ᛅԛᖪᓘႹᓜԖ෧ᕝᄃ‫ڼ‬ᒚ̝߄ጼ

ͳഈዂ ૺ̚Ꮈ
‫܅‬ቷຎᑻᗁጯ͕̚ ϩቲࡊ

Demodex Abscess: Clinical and Therapeutic Challenges

Chao-Hwei Wang Chung-Hsing Chang

A 52-year-old man suffered from recurrent erythematous papules, plaques, pustules and abscesses
over the anterior chest, abdomen and back with severe pruritus for four years. He was under long term
systemic steroid treatment for more than 4 years due to arthralgia. Steroid-induced folliculitis or
Pityrosporum folliculitis was impressed at first, but treatment with systemic minocyclin and topical
benzoyl peroxide for 4 weeks and systemic itraconazole for another 4 weeks showed no improvement.
A skin biopsy of an abscess taken from the back revealed a perifollicular infiltration with plasma cells,
neutrophils, eosinophils and some foreign body giant cells. Within the sebaceous duct and gland, there
were Demodex mites. KOH examinations of the specimens from abscesses revealed many Demodex
brevis mites. The skin lesions were unresponsive to topical antiparasitic treatment (benzoyl benzoate
and crotamiton). Therefore oral administration of levamisole HCl 50 mg 3 times a day for 10 days was
given and all the skin lesions and pruritus were subsided. (Dermatol Sinica 23: 144-147, 2005)

Key words: Demodex, Levamisole, Iatrogenic Cushing(s syndrome

˘Ҝ̣˩˟໐շّЯඏ੻ᅕ൭ѣ‫ܜ‬ഇֹϡᙷ‫׽‬ዔ۞ঽΫĂ΁‫ٺ‬αѐ݈ฟؕд਒ొև̄̈́
ࡦొ΍னࡓҒᏉЪّ͸ৃ̈́ᓘႹҡᐌϩቲສᚧ۞া‫ې‬Ą౵‫ܐ‬෧ᕝࠎᙷ‫׽‬ዔ͔൴۞ͨᝃ‫ߏٕۆ‬
ϩढ‫܂‬᭵ෂ͔൴̝ͨᝃ‫ۆ‬ĂགྷԸᄃ˾‫ڇ‬ԩϠ৵αฉ‫ޢ‬ঽի൑ԼචĂГԸᄃ˾‫ڇ‬itraconazoleα
ฉ‫ޢ‬া‫޺̪ې‬ᜈĄ‫ߏٺ‬ԧࣇઇ˞̷ͯᑭߤĂ̷ͯᑭߤពϯͨᝃ‫׹‬ಛѣል௟ࡪă๝ϿࡓϨҕ
஧ă๝ّ̚Ϩҕ஧ඈ൴‫ۆ‬௟ࡪওማĂ֭дϩ਌ཛྷგට̈́ཛྷវ̰൴னϩ਌ᛅԛᖪ (Demodex bre-
vis)ĂᓘႹ۞KOHᙡᑭ࠻‫ז‬ధкϩ਌ᛅԛᖪĄϩቲ̼ᓘّᓘႹ̈́ສᚧ۞া‫ې‬дග̟γϡben-
zoyl benzoate ᄃ crotamiton‫ڼ‬ᒚ‫ֶޢ‬ᖞ޺ᜈćГԼගᄃ˾‫ˬ͇˘ڇ‬Ѩ۞50mg levamisole HClా
ᜈ‫ڇ‬ϡ˩͇‫ޢ‬Ăϩৃᄃສᚧඈা‫ې‬ᒔ଀‫ځ‬ពԼචĄώಡӘ೩΍˘็௚‫ڼ‬ᒚεୀĂ֭ࢵѨͽ
levamisole HClјΑ‫ڼ‬ᒚ۞ᛅԛᖪঽĄ(̚රϩᄫ 23: 144-147, 2005)

From the Department of Dermatology, Tzu Chi University and Tzu Chi Medical Center, Hualien, Taiwan
Accepted for publication: March, 08, 2005
Reprint requests: Chung Hsing Chang, PhD., Department of Dermatology, Tzu Chi University and Tzu Chi Medical Center,
Hualien, No 707, Sec.3, Zhongyang Rd.. Hualien City, Hualien County 970, Taiwan (R.O.C.)
TEL: 886-3-8561825 FAX: 886-3-8577161 E-mail: chchang@tzuchi.com.tw

Dermatol Sinica, Sep 2005 144

ͳഈዂ
INTRODUCTION
Demodex folliculorum and Demodex brevis
are common inhabitants of the human piloseba-
ceous unit. Demodex folliculorum is more com-
mon than Demodex brevis and is characterized
by a larger size, and elongated posterior seg-
ment. It is usually located in the follicular
infundibulum and may be present in numbers
up to 10~15 per follicle. Demodex brevis is
shorter and more oval shaped. It is usually
found in sebaceous glands and ducts and is soli-
tary .1, 2 The prevalence of infestation with
Demodex species increases with age.3 A relation
between infestation with Demodex and several
types of eruptions has been well documented.1 ,4,
5, 6, 7
We describe an immune compromized
patient with unusual clinical manifestation of
Demodex infestation and were un-responsive to
numerous antiparasitic treatments but finally
cleared completely after oral levamisole therapy.
CASE REPORT
A 52-year-old man was seen with 4 years
history of moderate to severe pruritic skin erup-
tion involving mainly the chest, back and
abdomen. Physical examination revealed moon
face, plethora, hirsutism, but no folliculitis or
rosacea over the face. Multiple confluent ery-
thematous papules, pustules and abscess over
the chest, back and abdomen were found. Tinea
corporis and tinea cruris werer noted over the
trunk (Fig. 1). Tracing back his history, he had
taken black pills, a kind of Chinese herbal med-
Fig. 1
Confluene erythematons papnles, pustules, and abscess.
145
icine containing steroid, due to arthralgia for
more than 4 years.
Laboratory findings including routine
blood counts and acute phase proteins revealed
no abnormalities. Enzyme-linked immunosor-
bent assay for HIV was negative. ACTH: 15.6
pg/ml(10~46), Cortisol <1 ug/dl (5~25),
Aldosterone 74.6 pg/mL (37~240). Bacterial
cultures of skin swabs and contents from
abscesses failed to grow. A 10% potassium
hydroxide preparations of skin scraping from
back showed no fungal or yeast elements.
Steroid-induced folliculitis was impressed
at first, but the symptom persisted after oral
minocycline 200 mg/day and topical benzoyl
peroxide treatment for 4 weeks. Pityrosporum
folliculitis was then suspected but no significant
improvement after oral itraconazole 200 mg per
day for 4 weeks. Skin biopsy was performed on
the abscess of back. The histopathological pic-
ture was that of a perifollicular infiltration with
plasma cells, neutrophils, eosinophils and some
foreign body giant cells (Fig. 2, 3). Within the
sebaceous duct and gland, there were Demodex
mites. 10% potassium hydroxide preparations of
abscess from the back revealed multiple
Demodex brevis within the pus smear (Fig. 4).
Our final diagnosis was abscesses due to
Demodex brevis. Antiparasitic treatment, which
previously were reported to eradicate infesta-
tions with Demodex mite, including benzoyl
benzoate, crotamiton, and metronidazole gel, all
failed to relieve the skin manifestations.
Fig. 2
Infiltration around hair follicle with hair follicle destruction
and granulomatous infiltration. (H&E, 40X)
Dermatol Sinica, September 2005
 ᛅԛᖪᓘႹᓜԖ෧ᕝᄃ‫ڼ‬ᒚ̝߄ጼ

Rapid and complete recovery was finally appearance of cutaneous lesions.3, 8-10, 21
achieved after systemic levamisole 50 mg orally In report of Demodex folliculitis, use of
3 times a day for 10 days. Subsequent follow up topical antiparasitic agent result in clearing the
evaluation for the next 9 months showed excel- lesions; 5, 7, 11 some investigator point out,
lent control of the disease. Demodex brevis is far more difficult to eradicate
in using topical antiparasitic agent.12, 13 In our
DISCUSSION case, the patient with Demodex brevis folliculi-
Demodex folliculorum and Demodex bre- tis refractory to all topical antiparasitic reme-
vis are common parasites in the hair follicles dies, including benzoyl benzoate, crotamiton,
and in the pilosebaceous gland of human skin.1, 2 metronidazole (Table 1). The response to the
The mites are generally found on the forehead, topical or systemic drugs listed in Table 1 was
cheeks, nose and nasolabial folds, occasionally not convincing. The symptom improved rapidly
on the trunk. In certain circumstances, abnor- after systemic monotherapy with 150 mg lev-
mally large numbers of mites probably induced amisole orally 3 times a day for 2 weeks.
some skin disorders. The clinical manifestations Levamisole is an anti-helminthic drug with
of demodicidosis include granulomatous immuno-modulating properties. It can restore
rosacea, granulomatous perioral dermatitis, and depressed immune function, stimulate forma-
pustular folliculitis, papulopustular dermatosis tion of antibodies, enhance T-cell responses by
of scalp, blepharitis, and spinulosis of the face.4-7 stimulating T cell activation and proliferation,
Unlike previously reported Demodex-associated
cases, our patient did not have the usual symp-
toms or signs. There is no report of skin lesion Table 1. Unsuccesful attempts in treatment
on the trunk with or without face involvement. Medication dose Duration (day)
In our patient, there are multiple confluent ery- Systemic:
thematous papules, nodules and pustules with Minocycline 200mg/qd 28
severe itching, but no other skin lesion over the Itraconazole 200mg/qd 28
face. Nimesulide 200mg/day 28
The participation of Demodex in the patho- Topical:
genesis of skin lesions has long been debated. Fusidic acid cream 28
Current hypotheses state that either an immuno- Benzoyl peroxide 28
logic deficiency favoring an increase in the num- Benzoyl benzoate lotion 28
ber of mites or an abnormal immunologic reac- Crotamiton 28
tion of the skin to the parasites might provoke the Metronidazole gel 28

Fig. 3 Fig. 4
Demodex brevis in the sevaceous duct and gland with peri- Demodex brevis within pus smear (KOH)
follicular infiltration. (H&E, 400X)

Dermatol Sinica, September 2005 146

ͳഈዂ
and increase neutrophil mobility, adherence and
chemotaxis.14-16 It is also an acetylcholine nico-
tinic receptor agonist,16, 17 which is highly effective
in eradicating Ascarid and Trichostrongylus.
Levamisole has been reported to be effective
against pediculosis as well.16 Our report first
demonstrates that systemic levamisole is effec-
tive in the deep Demodex abscess while topical
medicines are in vain.
The Demodex mites which are the same to
lice belong to class Arachnida.2 Recent reports
of demodicidosis in association with acquired
immunodeficiency syndrome (AIDS) and can-
cer chemotherapy have suggested that immune
deficiency might cause overgrowth of the
mite. 10, 18-20 Akilov et al. evaluated immune
response in demodicosis, they found the readi-
ness of lymphocytes to undergo apoptosis in
parallel to the increasing density of the mites.
This could be the result of local immunosup-
pression caused by the mites, which allows
mites to survival and provoke the skin lesions.21
In short, levamisole can enhance T-cell respons-
es and increase the function of the neutrophil, it
can also eradicate Ascarid, hence we chose lev-
amisole to treat our patient.
In conclusion, we were confused by the
clinical symptoms and disappointed in our
numerous therapeutic attempts, but we were
surprised by the rapid and lasting clearing with
oral levamisole. We encourage further trials
with oral levamisole to provide evidence-base
support for this therapeutic approach.
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Dermatol Sinica, September 2005