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Year : 2016  |  Volume : 61  |  Issue : 4  |  Page : 453-454
Clues to facial demodicidosis: A case illustration

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication7-Jul-2016

Correspondence Address:
Neena Khanna
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.185730

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How to cite this article:
Gupta V, Bhatia R, Yadav D, Khanna N. Clues to facial demodicidosis: A case illustration. Indian J Dermatol 2016;61:453-4

How to cite this URL:
Gupta V, Bhatia R, Yadav D, Khanna N. Clues to facial demodicidosis: A case illustration. Indian J Dermatol [serial online] 2016 [cited 2022 Aug 17];61:453-4. Available from:


A 46-year-old, otherwise healthy, female presented to us with burning sensation and redness on the face for the past 6 months. She denied history of flushing or photosensitivity and had not noticed any exacerbating or relieving factors. Treatment history included pimecrolimus 1% cream twice daily and sunscreens for 3 months with a suspected diagnosis of rosacea, which had led to an exacerbation of her symptoms. History was relevant for melasma, for which she had used topical steroid-containing preparations intermittently for several years. Owing to the suboptimal reduction in the pigmentation, she had resorted to heavy make-up to camouflage the hyperpigmentation. On examination, dull erythema was perceptible on the central forehead, bilateral cheeks, perioral region, and chin with minimal semi-adherent "spiny" scaling in the perioral location, giving the skin a "nutmeg grater" feel [Figure 1]. A 40% potassium hydroxide (KOH) mount prepared from the scrapings from the perioral region showed multiple Demodex mites [Figure 2]. Dermoscopic examination using nonpolarized light did not show any specific features of Demodex infestation, namely, "Demodex tails" or "Demodex follicular openings" [Figure 3]. The patient refused a skin biopsy. With a diagnosis of facial demodicidosis, the patient was treated with topical ivermectin 0.5% cream once daily for application on the affected areas and advised to stop using cosmetics and topical steroids. At 1-month follow-up, there was complete resolution of her symptoms, and clinically there was no erythema and scaling. A repeat KOH preparation from the same sites did not reveal any Demodex mites.
Figure 1: Diffuse dull erythema on the cheeks and perioral region, with fine scaling appreciable in the perioral location

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Figure 2: (a) Potassium hydroxide mount showing multiple Demodex mites (arrows, ×100). (b) Under high power (×400)

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Figure 3: Dermoscopic examination using nonpolarized light showing only erythema and few telangiectasias. No Demodex tails or Demodex follicular openings are seen

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Demodex folliculorum and Demodex brevis are commensal mites which inhabit the pilosebaceous units in humans. However, multiplication of these mites beyond a certain limit can lead to "demodicidosis." Its morphological variants include pityriasis folliculorum, rosacea-like demodicidosis, and demodicidosis gravis (granulomatous rosacea-like demodicidosis). [1],[2] It is noteworthy that finding an occasional mite is not diagnostic. At present, visualization of five or more mites under a low-power field or per 5 cm 2 on standardized skin surface biopsy is considered significant, but this figure is based on limited studies. [1],[2] That is why the diagnosis of demodicidosis rests not only on finding Demodex mites in high numbers but also on the specific clinical presentation and a positive response to acaricidal agents, both clinical as well as parasitological. [1],[3] The morphology of facial lesions in our patient fits well with the description of pityriasis folliculorum variant of facial demodicidosis. The diagnosis was confirmed by demonstration of several mites on KOH mount, and the clinical and parasitological response to topical ivermectin. Our case provided several clues to suspect demodicidosis. Although burning sensation, centrofacial erythema, and the antecedent prolonged use of topical steroids are common to both erythemo-telangiectatic rosacea as well as facial demodicidosis, the absence of flushing episodes, photosensitivity, telangiectasias tilted the diagnosis in favor of the latter. Moreover, since pimecrolimus is an effective drug for rosacea, [4] the definite worsening of symptoms with its use in our patient further raised the suspicion. Pimecrolimus has been associated with demodicidosis, probably due to its immunosuppressive action. [5],[6],[7] Our patient was habitually using heavy make-up which can also contribute to demodicidosis, secondary to its occlusive effect on hair follicles. [2]

To conclude, demodicidosis is often misdiagnosed as rosacea owing to their similar presentations. Subtle differentiating clues may often be overlooked in a busy practice. Differentiating between the two entities is important as some treatment modalities for rosacea can aggravate demodicidosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Chen W, Plewig G. Human demodicosis: Revisit and a proposed classification. Br J Dermatol 2014;170:1219-25.  Back to cited text no. 1
Baima B, Sticherling M. Demodicidosis revisited. Acta Derm Venereol 2002;82:3-6.  Back to cited text no. 2
Rufli T, Mumcuoglu Y. The hair follicle mites Demodex folliculorum and Demodex brevis: Biology and medical importance. A review. Dermatologica 1981;162:1-11.  Back to cited text no. 3
Kim MB, Kim GW, Park HJ, Kim HS, Chin HW, Kim SH, et al. Pimecrolimus 1% cream for the treatment of rosacea. J Dermatol 2011;38:1135-9.  Back to cited text no. 4
Gorman CR, White SW. Rosaceiform dermatitis as a complication of treatment of facial seborrheic dermatitis with 1% pimecrolimus cream. Arch Dermatol 2005;141:1168.  Back to cited text no. 5
Yoon TY, Kim HJ, Kim MK. Pimecrolimus-induced rosacea-like demodicidosis. Int J Dermatol 2007;46:1103-5.  Back to cited text no. 6
Lübbe J, Stucky L, Saurat JH. Rosaceiform dermatitis with follicular Demodex after treatment of facial atopic dermatitis with 1% pimecrolimus cream. Dermatology 2003;207:204-5.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]

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