Anais
Brasileiros
de
Dermatologia
www.anaisdedermatologia.org.br
INVESTIGATION
Demodex
folliculorum
infestations
in
common
facial
dermatoses:
acne
vulgaris,
rosacea,
seborrheic
dermatitis
夽,夽夽
Ezgi
Aktas
¸
Karabay
∗,
Aslı
Aksu
C
¸erman
DepartmentofDermatologyandVenereology,FacultyofMedicine,Bahc¸es¸ehirUniversity,Istanbul,Turkey
Received18March2019;accepted26August2019 Availableonline12February2020
KEYWORDS Acnevulgaris; Dermatitis, seborrheic; Rosacea Abstract
Background: Demodexmitesarefoundontheskinofmanyhealthyindividuals.Demodexmites inhighdensitiesareconsideredtoplayapathogenicrole.
Objective: Toinvestigate the associationbetweenDemodex infestation andthe threemost commonfacialdermatoses:acnevulgaris,rosaceaandseborrheicdermatitis.
Methods: This prospective,observationalcase-control study included127 patients (43with acnevulgaris,43withrosaceaand41withseborrheicdermatitis)and77healthycontrols.The presenceofdemodicosiswasevaluatedbystandardizedskinsurfacebiopsyinboththepatient andcontrolgroups.
Results: Intermsofgenderandage,nosignificantdifferencewasfoundbetweenthepatients andcontrols(p>0.05).Demodexinfestationratesweresignificantlyhigherinpatientsthanin controls(p=0.001).Demodexinfestationratesweresignificantlyhigherintherosaceagroup thanacnevulgarisandseborrheicdermatitisgroupsandcontrols(p=0.001;p=0.024;p=0.001, respectively). Demodex infestationwas foundtobe significantlyhigherintheacnevulgaris andseborrheicdermatitisgroups thanincontrols(p=0.001 andp=0.001, respectively).No differencewasobservedbetweentheacnevulgarisandseborrheicdermatitisgroupsinterms ofdemodicosis(p=0.294).
Studylimitations: Smallsamplesizeisalimitationofthestudy.Thelackofanobjectivescoring systeminthediagnosisofDemodexinfestationisanotherlimitation.
夽 Howtocitethisarticle:Aktas¸KarabayE,Aksu¸ermanC A.Demodexfolliculoruminfestationsincommonfacialdermatoses:acnevulgaris,
rosacea,seborrheicdermatitis.AnBrasDermatol.2020;95:187---93.
夽夽StudyconductedattheDepartmentofDermatology,FacultyofMedicine,Bahc¸es¸ehirUniversity,Istanbul,Turkey. ∗Correspondingauthor.
E-mail:ezgiaktasmd@gmail.com(E.Aktas¸Karabay).
https://doi.org/10.1016/j.abd.2019.08.023
0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion: Thefindingsofthepresentstudyemphasizethatacnevulgaris,rosaceaand seb-orrheic dermatitis aresignificantly associated withDemodex infestation. Standardized skin surfacebiopsyisapracticaltoolinthedeterminationofDemodexinfestation.
©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Introduction
Demodex mites were first reported by Jakup Henle in 1871,anddetaileddescriptionsanddemonstrationsofthe pathogenweremadeinthefollowingyears.1TheDemodex
mitebelongstothefamilyDemodicidae.Demodex folliculo-rumandDemodexbrevisarethetwotypesofDemodexmites thatarepresentonhumanskinandfollicles.2Althoughthe
parasitemaybefoundoneveryareaofhumanskin,themite hasapredilectionforthefacialarea.Demodexmitesmay befoundonnormalskin withadensityof<5mites/cm2.A
diagnosisofdemodicosisorDemodexinfestationis consid-eredwhenclinicalsigns/symptomsappearandwhenmore than5mites/cm2arepresentorwhentheypenetrateinto
thedermis.3---6
Recently,studies evaluatingDemodexinfestations have increased.The roleof demodicosis has been investigated insomefacialconditions/dermatoses,andDemodexmites havebeenreportedtobeassociatedwithvariousskin mani-festations,includingpityriasisfolliculorum,3papulopustular
andgranulomatousrosacea,4,5pustularfolliculitis,7
inflam-matorypapule,8 folliculitis,9 SeborrheicDermatitis (SD),10
perioraldermatitis11andblepharitis.12,13
Rosacea, acne vulgaris(AV)and SDarethe threemost common inflammatory facial dermatoses; they affect the pilosebaceousunitandhaveapredilectionforthesebaceous gland-richfacialareas.6 Demodexmites arealsofound in
thepilosebaceousunit,causinginflammationandleadingto immune reactions.10 The present study was conducted to
investigatetheassociationbetweenAV,rosaceaandSDand demodicosis.
Methods
The study was reviewed and approved by the local ethicscommittee (protocol no22481095-020-1956,date of approval: 19/09/2018), and all participants gave written informedconsent.The studywascarriedoutaccording to theprinciplesexpressedintheDeclarationofHelsinki.
Acase---controlstudywasplannedtoinvestigatethe rela-tionshipbetweendemodicosisandfacialdermatoses,such asAV,rosaceaandSD.PatientswithonlypapulopustularAV andonly papulopustularrosaceawere included. Inthe SD group,patientswithmalar area,eyebrowsand/orchin or cheekareainvolvementwereenrolledinthestudy.All diag-nosesweremadebasedonclinicalexaminationsbythesame dermatologist.Complicatedvariants ofeach diseasewere excludedfromthestudy.
The study included 127 patients (43 with AV, 43 with rosaceaand41withSD)and77healthycontrols.Thecontrol groupcomprised77healthypeople,eithermedicalstudents orhospitalstaff,whowerematchedforageandgender,did
nothaveanydisease,andwerenotreceivinganysystemic or topical treatment. Allparticipants had Fitzpatrickskin type2 or 3.Foreach patient,the age,sex, clinical diag-nosis,symptoms,otherpotentialfacialdermatoses,recent treatmentforthefacialconditionanddateofconsultation wererecorded.None ofthesubjects wereunderany top-icaltreatment,includingmoisturizers,withinthelasttwo months.Subjectswithahistoryofanyablativefacial treat-ments(e.g.peelingandlaser)inthepriorsixmonthswere alsoexcluded.Patientswithahistoryofanysystemic dis-ease,systemictreatmentwithinsixmonthsofthestudyand whohavesmokinghabitwerealsoexcluded.
Thepresenceofdemodicosiswasevaluatedbythesame dermatologistineachpatient.Themicroscopicexamination ofmiteswasperformedbycyanoacrylateglueStandardized Skin SurfaceBiopsy (SSSB)inboth thepatientandcontrol groups.Twosamplesweretakenformiteexaminationfrom the erythematous/inflammatory lesionsof the disease on theface.Sampleswerecollectedfromcheeksandfrontal areaincontrols.Aslidecoveredwithcyanoacrylateglueand amarkedsquarewaspressedagainsttheskinsurface.After 30s,theslidewasremovedandthesampleswerecollected. The preparation was examined under a light microscope at 40× and 100× magnification. The performance of the SSSB is shown in fig. 1. The result was considered posi-tive whentherewere morethanfive Demodexmitesin a 1cm2areabySSSB.14MostoftheDemodexobservedbySSSB
wereD.folliculorum.D.brevis,whichmainlylivesdeeperin thesebaceousglands,israrelyobservedwiththissampling method.15
Statisticalanalysis
The Number Cruncher Statistical System 2007 (NCSS; Kaysville, Utah, USA) program was used for the statis-tical analysis. The descriptive data were expressed with mean±standard deviation, median, frequency and ratio. In the analysisof normallydistributed variables, an inde-pendentsample Shapiro---Wilkstestwasappliedtodiscern the differences between the twogroups. The differences between thetwoindependentgroupswere alsoexamined usingtheKruskalWallistestandDunn’stestfornon-normally distributedvariables.Tocomparequalitativevariables,the MannWhitney Utest, Pearson×2test andBonferroni cor-rected×2Posthoctestwereused.Theresultswerewithin the95% ConfidentialInterval,andp<0.05 wasconsidered statisticallysignificant.
Results
Atotalof204subjectswereenrolledinthestudy,including 127patientswithfacialdermatosisand77healthycontrols.
Figure 1 Performing the microscopic examination ofmites was performedby cyanoacrylateglue Standardized Skin Surface Biopsy(SSSB).(A)Preparationoftheslidecoveredwithcyanoacrylateglue;(B)Collectionofthesamplefromthecheek;(CandD) MicroscopicexaminationoftheDemodexmites(×40).
Table1 DemographicdataandthepresenceofDemodexinfestationinpatientsandcontrols
Patientgroup (n=127)
Controlgroup (n=77)
p
Age(years) Min---Max(Median) 15---79(30) 16---64(31) Z:−0.291
Meant±SD 32.36±11.61 32.90±11.25 0.771a Gender Female 82(61.7%) 51(38.3%) 2:0.059 Male 45(63.4%) 26(33.8%) 0.809b Demodex infestation Absent 61(48.0%) 75(97.4%) 2:52.580 Present 66(52.0%) 2(2.6%) 0.001b,c
a PearsonChi-Squaretest. b MannWhitneyUtest. c p<0.01.
In terms of gender andage, nosignificant differencewas found between the patients and controls (p>0.05); 66of the127patients(52.0%)hadaDemodexinfestation,while only two of the 77 healthy controls (2.6%) had infesta-tions. Demodexinfestation rates weresignificantly higher inpatientsthanincontrols(p=0.001)(Table1).
The patient groups were composed of 43 AV, 43 rosacea and 41 SD patients. The comparisons that were made between these groups and controls are shown in
tables2and3.
Themeanageofpatientswithrosaceawassignificantly higherthan for the AVpatients, SD patients and controls
Table2 Comparisonofdemographic data andthe presenceofDemodex infestation between patients withacne vulgaris, rosacea,seborrheicdermatitisandcontrols
Acnevulgaris (n=43) Rosacea (n=43) Seborrheic dermatitis(n=41) Controlgroup (n=77) p
Age(years) Min---Max (Median) 15---36(26) 23−79(37) 17---57(28) 16---64(31) 2:41.602 Mean±SD 25.49±5.95 40.70±12.83 30.83±9.09 32.90±11.25 0.001a,c Gender Female 35(81.4%) 31(72.1%) 16(39.0%) 51(66.2%) 2:18.287 Male 8(18.6%) 12(27.9%) 25(61.0%) 26(33.8%) 0.001b,c Demodicosis No 31(72.1%) 9(20.9%) 21(51.2%) 75(97.4%) 2:78.183 Yes 12(27.9%) 34(79.1%) 20(48.8%) 2(2.6%) 0.001b,c
aKruskalWallisTest. b PearsonChi-Squaretest. c p<0.01.
Table3 Subgroupcomparisonsintermsofage,genderandthepresenceofDemodexinfestation
Groups p(age)a p(gender)b p(Demodexinfestation)b
Rosacea---AV 0.001d 1.000 0.001d Rosacea---SD 0.001d 0.012c 0.024c Rosacea---Controls 0.001d 1.000 0.001d AV---SD 0.151 0.001d 0.294 AV---Controls 0.001d 0.462 0.001d SD--- Controls 1.000 0.024c 0.001d
AV,acnevulgaris;SD,seborrheicdermatitis.
aBonferroniDunn’sTest.
b BonferroniCorrectedPearsonChi-Squaretest. c p<0.05.
d p<0.01.
(p=0.001,p=0.001,andp=0.001,respectively).Themean ageofAVpatientswassignificantlylowerthanthecontrols (p=0.003).
Intermsofgender,themale-to-femaleratiowas signifi-cantlyhigherintheSDgroupcomparedwiththeAV,SDand controlgroups (p=0.012, p=0.001, andp=0.024; respec-tively).
Demodex infestation rates were significantly higher in therosacea group than in the AV,SD groups and controls (p=0.001,p=0.024,andp=0.001,respectively).Demodex infestationwasfoundtobesignificantlyhigherintheAVand SDgroupsthaninthecontrols(p=0.001,p=0.001, respec-tively). No difference was seen between the AV and SD groupsintermsofdemodicosis(p=0.294).
Discussion
ThisstudydemonstratedthatDemodexinfestationwas asso-ciatedwith AV,rosacea and SD. The highest incidence of infestationwasobservedintherosaceapatients,followed bySDandAV.ThepresenceofDemodexinfestationwas sig-nificantlyhigherintherosaceapatientsthanintheAVand SDpatientsandcontrols,whereastheinfestationwas signi-ficantlymorecommonintheAVandSDpatientsascompared withcontrols.
D.folliculorumandD.brevis,thetwoDemodexspecies, areubiquitouslyfoundonthenormalskinofadulthumans,
particularlyinthepilosebaceousunitsoftheface.16D.
fol-liculorumresideswithinthehairfollicle,whereasD.brevis is found predominantly in the sebaceous and meibomian glands.2 Demodexmitespenetrateintoskin cells
(particu-larlythekeratinocytesthatlinepilosebaceousfollicles)and ingesttheircontents.Demodexmitesfeedonthesebumand cellularproteinsthat areobtainedbyprotease containing thesalivaryenzymesofthemites.16,17 Thelipaseenzymes
of Demodex are also thought to play a role in digesting bacteriaor othermicroorganismsinadditiontothe diges-tionof lipidmaterial.18,19 The enzymaticprocessleads to
degradationof thefollicularepithelium,whichmayresult inperifollicularinflammation.16,17Demodexmitesmayalso
cause mechanical blockage of the follicle opening. More-over, itis thoughtthatextrafollicular mitesmayinduce a granulomatous foreign body reaction through their chiti-nous exoskeleton. Dying mites are thought to trigger an immuneresponseinthehostbyreleasingtheirinternal con-tents and the chitinous exoskeletons of degrading, dying mites, followed by inflammatory changes.20---22 Demodex
mites may also suppress the innate immune response of the hosts that provide for their survival.16 It has been
shown thatthe Tnantigen, whichis acarbohydrate coat-ingprovidingprotectionforcancercellsandparasitesfrom immunity, is expressed by Demodex mites.23,24 Demodex
mitesarealsoshowntoaffectthesecretionofinflammatory cytokines,suchasIL-8andTNF-alphaandTLRexpression,
through the interaction with cells of the pilosebaceous unit.23---28
The cause of clinical findings in Demodex infestation is stillunknown; but the aforementioned mechanismsare considered to play a role in the occurrence of Demodex infestation. Although demodicosis has been demonstrated in several skin conditions, the role of Demodex mites in dermatologicconditionsisstillcontroversial.
AVisamultifactorialdiseaseofthepilosebaceousunit. Itcanbeclassifiedascomedonal,papulopustularand nodu-lar acne. Althoughthe etiology ofAV remains unclarified, androgen, increasing sebum secretion, hyperkeratosis of thepilosebaceousduct,follicularorificeblockage andthe proliferationofpropionibacteriumacnearesomeofthe fac-tors thought tocontribute in the development of AV.29,30
Demodexmitesmaycontributetothedevelopmentofacne lesionsthroughfollicleblockage,leadingtodistensionand intrafollicularhyperkeratosisandcausinginflammationand immunereactions.31,32
Recently, many studies evaluating the relationship betweenAVandDemodexinfestationhavebeenconducted. Reportedly, 11.8% of 101 AV patients33 and 15.38% of 78
AVpatients34 showedDemodexpositivityin seperate
stud-ies.Inanother,nosignificantassociationbetweenDemodex and AV was observed.35 In a recent meta-analysis, 48 of
63 articles demonstrated a positive association between Demodex infestation and AV, while 15 showed controver-sial findings.31 In our study, significantly higher Demodex
positivitywasobservedinAVpatientsthaninhealthy con-trols.
Rosacea is a common chronic inflammatory cuta-neous disorder, mostly seen over the age of 30 years, with remission and exacerbation periods.36,37 Flushing,
erythema, telangiectasia, edema, papules, pustules, phy-matous changes and ocular lesions are the signs of the disease.36---38 Rosacea is classified as
Erythematotelang-iectatic Rosacea (ETR), Papulopustular Rosacea (PPR), phymatousrosacea,ocularrosaceaandvariant granuloma-tous rosacea according to the AmericanNational Rosacea Society (NRS) Expert Committeeclassificationand staging system, which also acts as a diagnostic tool.36,37
Vari-ous factors,includingabnormalities in cutaneousvascular homeostasis, climatic exposures, dermal matrix degrada-tion, chemical and ingested agents, pilosebaceous unit abnormalities and microbial organisms, have been intro-ducedin thepathogenesis,thoughtheetiologyof rosacea remains uncertain.37,38 Recently, many studies have been
conducted examining the relationship between Demodex mitesandrosacea,mostlydemonstratingapositive relation-ship. Demodex mites may contribute to the pathogenesis of rosacea in several ways. The blockage of hair folli-cles and sebaceous glands by an increased number of mites may resultin cutaneous barrier disruption and tis-suedamage.SubsequentincreasesinTLRexpression,chitin miteexoskeletons andreleases of internal mitecontents, including bacterial antigens, may trigger an inflamma-tory reaction and also result in an immune response followedbyneutrophilandmacrophageactivation.26,27,39---41
Particularly, rosacea T-cell-mediated immune responses to Demodex have been reported to play a role in the pathogenesis. Predominantly CD4 helper/inducer T lym-phocytes have been demonstrated in granulomas and in
perifollicularinfiltrates.5,42---44 Moreover,humoral immunity
has also been suggested to play a role in inflammatory reactions.45
Clinical studies have revealed increased numbers of Demodexmiteson theskin of rosacea patients compared withhealthycontrols.45 Demodicosishasbeen reportedto
behigheronthecheeksofpatientswithPPRthanon con-trols withhealthy skin.4,5,45,46 In the present study, 34 of
the43 rosacea patients had Demodex infestations, which wassignificantlyhigherthanAVandSDpatientsandhealthy controls.
SD, a chronic and superficial inflammatory dermatosis ofthe skin,is characterizedby erythematous,oilyyellow squames on the sebaceous gland-rich areas of the skin, includingthescalp,face,chest,backandflexuralareas.47,48
Increased sebum activity, Pityrosporum ovale infection, drugs,immunologicalabnormalities,geneticpredisposition, neurologicaldisorders,emotionalstress,diet,lifestyleand environmentalfactorshavebeenidentifiedascontributors inthepathogenesisofthediseaseoraggravatingSD symp-toms;still,theexactetiology ofSDremainsunknown.10,49
Demodexmitestendtobefoundonthepredilectionareas oftheSD.WebelievethatDemodex-inducedinflammation mayalsocontributeinthepathogenesisofSD.Karincaoglu etal.10 demonstratedsignificantlyhigherDemodex
positiv-ityonthelesionalandnon-lesionalskinofSDpatientsthan healthycontrols.TheyalsosuggestedthatSDitselfmaybe apredisposingfactortoDemodexinfestation,but nodata supportingthishypothesisareavailable.10 Inourstudy,we
alsodemonstratedahigherpresenceofDemodexinfestation inSDpatientsthanincontrols.
The study hasafew limitations. Forexample,we only made the diagnosis of Demodex infestation without an objectivescoringsystem,whichlimitsmakingcommentson theassociationbetweentheseverityoftheinfestationand thedermatoses.D.folliculorumis themostdemonstrated mitebySSSB,asitresideswithinthefollicles,whileD. bre-vislivesdeeper.TheabsenceofanexaminationofD.brevis, whichmayalso contributein thepathogenesisof the dis-eases,isalimitationofthestudy.Thesmallsamplesizeis anotherlimitation.
Conclusion
It is still unclarified whether demodicosis is the cause of skin diseases. But based on the findings of the present study,it may be concluded that, rosacea, AV and SD are significantlyassociatedwithDemodexinfestation.The reac-tivationoftheimmunesystem,inflammationandfollicular changescausedbytheDemodexmitesmightcontributein thedevelopmentofthediseases.SSSB,aneasilyaccessible andpracticaltool,maybeusedtodeterminethepresence ofaDemodexinfestation.Particularlyincasesresistantto therapies,anaccompanyingDemodexinfestationshouldbe considered.
Financial
support
Authors’
contributions
Ezgi Aktas¸ Karabay: Approval of the final version of the manuscript;conception and planning of thestudy; elabo-ration andwriting of the manuscript;obtaining, analysis, and interpretation of the data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; criticalreview of the literature; critical review of themanuscript.
AslıAksuC¸erman:Statisticanalysis;approvalofthefinal versionofthemanuscript;criticalreviewofthemanuscript.
Conflicts
of
interest
Nonedeclared.
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