Dermatol Sinica, Sep 2005 144

Demodex Abscess: Clinical and Therapeutic ChallengesChao-Hwei Wang Chung-Hsing Chang

A 52-year-old man suffered from recurrent erythematous papules, plaques, pustules and abscessesover the anterior chest, abdomen and back with severe pruritus for four years. He was under long termsystemic steroid treatment for more than 4 years due to arthralgia. Steroid-induced folliculitis orPityrosporum folliculitis was impressed at first, but treatment with systemic minocyclin and topicalbenzoyl 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, therewere Demodex mites. KOH examinations of the specimens from abscesses revealed many Demodexbrevis mites. The skin lesions were unresponsive to topical antiparasitic treatment (benzoyl benzoateand crotamiton). Therefore oral administration of levamisole HCl 50 mg 3 times a day for 10 days wasgiven and all the skin lesions and pruritus were subsided. (Dermatol Sinica 23: 144-147, 2005)

Key words: Demodex, Levamisole, Iatrogenic Cushing s syndrome

itraconazole

(Demodex bre-

vis) KOH ben-

zoyl benzoate crotamiton 50mg levamisole HCl

levamisole HCl ( 23: 144-147, 2005)

From the Department of Dermatology, Tzu Chi University and Tzu Chi Medical Center, Hualien, TaiwanAccepted for publication: March, 08, 2005Reprint 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

145 Dermatol Sinica, September 2005

INTRODUCTIONDemodex folliculorum and Demodex brevis

are common inhabitants of the human piloseba-ceous unit. Demodex folliculorum is more com-mon than Demodex brevis and is characterizedby a larger size, and elongated posterior seg-ment. It is usually located in the follicularinfundibulum and may be present in numbersup to 10~15 per follicle. Demodex brevis isshorter and more oval shaped. It is usuallyfound in sebaceous glands and ducts and is soli-tary.1, 2 The prevalence of infestation withDemodex species increases with age.3 A relationbetween infestation with Demodex and severaltypes of eruptions has been well documented.1 ,4,

5, 6, 7 We describe an immune compromizedpatient with unusual clinical manifestation ofDemodex infestation and were un-responsive tonumerous antiparasitic treatments but finallycleared completely after oral levamisole therapy.

CASE REPORTA 52-year-old man was seen with 4 years

history of moderate to severe pruritic skin erup-tion involving mainly the chest, back andabdomen. Physical examination revealed moonface, plethora, hirsutism, but no folliculitis orrosacea over the face. Multiple confluent ery-thematous papules, pustules and abscess overthe chest, back and abdomen were found. Tineacorporis and tinea cruris werer noted over thetrunk (Fig. 1). Tracing back his history, he hadtaken black pills, a kind of Chinese herbal med-

icine containing steroid, due to arthralgia formore than 4 years.

Laboratory findings including routineblood counts and acute phase proteins revealedno abnormalities. Enzyme-linked immunosor-bent assay for HIV was negative. ACTH: 15.6pg/ml(10~46), Cortisol <1 ug/dl (5~25),Aldosterone 74.6 pg/mL (37~240). Bacterialcultures of skin swabs and contents fromabscesses failed to grow. A 10% potassiumhydroxide preparations of skin scraping fromback showed no fungal or yeast elements.

Steroid-induced folliculitis was impressedat first, but the symptom persisted after oralminocycline 200 mg/day and topical benzoylperoxide treatment for 4 weeks. Pityrosporumfolliculitis was then suspected but no significantimprovement after oral itraconazole 200 mg perday for 4 weeks. Skin biopsy was performed onthe abscess of back. The histopathological pic-ture was that of a perifollicular infiltration withplasma cells, neutrophils, eosinophils and someforeign body giant cells (Fig. 2, 3). Within thesebaceous duct and gland, there were Demodexmites. 10% potassium hydroxide preparations ofabscess from the back revealed multipleDemodex brevis within the pus smear (Fig. 4).Our final diagnosis was abscesses due toDemodex brevis. Antiparasitic treatment, whichpreviously were reported to eradicate infesta-tions with Demodex mite, including benzoylbenzoate, crotamiton, and metronidazole gel, allfailed to relieve the skin manifestations.

Fig. 1Confluene erythematons papnles, pustules, and abscess.

Fig. 2 Infiltration around hair follicle with hair follicle destructionand granulomatous infiltration. (H&E, 40X)

Dermatol Sinica, September 2005 146

Rapid and complete recovery was finallyachieved after systemic levamisole 50 mg orally3 times a day for 10 days. Subsequent follow upevaluation for the next 9 months showed excel-lent control of the disease.

DISCUSSIONDemodex folliculorum and Demodex bre-

vis are common parasites in the hair folliclesand in the pilosebaceous gland of human skin.1, 2

The mites are generally found on the forehead,cheeks, nose and nasolabial folds, occasionallyon the trunk. In certain circumstances, abnor-mally large numbers of mites probably inducedsome skin disorders. The clinical manifestationsof demodicidosis include granulomatousrosacea, granulomatous perioral dermatitis, andpustular folliculitis, papulopustular dermatosisof scalp, blepharitis, and spinulosis of the face.4-7

Unlike previously reported Demodex-associatedcases, our patient did not have the usual symp-toms or signs. There is no report of skin lesionon the trunk with or without face involvement.In our patient, there are multiple confluent ery-thematous papules, nodules and pustules withsevere itching, but no other skin lesion over theface.

The participation of Demodex in the patho-genesis of skin lesions has long been debated.Current hypotheses state that either an immuno-logic deficiency favoring an increase in the num-ber of mites or an abnormal immunologic reac-tion of the skin to the parasites might provoke the

appearance of cutaneous lesions.3, 8-10, 21

In report of Demodex folliculitis, use oftopical antiparasitic agent result in clearing thelesions;5, 7, 11 some investigator point out,Demodex brevis is far more difficult to eradicatein using topical antiparasitic agent.12, 13 In ourcase, the patient with Demodex brevis folliculi-tis refractory to all topical antiparasitic reme-dies, including benzoyl benzoate, crotamiton,metronidazole (Table 1). The response to thetopical or systemic drugs listed in Table 1 wasnot convincing. The symptom improved rapidlyafter systemic monotherapy with 150 mg lev-amisole orally 3 times a day for 2 weeks.

Levamisole is an anti-helminthic drug withimmuno-modulating properties. It can restoredepressed immune function, stimulate forma-tion of antibodies, enhance T-cell responses bystimulating T cell activation and proliferation,

Fig. 3 Demodex brevis in the sevaceous duct and gland with peri-follicular infiltration. (H&E, 400X)

Fig. 4 Demodex brevis within pus smear (KOH)

Table 1. Unsuccesful attempts in treatment

Medication dose Duration (day)Systemic:Minocycline 200mg/qd 28Itraconazole 200mg/qd 28Nimesulide 200mg/day 28Topical:Fusidic acid cream 28Benzoyl peroxide 28Benzoyl benzoate lotion 28 Crotamiton 28Metronidazole gel 28

147 Dermatol Sinica, September 2005

and increase neutrophil mobility, adherence andchemotaxis.14-16 It is also an acetylcholine nico-tinic receptor agonist,16, 17 which is highly effectivein eradicating Ascarid and Trichostrongylus.Levamisole has been reported to be effectiveagainst pediculosis as well.16 Our report firstdemonstrates that systemic levamisole is effec-tive in the deep Demodex abscess while topicalmedicines are in vain.

The Demodex mites which are the same tolice belong to class Arachnida.2 Recent reportsof demodicidosis in association with acquiredimmunodeficiency syndrome (AIDS) and can-cer chemotherapy have suggested that immunedeficiency might cause overgrowth of themite.10, 18-20 Akilov et al. evaluated immuneresponse in demodicosis, they found the readi-ness of lymphocytes to undergo apoptosis inparallel to the increasing density of the mites.This could be the result of local immunosup-pression caused by the mites, which allowsmites to survival and provoke the skin lesions.21

In short, levamisole can enhance T-cell respons-es and increase the function of the neutrophil, itcan also eradicate Ascarid, hence we chose lev-amisole to treat our patient.

In conclusion, we were confused by theclinical symptoms and disappointed in ournumerous therapeutic attempts, but we weresurprised by the rapid and lasting clearing withoral levamisole. We encourage further trialswith oral levamisole to provide evidence-basesupport for this therapeutic approach.

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