in all cases) can be used.

Alternative: therapy trial with doxycycline (e.g. Doxycycline Stada) 2 times/day 100 mg p.o.

Alternative: In the idea that retinoids can deprive the mites of their livelihood, isotretinoin (e.g. isotretinoin-ratiopharm; acne normin) should be discussed in severe cases. Dosage: Initial 0.5 mg/kg bw/day p.o., maintenance therapy 10-20 mg/day p.o.

Alternatively: Ivermectin 150-200 μg/kg KG p.o. as ED.

Case report(s)
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  • The 42-year-old Latin teacher has been noticing periocularly localized inflammatory nodules for over 1/2 year. Little itching. Resistance to therapy despite carefully carried out therapy prescribed by the family doctor. On request also some glucocorticoid-containing ointments.
  • Findings: Periocularly settled, condensed towards the eye, running out to the periphery, red and reddish-brownish follicular nodules. Erythema in parts flat and slightly scaly.
  • Histology: Perifollicular granuloma; several follicular mites detectable.
  • Therapy: Treatment with 10% crotamiton emulsion 2 times/day. After 6 weeks complete healing of the lesions.

Literature
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  1. Baima B, Sticherling M et al (2002) Demodicidosis revisited. Acta Derm Venereol 82: 3-6
  2. Cotliar J et al (2013) Demodex folliculitis mimicking acute graft-vs-hostdisease
    . JAMA Dermatol 149:1407-1409
  3. Forstinger C et al (1999) Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream. J Am Acad Dermatol 41: 775-777
  4. Forton F et al (1993) Density of Demodex folliculorum in rosacea: a case-control study using standardized skin-surface biopsy. Br J Dermatol 128: 650-659
  5. Guerrero-González GA et al (2014) Crusted demodicosis in an immunocompetent pediatric patient. Case Rep Dermatol Med doi: 10.1155/2014/458046
  6. Jansen T et al (2001) Rosacea-like demodicidosis associated with acquired immunodeficiency syndrome. Br J Dermatol 144: 139-142
  7. Morras PG et al (2003) Rosacea-like demodicidosis in an immunocompromised child. Pediatric dermatol 20: 28-30
  8. Melnik B et al (2018) Acne and rosacea. In: Braun-Falco`s Dermatology, Venerology Allergology G. Plewig et al. (Hrsg) Springer Verlag S 1331
  9. Vu JR et al (2011) Demodex folliculitis. J Pediatr Adolesc Gynecol 24:320-321

  10. Weingartner JS et al. (2012) What is your diagnosis? Demodex folliculitis. Cutis. 90:65-66

  11. Yun SH et al (2013) Demodex folliculitis presenting as periocular vesiculopustular rash. Orbit 32:370-371

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020