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    Demodex Folliculitis

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    Deba P Sarma
    Harbert T, Sarma D. (2011). An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? J Dermatol Case Rep. J Dermatol Case Rep. 2011 Sep 21;5(3):56-7. PMID 22187582 PubMED. J Dermatol Case Rep. 2011 September 21; 5(3): 56–57. Published online 2011 September 21. doi: 10.3315/jdcr.2011.1077 PMCID: PMC3184778 Copyright : © 2011 Specjalisci Dermatolodzy Photoletter to the editor: An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? Tracey Harbert1 and Deba P Sarma2* 1Department of Pathology, Creighton University Medical Center, Omaha, NE, USA. 2Department of Pathology, Lakeside Hospital, Omaha, NE, USA. *Corresponding author: Deba P Sarma, MD, Department of Pathology, Lakeside Hospital, Omaha, NE 68130. E-mail: [email protected]. Received April 9, 2011; Accepted May 10, 2011. Abstract Folliculitis has many etiologies including bacterial, fungal, viral and parasitic. Therefore, an accurate determination of the cause is necessary to direct treatment. This is a case of a 60-year-old man who presented with an erythematous papule on his chest. Biopsy showed granulomatous inflammation, abscess formation, and the causative agent was Demodex. Keywords: demodex, folliculitis, histopathology Introduction Folliculitis presents as single or multiple erythematous papules, pustules, ulcerations, or blisters on hair bearing skin. There are multiple etiologies including bacteria, viruses, fungi, and parasites. Host risk factors include age and immunosuppresion. Skin breakage is often a predisposing factor, although some cases may originate due to bacterial overgrowth in intact skin, particularly in immunocompromised hosts. Because of the wide variety of etiologies, accurate identification is needed to appropriately treat the cause. Other Sections▼ Case Report A 60-year-old man presented with an erythematous papule on his chest. He did not have any evidence of immunosuppression. A punch biopsy was obtained. Sections stained with hematoxylin and eosin showed skin with a hair follicle and associated adnexal structures. There was a parafollicular abscess formation with foamy macrophages, giant cells, and histiocytes surrounded by lymphocytes. A degenerating parasite with cuticle and internal structures was noted within the abscess [Fig. 1]. Figure 1 Figure 1 Low power view of the biopsy showing skin with a hair follicle and associated sebaceous gland. There is parafollicular dermal abscess formation and granulomatous inflammation. Black arrow points to the etiologic agent (A). Note the causative agent (red (more ...) Other Sections▼ Discussion Folliculitis is caused by various infectious agents including bacteria, viruses, fungi, and parasites. The most common type is bacterial folliculitis usually caused by Staphylococcus aureus. Other bacterial agents that may cause folliculitis include Pseudomonas, Klebsiella, Proteus, and Treponema pallidum in secondary syphilis.[1] Fungal etiologies include the dermatophytes, Pityrosporum, and Candida. Rare viral folliculits is usually the result of Herpes virus infection. Very rarely, folliculitis is caused by parasites of Demodex species. These parasites have tropism for hair follicles and sebaceous glands and commonly cause asymptomatic infestation in the face, scalp, neck, eyelids, and upper chest. The prevelance of Demodex infestation increases with age and is approximately 30% in young adults and almost 100% in middle to older aged adults.[1] When symptomatic infection occurs, it is most associated with older age and immunosuppresion (HIV infection, chemotherapy, organ transplantation).[1] An instance of immunosuppresion-induced Demodex infection was reported in the case of a 43-year-old male with tumor stage mycosis fungoides treated with total-skin electron beam therapy who developed multiple follicular pustules caused by Demodex overgrowth.[2] Other

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    Demodex Folliculitis

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    Harbert T, Sarma D. (2011). An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? J Dermatol Case Rep. J Dermatol Case Rep. 2011 Sep 21;5(3):56-7. PMID 22187582 PubMED. J Dermatol Case Rep. 2011 September 21; 5(3): 56–57. Published online 2011 September 21. doi: 10.3315/jdcr.2011.1077 PMCID: PMC3184778 Copyright : © 2011 Specjalisci Dermatolodzy Photoletter to the editor: An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? Tracey Harbert1 and Deba P Sarma2* 1Department of Pathology, Creighton University Medical Center, Omaha, NE, USA. 2Department of Pathology, Lakeside Hospital, Omaha, NE, USA. *Corresponding author: Deba P Sarma, MD, Department of Pathology, Lakeside Hospital, Omaha, NE 68130. E-mail: [email protected]. Received April 9, 2011; Accepted May 10, 2011. Abstract Folliculitis has many etiologies including bacterial, fungal, viral and parasitic. Therefore, an accurate determination of the cause is necessary to direct treatment. This is a case of a 60-year-old man who presented with an erythematous papule on his chest. Biopsy showed granulomatous inflammation, abscess formation, and the causative agent was Demodex. Keywords: demodex, folliculitis, histopathology Introduction Folliculitis presents as single or multiple erythematous papules, pustules, ulcerations, or blisters on hair bearing skin. There are multiple etiologies including bacteria, viruses, fungi, and parasites. Host risk factors include age and immunosuppresion. Skin breakage is often a predisposing factor, although some cases may originate due to bacterial overgrowth in intact skin, particularly in immunocompromised hosts. Because of the wide variety of etiologies, accurate identification is needed to appropriately treat the cause. Other Sections▼ Case Report A 60-year-old man presented with an erythematous papule on his chest. He did not have any evidence of immunosuppression. A punch biopsy was obtained. Sections stained with hematoxylin and eosin showed skin with a hair follicle and associated adnexal structures. There was a parafollicular abscess formation with foamy macrophages, giant cells, and histiocytes surrounded by lymphocytes. A degenerating parasite with cuticle and internal structures was noted within the abscess [Fig. 1]. Figure 1 Figure 1 Low power view of the biopsy showing skin with a hair follicle and associated sebaceous gland. There is parafollicular dermal abscess formation and granulomatous inflammation. Black arrow points to the etiologic agent (A). Note the causative agent (red (more ...) Other Sections▼ Discussion Folliculitis is caused by various infectious agents including bacteria, viruses, fungi, and parasites. The most common type is bacterial folliculitis usually caused by Staphylococcus aureus. Other bacterial agents that may cause folliculitis include Pseudomonas, Klebsiella, Proteus, and Treponema pallidum in secondary syphilis.[1] Fungal etiologies include the dermatophytes, Pityrosporum, and Candida. Rare viral folliculits is usually the result of Herpes virus infection. Very rarely, folliculitis is caused by parasites of Demodex species. These parasites have tropism for hair follicles and sebaceous glands and commonly cause asymptomatic infestation in the face, scalp, neck, eyelids, and upper chest. The prevelance of Demodex infestation increases with age and is approximately 30% in young adults and almost 100% in middle to older aged adults.[1] When symptomatic infection occurs, it is most associated with older age and immunosuppresion (HIV infection, chemotherapy, organ transplantation).[1] An instance of immunosuppresion-induced Demodex infection was reported in the case of a 43-year-old male with tumor stage mycosis fungoides treated with total-skin electron beam therapy who developed multiple follicular pustules caused by Demodex overgrowth.[2] Other

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    Harbert T, Sarma D. (2011). An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? J Dermatol Case Rep. J Dermatol Case Rep. 2011 Sep 21;5(3):56-7. PMID 22187582 PubMED. J Dermatol Case Rep. 2011 September 21; 5(3): 56–57. Published online 2011 September 21. doi: 10.3315/jdcr.2011.1077 PMCID: PMC3184778 Copyright : © 2011 Specjalisci Dermatolodzy Photoletter to the editor: An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? Tracey Harbert1 and Deba P Sarma2* 1Department of Pathology, Creighton University Medical Center, Omaha, NE, USA. 2Department of Pathology, Lakeside Hospital, Omaha, NE, USA. *Corresponding author: Deba P Sarma, MD, Department of Pathology, Lakeside Hospital, Omaha, NE 68130. E-mail: [email protected]. Received April 9, 2011; Accepted May 10, 2011. Abstract Folliculitis has many etiologies including bacterial, fungal, viral and parasitic. Therefore, an accurate determination of the cause is necessary to direct treatment. This is a case of a 60-year-old man who presented with an erythematous papule on his chest. Biopsy showed granulomatous inflammation, abscess formation, and the causative agent was Demodex. Keywords: demodex, folliculitis, histopathology Introduction Folliculitis presents as single or multiple erythematous papules, pustules, ulcerations, or blisters on hair bearing skin. There are multiple etiologies including bacteria, viruses, fungi, and parasites. Host risk factors include age and immunosuppresion. Skin breakage is often a predisposing factor, although some cases may originate due to bacterial overgrowth in intact skin, particularly in immunocompromised hosts. Because of the wide variety of etiologies, accurate identification is needed to appropriately treat the cause. Other Sections▼ Case Report A 60-year-old man presented with an erythematous papule on his chest. He did not have any evidence of immunosuppression. A punch biopsy was obtained. Sections stained with hematoxylin and eosin showed skin with a hair follicle and associated adnexal structures. There was a parafollicular abscess formation with foamy macrophages, giant cells, and histiocytes surrounded by lymphocytes. A degenerating parasite with cuticle and internal structures was noted within the abscess [Fig. 1]. Figure 1 Figure 1 Low power view of the biopsy showing skin with a hair follicle and associated sebaceous gland. There is parafollicular dermal abscess formation and granulomatous inflammation. Black arrow points to the etiologic agent (A). Note the causative agent (red (more ...) Other Sections▼ Discussion Folliculitis is caused by various infectious agents including bacteria, viruses, fungi, and parasites. The most common type is bacterial folliculitis usually caused by Staphylococcus aureus. Other bacterial agents that may cause folliculitis include Pseudomonas, Klebsiella, Proteus, and Treponema pallidum in secondary syphilis.[1] Fungal etiologies include the dermatophytes, Pityrosporum, and Candida. Rare viral folliculits is usually the result of Herpes virus infection. Very rarely, folliculitis is caused by parasites of Demodex species. These parasites have tropism for hair follicles and sebaceous glands and commonly cause asymptomatic infestation in the face, scalp, neck, eyelids, and upper chest. The prevelance of Demodex infestation increases with age and is approximately 30% in young adults and almost 100% in middle to older aged adults.[1] When symptomatic infection occurs, it is most associated with older age and immunosuppresion (HIV infection, chemotherapy, organ transplantation).[1] An instance of immunosuppresion-induced Demodex infection was reported in the case of a 43-year-old male with tumor stage mycosis fungoides treated with total-skin electron beam therapy who developed multiple follicular pustules caused by Demodex overgrowth.[2] Other

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    Demodex Folliculitis

    Uploaded by

    Deba P Sarma
    Harbert T, Sarma D. (2011). An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? J Dermatol Case Rep. J Dermatol Case Rep. 2011 Sep 21;5(3):56-7. PMID 22187582 PubMED. J Dermatol Case Rep. 2011 September 21; 5(3): 56–57. Published online 2011 September 21. doi: 10.3315/jdcr.2011.1077 PMCID: PMC3184778 Copyright : © 2011 Specjalisci Dermatolodzy Photoletter to the editor: An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis? Tracey Harbert1 and Deba P Sarma2* 1Department of Pathology, Creighton University Medical Center, Omaha, NE, USA. 2Department of Pathology, Lakeside Hospital, Omaha, NE, USA. *Corresponding author: Deba P Sarma, MD, Department of Pathology, Lakeside Hospital, Omaha, NE 68130. E-mail: [email protected]. Received April 9, 2011; Accepted May 10, 2011. Abstract Folliculitis has many etiologies including bacterial, fungal, viral and parasitic. Therefore, an accurate determination of the cause is necessary to direct treatment. This is a case of a 60-year-old man who presented with an erythematous papule on his chest. Biopsy showed granulomatous inflammation, abscess formation, and the causative agent was Demodex. Keywords: demodex, folliculitis, histopathology Introduction Folliculitis presents as single or multiple erythematous papules, pustules, ulcerations, or blisters on hair bearing skin. There are multiple etiologies including bacteria, viruses, fungi, and parasites. Host risk factors include age and immunosuppresion. Skin breakage is often a predisposing factor, although some cases may originate due to bacterial overgrowth in intact skin, particularly in immunocompromised hosts. Because of the wide variety of etiologies, accurate identification is needed to appropriately treat the cause. Other Sections▼ Case Report A 60-year-old man presented with an erythematous papule on his chest. He did not have any evidence of immunosuppression. A punch biopsy was obtained. Sections stained with hematoxylin and eosin showed skin with a hair follicle and associated adnexal structures. There was a parafollicular abscess formation with foamy macrophages, giant cells, and histiocytes surrounded by lymphocytes. A degenerating parasite with cuticle and internal structures was noted within the abscess [Fig. 1]. Figure 1 Figure 1 Low power view of the biopsy showing skin with a hair follicle and associated sebaceous gland. There is parafollicular dermal abscess formation and granulomatous inflammation. Black arrow points to the etiologic agent (A). Note the causative agent (red (more ...) Other Sections▼ Discussion Folliculitis is caused by various infectious agents including bacteria, viruses, fungi, and parasites. The most common type is bacterial folliculitis usually caused by Staphylococcus aureus. Other bacterial agents that may cause folliculitis include Pseudomonas, Klebsiella, Proteus, and Treponema pallidum in secondary syphilis.[1] Fungal etiologies include the dermatophytes, Pityrosporum, and Candida. Rare viral folliculits is usually the result of Herpes virus infection. Very rarely, folliculitis is caused by parasites of Demodex species. These parasites have tropism for hair follicles and sebaceous glands and commonly cause asymptomatic infestation in the face, scalp, neck, eyelids, and upper chest. The prevelance of Demodex infestation increases with age and is approximately 30% in young adults and almost 100% in middle to older aged adults.[1] When symptomatic infection occurs, it is most associated with older age and immunosuppresion (HIV infection, chemotherapy, organ transplantation).[1] An instance of immunosuppresion-induced Demodex infection was reported in the case of a 43-year-old male with tumor stage mycosis fungoides treated with total-skin electron beam therapy who developed multiple follicular pustules caused by Demodex overgrowth.[2] Other

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    The patient was diagnosed with Demodex folliculitis after biopsy showed a degenerating parasite (Demodex mite) within a dermal abscess. Demodex folliculitis is caused by an overgrowth of Demodex mites within the hair follicles and sebaceous glands.

    Demodex folliculitis (Demodicidosis)

    The two species are Demodex folliculorum and Demodex brevis. D. folliculorum are longer, occupy hair follicles in groups, and have arrow shaped eggs. D. brevis are shorter, occupy sebaceous glands singly, and have oval eggs.

    Unknown: Biopsy of an erythematous folliculocentric papular lesion on

    the chest of a 60-year-old man.

    Tracey Harbert, MD and Deba P Sarma, MD

    Department of Pathology, Creighton University Medical Center, Omaha, NE 68134

    Corresponding author: Deba P Sarma, MD, Creighton University Medical Center, Omaha, NE 68134. E-
    mail: [email protected]

    A 60-year-old man presented with an erythematous papule on his chest. A punch


    biopsy was obtained. Sections stained with hematoxylin and eosin showed skin with a
    hair follicle and associated adnexal structures. There was parafollicular abscess
    formation with foamy macrophages, giant cells, and histiocytes surrounded by
    lymphocytes. A degenerating parasite with cuticle and internal structures was noted
    within the abscess.

    Figure 1. Low power view of the biopsy showing skin with a hair follicle and associated
    sebaceous gland. There is parafollicular dermal abscess formation and granulomatous
    inflammation. Black arrow points to the etiologic agent.
    Figure 2. Note the causative agent (red arrow) with well-defined cuticle surrounded by
    neutrophils within the abscess cavity. There is a blunt ended abdomen and leg structures
    with terminal hooklets.

    What is your diagnosis?

    Answer: Demodex folliculitis (Demodicidosis)

    Abstract:

    Folliculitis has many etiologies including bacterial, fungal, viral and parasitic.
    Therefore, an accurate determination of the cause is necessary to direct treatment. This is
    a case of a 60-year-old man who presented with an erythematous papule on his chest.
    Biopsy showed granulomatous inflammation, abscess formation, and the causative agent
    was Demodex. Demodex folliculitis is briefly reviewed.
    Introduction:

    Folliculitis presents as single or multiple erythematous papules, pustules,


    ulcerations, or blisters on hair bearing skin. There are multiple etiologies including
    bacteria, viruses, fungi, and parasites. Host risk factors include age and
    immunosuppresion. Skin breakage is often a predisposing factor, although some cases
    may originate due to bacterial overgrowth in intact skin, particularly in
    immunocompromised hosts. Because of the wide variety of etiologies, accurate
    identification is needed to appropriately treat the cause.

    Report of Case:

    A 60-year-old man presented with an erythematous papule on his chest. He did


    not have any evidence of immunosuppression. A punch biopsy was obtained. Sections
    stained with hematoxylin and eosin showed skin with a hair follicle and associated
    adnexal structures. There was a parafollicular abscess formation with foamy
    macrophages, giant cells, and histiocytes surrounded by lymphocytes. A degenerating
    parasite with cuticle and internal structures was noted within the abscess.

    Discussion:

    Folliculitis is caused by various infectious agents including bacteria, viruses,


    fungi, and parasites. The most common type is bacterial folliculitis usually caused by
    Staphylococcus aures. Other bacterial agents that may cause folliculitis include
    Pseudomonas, Klebsiella, Proteus, and Treponema pallidum in secondary syphilis [1].
    Fungal etiologies include the dermatophytes, Pityrosporum, and Candida. Rare viral
    folliculits is usually the result of Herpes virus infection.
    Very rarely, folliculitis is caused by parasites of Demodex species. Theses
    parasites have tropism for hair follicles and sebaceous glands and commonly cause
    asymptomatic infestation in the face, scalp, neck, eyelids, and upper chest. The
    prevelance of Demodex infestation increases with age and is approximately 30% in
    young adults and almost 100% in middle to older aged adults [1]. When symptomatic
    infection occurs, it is most associated with older age and immunosuppresion (HIV
    infection, chemotherapy, organ transplantation) [1]. An instance of immunosuppresion-
    induced Demodex infection was reported in the case of a 43-year-old male with tumor
    stage mycosis fungoides treated with total-skin electron beam therapy who developed
    multiple follicular pustules caused by Demodex overgrowth [2]. Other predisposing
    factors are skin trauma as was the case for a 37-year-old male with skin trauma secondary
    to frequent shaving. Other predisposing factors include acne rosacea, granulomatous
    rosacea, pityriasis folliculorum, demodectic blepharitis, perioral dermatitis, and
    papulopustular scalp eruptions [1].

    The Demodex mite is covered with a cuticle and has a head, thorax, and abdomen.
    The head has needle-like protruding mouthparts used for consuming skin cells. There are
    eight legs that have three articulations and three terminal hooklets each. The abdomen
    and thorax are striated and semi-transparent. There are two species of Demodex:
    Demodex folliculorum and Demodex brevis. These two species vary in morphology and
    typical location in the skin. D. folliculorum are longer (~280 µm), have long tubular
    posterior segments, have arrow shaped eggs, and occupy the follicular infundibulum in
    groups of 10-15 members. D. brevis mites are shorter (~170 µm), have a more pointed
    posterior segment, oval eggs, and are present singly in sebaceous glands [1]. These
    parasites may be seen in cytological specimens (lesion fluid aspirates) as refractile
    tubular structures and body parts amidst a background of squamous cells, acute
    inflammation and fibrin [1]. There are also reports of Demodex mites found in potassium
    hydroxide preparations [3, 4].

    Treatment for Demodex folliculitis is oral ivermectin and topical permethrin


    cream. There are also reports of successful treatment with crotamiton or 6% sulphur [3,
    4]. Demodex infestation may be diagnosed with biopsy after unsuccessful treatment with
    antibiotics [3, 4].

    References

    1. Dong, H. and Duncan, L. D. (2006), Cytologic findings in Demodex folliculitis: A


    case report and review of the literature. Diagnostic Cytopathology 34: 232–
    234.PubMed PMID16548003

    2. Nakagawa T, Sasaki M, Fujita K, Nishimoto, M, Takaiwa T. (1996). Demodex


    folliculitis on the trunk of a patient with mycosis fungoides. Clinical and
    Experimental Dermatology. 21(2):148-150. PubMed PMID 8759206

    3. Purcell SM, Hays TJ, Dixon SL (1986). Pustular folliculitis associated with Demodex
    folliculorum, J Am Acad Dermatol 15:1159-62. PubMed PMID : 3771870

    4. Karincaoglu Y, Bayram N, Aycan O, Esrefoglu M. (2004). The clinical importance of


    demodex folliculorum presenting with nonspecific facial signs and symptoms. J
    Dermatol. 31(8):618-26. PubMed PMID: 15492434
    Legends for the figures

    Figure 1. Low power view of the biopsy showing skin with a hair follicle and associated
    sebaceous gland. There is parafollicular dermal abscess formation and granulomatous
    inflammation. Black arrow points to the etiologic agent.

    Figure 2. Note the causative agent (red arrow) with well-defined cuticle surrounded by
    neutrophils within the abscess cavity. There is a blunt ended abdomen and leg structures
    with terminal hooklets.

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