You are on page 1of 4

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 icine containing steroid, due to arthralgia for


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

Fig. 1 Fig. 2
Confluene erythematons papnles, pustules, and abscess. Infiltration around hair follicle with hair follicle destruction
and granulomatous infiltration. (H&E, 40X)

145 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 6. Farina MC, Requena L, Sarasa KL, et al.:
chemotaxis.14-16 It is also an acetylcholine nico- Spinulosis of the face as a manifestation of
tinic receptor agonist,16, 17 which is highly effective demodicidosis. Br J Dermatol. 138: 901-903, 1998
7. Grossmann B, Jung K, Linse R: Tubero-pustular
in eradicating Ascarid and Trichostrongylus. demodicosis. Hautarzt 50: 491-494, 1999.
Levamisole has been reported to be effective 8. Forton F, Seys B, Marchal JL, et al.: Demodex fol-
against pediculosis as well.16 Our report first liculorum and topical treatment: acaricidal action
demonstrates that systemic levamisole is effec- evaluated by standardized skin surface biopsy. Br
tive in the deep Demodex abscess while topical J Dermatol 138: 461-466, 1998.
medicines are in vain. 9. Ayres S: Demodex folliculorum as a pathogen.
Cutis 37: 441, 1986.
The Demodex mites which are the same to
10.Patricia M, Susana P, Isabel L, et al.: Rosacea-like
lice belong to class Arachnida.2 Recent reports demodicidosis in an immunocompromised child.
of demodicidosis in association with acquired Ped Dermatol 20: 28-30, 2003.
immunodeficiency syndrome (AIDS) and can- 11. Martin S, Christian A, Gerd P. Demodex abscesses:
cer chemotherapy have suggested that immune Clinical and therapeutic challenges. J Am Acad
deficiency might cause overgrowth of the Dermatol 49: 272-274, 2003.
12.Jansen T, Kastner U, Kreuter A, et al.: Rosacea-
mite. 10, 18-20 Akilov et al. evaluated immune
like demodecidosis associated with acquired
response in demodicosis, they found the readi- immunodeficiency syndrome. Br J Dermatol 144:
ness of lymphocytes to undergo apoptosis in 139-142, 2001.
parallel to the increasing density of the mites. 13. Georgala S, Katoulis AC, Kylafis GD, et al.:
This could be the result of local immunosup- Increased density of Demodex folliculorum and
pression caused by the mites, which allows evidence of delayed hypersensitivity reaction in
subjects with papulopustular rosacea. JEADV 15,
mites to survival and provoke the skin lesions.21
441-444, 2001.
In short, levamisole can enhance T-cell respons- 14.Rongioletti F, Ghio L, Finevri F, et al.: Purpura of
es and increase the function of the neutrophil, it the ears; a distinctive vasculopathy with circulat-
can also eradicate Ascarid, hence we chose lev- ing autoantibodies complicating long-term treat-
amisole to treat our patient. ment with levamisole in children. Br J Dermatol
In conclusion, we were confused by the 140: 948-951, 1999.
15.Parsad D, Saini R, Negi KS: Comparison of com-
clinical symptoms and disappointed in our
bination of cimetidine and levamisole with cimeti-
numerous therapeutic attempts, but we were dine alone in the treatment of recalcitrant warts.
surprised by the rapid and lasting clearing with Australas J Dermatol 40: 93-95, 1999.
oral levamisole. We encourage further trials 16.Namazi MR. Levamisole: a safe and economical
with oral levamisole to provide evidence-base weapon against pediculosis. Int J Dermatol 40:
support for this therapeutic approach. 794, 2001.
17.Culetto E, Baylis HA, Richmond JE, et al.: The
Caenorhabditis elegans unc-63 gene encodes a lev-
REFERENCES amisole-sensitive nicotinic acetylcholine receptor
1. Rufli T, Mumcuoglu Y: The hair follicle mites alpha subunit. J Biol Chem 279: 42476-42483, 2004.
Demodex folliculorum and Demodex brevis: biology 18.Aydingoz IE, Dervent B, Guney O: Demodex fol-
and medical importance. A review. Dermatologica liculorum in pregnancy. Int J Dermatol 39: 743-
162: 1-11, 1981. 745, 2000.
2. Burns DA: Follicle mites and their role in disease. 19.Aquilina C, Viraben R, Sire S: Ivermectin-responsive
Clin Exp Dermatol 17: 552-555, 1992. Demodex infestation during human immunodeficiency
3. Bonnar E, Ophth MC, Eustace P, et al.: The virus infection. A case report and literature review.
Demodex mite population in rosacea. J Am Acad Dermatology. 205: 394-397, 2002.
Dermatol. 28: 443-448,1993. 20.Sarro RA, Hong JJ, Elgart ML: An unusual
4. Forton F: Demodex-associated folliculitis. Am J demodicidosis manifestation in a patient with
Dermatopathol 20: 536-537, 1998. AIDS. J Am Acad Dermatol 38: 120-121, 1998.
5. Jansen T, Kastner U, Kreuter A, et al.: Rosacea- 21.Akilov OE, Mumcuoglu KY: Immune response in
like demodicidosis associated with acquired demodicosis. J Eur Acad Dermatol Venereol 18:
immunodeficiency syndrome. Br J Dermatol. 144: 440-444, 2004.
139-142, 2001.

147 Dermatol Sinica, September 2005