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The Ecology of Your Face: Demodex, Rosacea and You

Ecology of your face: Demodex, rosacea and youAs a disorder of unknown origin, rosacea’s signs and symptoms may be attributable to a variety of possible causes , such as a dysfunctional immune system, genetics, a propensity toward flushing and various external factors that may trigger these unhealthy responses.

Even before the emergence of new scientific evidence, Demodex, a microscopic mite that is a normal inhabitant of human facial skin, was long considered a potential culprit in rosacea flare-ups by virtue of its often-greater numbers on the faces of individuals with this disorder.1, 2 Now a growing body of medical research on Demodex has uncovered a broad range of knowledge that may yield a clearer picture of its characteristics and prevalence, as well as its possible role in triggering or enhancing the signs and symptoms of rosacea.

Demodex may be best understood in the context of the human microbiome – the ecological community of microorganisms that live within and on the human body, and has been the subject of a recent five-year study at the National Institutes of Health that is leading to a paradigm shift in the understanding of the human body.3

Microbes are our friends

Contrary to popular perception, humans are not biologically self-sufficient organisms whose immune systems must fight off invasion by microbes in order to avoid disease. In fact, it’s just the opposite: the human body can’t survive without them. For example, according to the Human Microbiome Project , bacteria in the gastrointestinal tract are essential to allow people to digest foods and absorb certain nutrients. In addition, these fundamental microbes produce beneficial compounds like certain vitamins and protective anti-inflammatories that humans cannot produce by themselves.

Moreover, of the trillions of cells in a typical human body – at least 10 times as many cells in a single individual as there are stars in the Milky Way – only about one in 10 is human, and the remaining 90 percent are microbes.4 Because they are so small, however, they account for only about 1 to 2 percent of our body mass – about three to five pounds in weight, or enough to fill a big soup can.3

The process of acquiring microbes is a lifelong activity and begins the moment we are born. Though babies develop in a sterile environment – the uterus is without microorganisms – a newborn emerges as a bacterial sponge, and begins picking up microbes that contribute to its health and ability to survive beginning with its passage through the birth canal. Microbes include bacteria, fungi, protozoa and others, and may be found in greatest concentrations in the ears, nose, mouth, vagina, digestive tract, anus and the skin.5

Like other microbes, Demodex mites are a natural part of this human microbiome, and they may serve a useful function by feeding off of dead skin cells to help rid the face of waste. In fact, dead human skin cells are the largest component of household dust and, just like dust mites , Demodex folliculorum may be part of a natural cleaning system.6

The Demodex mite

Demodex folliculorumWhile Demodex may have only recently gained more attention in the rosacea research community, the mite has a much longer history in the realm of medical science. According to Dr. Rusiecka-Ziółkowska and colleagues in the Department of Microbiology at Wroclaw Medical University in Poland, reports of Demodex mites were recorded as early as 1841, more than 150 years ago. A year later, a German dermatologist found Demodex-type mites in hair follicles, almost 100 years before human Demodex was first observed in the development of rosacea.7

Great numbers of Demodex appear to be very common in virtually all humans. Using advanced technology, researcher Dr. Megan Thoemmes and colleagues recently found that Demodex mites exist in every adult over 18 years old.8 Moreover, researchers have discovered that two separate species of Demodex inhabit the skin of humans – D. folliculorum, which live in hair follicles primarily on the face as well as in the meibomian glands of the eyelids, and D. brevis, which live in the sebaceous glands of the skin.8,9

Demodex have often been found in 15 to 18 times greater numbers in rosacea patients than in healthy subjects,1,2 and medical scientists have advanced a variety of theories about why this unusually high incidence may trigger inflammation in individuals with rosacea. A recent meta-analysis of 48 studies on Demodex found a significant association between the relative density of Demodex and the development of rosacea, suggesting that the mites may be involved in the disease process, according to Dr. Erin Lesesky, assistant professor of dermatology at Duke University.10 Moreover, while it has long been debated whether the higher incidence of Demodex is a cause or a result of rosacea, new evidence has increasingly suggested it may be the former.

In a recent key medical journal article, Dr. Fabienne Forton , a dermatologist in Brussels, Belgium, characterized the mites as a potential missing link in understanding the onset of subtype 2 (papulopustular) rosacea.2 She hypothesized that skin infections and disruption of the skin barrier may set off a chain of inflammatory reactions in individuals with rosacea, noting that when the number of mites is reduced to normal through treatment the typical rosacea complaint of sensitive skin often disappears. Dr. Stanislaw Jarmuda and colleagues also found that while mite density is greater on the skin of individuals with rosacea, mites are even more dense in individuals with the bumps and pimples of papulopustular rosacea.9

Other researchers believe D. folliculorum‘s true connection to rosacea may be via Bacillus oleronius, a bacterium on the Demodex mite that was found to stimulate an immune response in some individuals with rosacea, according to Dr. Kevin Kavanagh and colleagues at the National University of Ireland-Maynooth.11 In addition, the B. oleronius association may hold true for those with ocular rosacea as well. Dr. Jianjing Li and colleagues at the Ocular Surface Center in Miami found a significant correlation between facial rosacea, infestation of the eyes with Demodex mites and reaction to B. oleronius.12

While rosacea may have many causes, individuals who suspect they have this disorder are urged to see a dermatologist for diagnosis and appropriate treatment. “Patients who don’t respond to traditional treatment for papulopustular rosacea may have an increased density of Demodex mites or an increased immune response to these mites,” Dr. Lesesky said , noting that treatments with antiparasitic properties targeting Demodex might be useful for successful patient management.13

Demodex references

1. Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med Microbiol 2012;61:1504-1510.

2. Forton FMN. Papulopustular rosacea, skin immunity and Demodex: pityriasis folliculorum as a missing link. J Eur Acad Dermatol Venereol 2012;26:19–28.

3. NIH Human Microbiome Project defines normal bacterial makeup of the body. National Institutes of Health June 13, 2012.

4. Marantz Henig R. Fat factors. New York Times Aug. 123, 2006.

5. Ackerman J. How bacterial affect our bodies protect our health. Scientific American May 15, 2012, pp.

6. House dust mite. Wikipedia Accessed 11/25/14.

7. Rusiecka-Ziółkowska J, Nokiel M, Fleischer M. Demodex – an old pathogen or a new one? Adv Clin Exp Med 2014;23:295–298.

8. Thoemmes MS, Fergus DJ, Urban J, Trautwein M, Dunn RR (2014) Ubiquity and diversity of human-associated Demodex mites. Public Library of Science One 9(8):e106265. Doi:10.1371/journal.pone.0106265.

9. Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Medical Microbiol 2012;61:1504-1510.

10. Zhao YE, Wu LP, Peng Y, et al. Retrospective analysis of association between Demodex infestation and rosacea. Arch Dermatol 2010;146(8):896-902.

11. Erbagci Z, Ozgoztaosi O. The significance of Demodex folliculorum density in rosacea. Int J Dermatol 1998;37:421-425.

12. Li J, O’Reilly N, Sheha H, et al. Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with facial rosacea. Ophthalmology 2010;117:870-877.

13. Demodex surfaces again at summer AAD meeting. National Rosacea Society Weblog Accessed 11/25/14.

 

Acknowledgment: This section was reviewed and edited by Dr. Julie Harper, clinical associate professor of Dermatology at the University of Alabama-Birmingham.

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Pediatric Skin Care: Survey of the Cutis Editorial Board

Article

Resistant Scalp Folliculitis Secondary to Demodex Infestation

Cutis. 2005 November;76(5):321-324


Author(s):

Sanfilippo AM
English Jc Iii

Author and Disclosure Information

Angela M. Sanfilippo, MD; Joseph C. English III, MD

Dr. Sanfilippo is a dermatology resident and Dr. English is Assistant Professor of Dermatology, University of Pittsburgh Medical Center, Department of Dermatology, Pennsylvania.

Drs. Sanfilippo and English report no conflict of interest.

Folliculitis is a common complaint and its etiology may be related to a variety of factors. We examine a case involving a 57-year-old white man presenting with scalp erythema and folliculitis secondary to Demodex mite infestation. We discuss the pathophysiology of Demodex folliculitis, as well as the epidemiology, clinical manifestation, diagnosis, and treatment of this infection.


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References

  1. Norn MS. Demodex folliculorum. incidence, regional distribution, pathogenicity. Dan Med Bull. 1971;18:14-17.
  2. Plewig G, Klingman AM. The role of Demodex. In: Plewig J, Klingman AM, eds. Acne and Rosacea. 2nd ed. Berlin, Germany: Springer-Verlag; 1993:482-486.
  3. Ayres S Jr, Ayres S 3rd. Demodectic eruptions (demidicidosis) in the human. 30 years’ experience with 2 commonly unrecognized entities: pityriasis folliculorum (Demodex) and acne rosacea (Demodex type). Arch Dermatol. 1961;83:816-827.
  4. Woolley TA. Acarology: Mites and Human Welfare. New York, New York: Wiley Interscience; 1988.
  5. Baker E. An Introduction to Acarology. New York, New York: MacMillan Company; 1952.
  6. Forton F, Seys B. Density of Demodex folliculorum in rosacea: a case-control study using standardized skin-surface biopsy. Br J Dermatol. 1993;128:650-659.
  7. Georgala S, Katoulis AC, Kylafis GD, et al. Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. J Eur Acad Dermatol Venereol. 2001;15:441-444.
  8. Spickett SG. Aetiology of rosacea. Br Med J. 1962;1:1625-1626.
  9. Vollmer RT. Demodex-associated folliculitis. Am J Dermatopathol. 1996;18:589-591.
  10. Meinking TL, Taplin D, Hermida JL, et al. The treatment of scabies with ivermectin. N Engl J Med. 1995;333:26-30.
  11. Aylesworth R, Vance JC. Demodex folliculorum and Demodex brevis in cutaneous biopsies. J Am Acad Dermatol. 1982;7:583-589.
  12. Marks R, Harcourt-Weber JN. Histopathology of rosacea. Arch Dermatol. 1969;100:683-691.
  13. Nutting WB, Green AC. Pathogenesis associated with hair follicle mites (Demodex spp) in Australian Aborigines. Br J Dermatol. 1976;94:307-312.

Folliculitis is a common complaint seen in dermatology practice. The differential diagnosis of folliculitis is broad and includes Demodex folliculitis. In humans, the Demodex mite species Demodex folliculorum and Demodex brevis have been found to inhabit the pilosebaceous unit. D folliculorum typically is found in the follicular infundibulum; D brevis exists in the sebaceous and meibomian glands.1 Although the prevalence of Demodex approaches 100% in middle-aged and elderly adults,1 mite density normally is low in healthy skin.2Demodex mites are considered pathogenic only when they are found in large numbers or in an intradermal location3; therefore, it has been suggested that D folliculorum may play a role in various papular and pustular eruptions of the head and neck, such as demodicosis and rosacea.3 We examine a case of scalp folliculitis secondary to Demodex infection and the role that this organism plays in the pathogenesis of folliculitis, as well as the available treatment options.

Case Report

A 57-year-old white man presented to our department in June 2004 with an “infected scalp” and scalp irritation for 2 months. The patient was diagnosed with bacterial folliculitis and treated with clindamycin 1% gel twice daily for 1 month. He presented for follow-up in July 2004 with continued complaint of scalp pruritus and rash (Figure 1). Results of an examination showed a deep pink 10X7-cm plaque on the scalp with hyperkeratosis and pustules. An ectoparasite wet mount prepared from one of the pustules revealed the presence of several Demodex mites (Figure 2). The patient was treated with sulfacetamide 10% plus sulfur 5% cream twice daily, in addition to a 2-week course of selenium sulfide 2.5% shampoo once daily. When the patient was seen for follow-up in September 2004, his entire scalp had cleared (Figure 3). He was instructed to continue the selenium sulfide 2.5% shampoo twice weekly for 6 months to prevent recurrence.

Please refer to the PDF to view the figures

Comment

The Demodex mite is a ubiquitous arthropod measuring approximately 0.1 to 0.4 mm in length. Typically, it infests areas around the eyelids, nose, and ear canals in human hosts.4 The life cycle of the mite is 18 to 24 days. The female mite lays 20 to 24 eggs in a hair follicle where the eggs are nourished by the surrounding pilosebaceous unit. The eggs hatch and the nymphs continue to live in the follicle where their main source of food is human glandular secretions.5 The mite primarily is an asymptomatic inhabitant of human pilosebaceous follicles and poses no harm to the host.1

The role of D folliculorum in cutaneous disease in humans remains controversial. The pathogenicity is difficult to establish secondary to the localization of the disease, the widespread prevalence of infection with the D folliculorum mite, and the obligate nature of the parasite; therefore, the detection of the presence of the mite is not, in and of itself, enough evidence to establish pathogenicity.6 Results of immunohistochemical staining have shown that helper T lymphocytes predominate in the dermal infiltrate of demodicosis suggesting a possible role of cell-mediated immune response and delayed hypersensitivity.7 There also is evidence for a humoral immune response component with increased macrophages and Langerhans cells in the presence of infestation with Demodex.7

Demodex mites have been implicated as a causative agent in rosacea and pustular folliculitis.6 It is important to consider the possibility that the vascular changes of rosacea create an environment that is favorable to the multiplication of Demodex mites and their penetration into the dermis.8 Forton and Seys6 reported that Demodex mites are associated with the inflammatory symptoms of rosacea and that the mites are present in greater numbers and higher frequencies in patients with rosacea. Additionally, a study by Georgala et al7 evaluated the importance of D folliculorum in the etiology and course of rosacea and showed that D folliculorum was found in 83 (90.2%) of 92 rosacea subjects studied but in only 11 (11.9%) of the 92 controls, thereby concluding that although Demodex mites may not be the cause of rosacea, they may represent an important cofactor. Finally, Vollmer9 examined 388 follicles in 24 resections of skin for the presence of histologic folliculitis and Demodex mites. Results showed that Demodex mites were found in 87 (42%) of 208 follicles with inflammation but in just 18 (10%) of 180 follicles without inflammation. Furthermore, 87 (83%) of 105 follicles with Demodex showed inflammation, which demonstrated a nonrandom association between these 2 entities.9 A study by Meinking et al10 supported the rapid clearing of papulopustular dermatosis of the scalp and granulomatous rosacea when treated with scabicidal preparations such as permethrin or ivermectin, thereby supporting the pathogenic role of Demodex in papulopustular eruptions.

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References

 

 

  1. Norn MS. Demodex folliculorum. incidence, regional distribution, pathogenicity. Dan Med Bull. 1971;18:14-17.
  2. Plewig G, Klingman AM. The role of Demodex. In: Plewig J, Klingman AM, eds. Acne and Rosacea. 2nd ed. Berlin, Germany: Springer-Verlag; 1993:482-486.
  3. Ayres S Jr, Ayres S 3rd. Demodectic eruptions (demidicidosis) in the human. 30 years’ experience with 2 commonly unrecognized entities: pityriasis folliculorum (Demodex) and acne rosacea (Demodex type). Arch Dermatol. 1961;83:816-827.
  4. Woolley TA. Acarology: Mites and Human Welfare. New York, New York: Wiley Interscience; 1988.
  5. Baker E. An Introduction to Acarology. New York, New York: MacMillan Company; 1952.
  6. Forton F, Seys B. Density of Demodex folliculorum in rosacea: a case-control study using standardized skin-surface biopsy. Br J Dermatol. 1993;128:650-659.
  7. Georgala S, Katoulis AC, Kylafis GD, et al. Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. J Eur Acad Dermatol Venereol. 2001;15:441-444.
  8. Spickett SG. Aetiology of rosacea. Br Med J. 1962;1:1625-1626.
  9. Vollmer RT. Demodex-associated folliculitis. Am J Dermatopathol. 1996;18:589-591.
  10. Meinking TL, Taplin D, Hermida JL, et al. The treatment of scabies with ivermectin. N Engl J Med. 1995;333:26-30.
  11. Aylesworth R, Vance JC. Demodex folliculorum and Demodex brevis in cutaneous biopsies. J Am Acad Dermatol. 1982;7:583-589.
  12. Marks R, Harcourt-Weber JN. Histopathology of rosacea. Arch Dermatol. 1969;100:683-691.
  13. Nutting WB, Green AC. Pathogenesis associated with hair follicle mites (Demodex spp) in Australian Aborigines. Br J Dermatol. 1976;94:307-312.

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