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Not acne, but what?
AN OTHERWISE HEALTHY
Scattered papules and pustules were present on the forehead, nose, and cheeks, with background erythema and telangiectasias (FIGURE 1). A few pinpoint crusted excoriations were noted. A sample was taken from the papules and pustules using a #15 blade and submitted for examination.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Rosacea with Demodex mites
Under light microscopy, the scraping revealed Demodex mites (FIGURE 2). It has been proposed that these mites play a role in the inflammatory process seen in rosacea, although studies have yet to determine whether the inflammatory symptoms of rosacea cause the mites to proliferate or if the mites contribute to the initial inflammatory process.1,2
Demodex folliculorum and D brevis are part of normal skin flora; they are found in about 12% of all follicles and most commonly involve the face.3 They often become abundant in the presence of numerous sebaceous glands. Men have more sebaceous glands than women do, and thus run a greater risk for infestation with mites. An abnormal proliferation of Demodex mites can lead to demodicosis.
Demodex mites can be examined microscopically via the skin surface sampling technique known as scraping, which was done in this case. Samples taken from the papules and pustules utilizing a #15 blade are placed in immersion oil on a glass slide, cover-slipped, and examined by light microscopy.
Rosacea is thought to be an inflammatory disease in which the immune system is triggered by a variety of factors, including UV light, heat, stress, alcohol, hormonal influences, and microorganisms.1,4 The disease is found in up to 10% of the population worldwide.1
The diagnosis of rosacea requires at least 1 of the 2 “core features”—persistent central facial erythema or phymatous changes—or 2 of 4 “major features”: papules/pustules, ocular manifestation, flushing, and telangiectasias. There are 3 phenotypes: ocular, papulopustular, and erythematotelangiectatic.5,6
Continue to: The connection
The connection. Papulopustular and erythematotelangiectatic rosacea may be caused by a proliferation of Demodex mites and increased vascular endothelial growth factor production.2 In fact, a proliferation of Demodex is seen in almost all cases of papulopustular rosacea and more than 60% of cases of erythematotelangiectatic rosacea.2
Patient age and distribution of lesions narrowed the differential
Acne vulgaris is an inflammatory disease of the pilosebaceous units caused by increased sebum production, inflammation, and bacterial colonization (Propionibacterium acnes) of hair follicles on the face, neck, chest, and other areas. Both inflammatory and noninflammatory lesions can be present, and in serious cases, scarring can result.7 The case patient’s age and accompanying broad erythema were more consistent with rosacea than acne vulgaris.
Seborrheic dermatitis is a common skin condition usually stemming from an inflammatory reaction to a common yeast. Classic symptoms include scaling and erythema of the scalp and central face, as well as pruritus. Topical antifungals such as ketoconazole 2% cream and 2% shampoo are the mainstay of treatment.8 The broad distribution and papulopustules in this patient argue against the diagnosis of seborrheic dermatitis.
Systemic lupus erythematosus is a systemic inflammatory disease that often has cutaneous manifestations. Acute lupus manifests as an erythematous “butterfly rash” across the face and cheeks. Chronic discoid lupus involves depigmented plaques, erythematous macules, telangiectasias, and scarring with loss of normal hair follicles. These findings classically are photodistributed.9 The classic broad erythema extending from the cheeks over the bridge of the nose was not present in this patient.
Treatment is primarily topical
Mild cases of rosacea often can be managed with topical antibiotic creams. More severe cases may require systemic antibiotics such as tetracycline or doxycycline, although these are used with caution due to the potential for antibiotic resistance.
Ivermectin 1% cream is a US Food and Drug Administration–approved medication that is applied once daily for up to a year to treat the inflammatory pustules associated with Demodex mites. Although it is costly, studies have shown better results with topical ivermectin than with other topical medications (eg, metronidazole 0.75% gel or cream). However, metronidazole 0.75% gel applied twice daily and oral tetracycline 250 mg or doxycycline 100 mg daily or twice daily for at least 2 months often are utilized when the cost of topical ivermectin is prohibitive.10
Our patient was treated with a combination of doxycycline 100 mg daily for 30 days and
1. Forton FMN. Rosacea, an infectious disease: why rosacea with papulopustules should be considered a demodicosis. A narrative review. J Eur Acad Dermatol Venereol. 2022;36:987-1002. doi: 10.1111/jdv.18049
2. Forton FMN. The pathogenic role of demodex mites in rosacea: a potential therapeutic target already in erythematotelangiectatic rosacea? Dermatol Ther (Heidelb). 2020;10:1229-1253. doi: 10.1007/s13555-020-00458-9
3. Elston DM. Demodex mites: facts and controversies. Clin Dermatol. 2010;28:502-504. doi: 10.1016/j.clindermatol.2010.03.006
4. Erbağci Z, OzgöztaŞi O. The significance of demodex folliculorum density in rosacea. Int J Dermatol. 1998;37:421-425. doi: 10.1046/j.1365-4362.1998.00218.x
5. Tan J, Almeida LMC, Criber B, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-438. doi: 10.1111/bjd.15122
6. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78:148-155. doi: 10.1016/j.jaad.2017.08.037
7. Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet. 2012;379:361-372. doi: 10.1016/S0140-6736(11)60321-8.
8. Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91:185-190.
9. Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol. 1996;135:355-362.
10. Raedler LA. Soolantra (ivermectin) 1% cream: a novel, antibiotic-free agent approved for the treatment of patients with rosacea. Am Health Drug Benefits. 2015;8(Spec Feature):122-125.
AN OTHERWISE HEALTHY
Scattered papules and pustules were present on the forehead, nose, and cheeks, with background erythema and telangiectasias (FIGURE 1). A few pinpoint crusted excoriations were noted. A sample was taken from the papules and pustules using a #15 blade and submitted for examination.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Rosacea with Demodex mites
Under light microscopy, the scraping revealed Demodex mites (FIGURE 2). It has been proposed that these mites play a role in the inflammatory process seen in rosacea, although studies have yet to determine whether the inflammatory symptoms of rosacea cause the mites to proliferate or if the mites contribute to the initial inflammatory process.1,2
Demodex folliculorum and D brevis are part of normal skin flora; they are found in about 12% of all follicles and most commonly involve the face.3 They often become abundant in the presence of numerous sebaceous glands. Men have more sebaceous glands than women do, and thus run a greater risk for infestation with mites. An abnormal proliferation of Demodex mites can lead to demodicosis.
Demodex mites can be examined microscopically via the skin surface sampling technique known as scraping, which was done in this case. Samples taken from the papules and pustules utilizing a #15 blade are placed in immersion oil on a glass slide, cover-slipped, and examined by light microscopy.
Rosacea is thought to be an inflammatory disease in which the immune system is triggered by a variety of factors, including UV light, heat, stress, alcohol, hormonal influences, and microorganisms.1,4 The disease is found in up to 10% of the population worldwide.1
The diagnosis of rosacea requires at least 1 of the 2 “core features”—persistent central facial erythema or phymatous changes—or 2 of 4 “major features”: papules/pustules, ocular manifestation, flushing, and telangiectasias. There are 3 phenotypes: ocular, papulopustular, and erythematotelangiectatic.5,6
Continue to: The connection
The connection. Papulopustular and erythematotelangiectatic rosacea may be caused by a proliferation of Demodex mites and increased vascular endothelial growth factor production.2 In fact, a proliferation of Demodex is seen in almost all cases of papulopustular rosacea and more than 60% of cases of erythematotelangiectatic rosacea.2
Patient age and distribution of lesions narrowed the differential
Acne vulgaris is an inflammatory disease of the pilosebaceous units caused by increased sebum production, inflammation, and bacterial colonization (Propionibacterium acnes) of hair follicles on the face, neck, chest, and other areas. Both inflammatory and noninflammatory lesions can be present, and in serious cases, scarring can result.7 The case patient’s age and accompanying broad erythema were more consistent with rosacea than acne vulgaris.
Seborrheic dermatitis is a common skin condition usually stemming from an inflammatory reaction to a common yeast. Classic symptoms include scaling and erythema of the scalp and central face, as well as pruritus. Topical antifungals such as ketoconazole 2% cream and 2% shampoo are the mainstay of treatment.8 The broad distribution and papulopustules in this patient argue against the diagnosis of seborrheic dermatitis.
Systemic lupus erythematosus is a systemic inflammatory disease that often has cutaneous manifestations. Acute lupus manifests as an erythematous “butterfly rash” across the face and cheeks. Chronic discoid lupus involves depigmented plaques, erythematous macules, telangiectasias, and scarring with loss of normal hair follicles. These findings classically are photodistributed.9 The classic broad erythema extending from the cheeks over the bridge of the nose was not present in this patient.
Treatment is primarily topical
Mild cases of rosacea often can be managed with topical antibiotic creams. More severe cases may require systemic antibiotics such as tetracycline or doxycycline, although these are used with caution due to the potential for antibiotic resistance.
Ivermectin 1% cream is a US Food and Drug Administration–approved medication that is applied once daily for up to a year to treat the inflammatory pustules associated with Demodex mites. Although it is costly, studies have shown better results with topical ivermectin than with other topical medications (eg, metronidazole 0.75% gel or cream). However, metronidazole 0.75% gel applied twice daily and oral tetracycline 250 mg or doxycycline 100 mg daily or twice daily for at least 2 months often are utilized when the cost of topical ivermectin is prohibitive.10
Our patient was treated with a combination of doxycycline 100 mg daily for 30 days and
AN OTHERWISE HEALTHY
Scattered papules and pustules were present on the forehead, nose, and cheeks, with background erythema and telangiectasias (FIGURE 1). A few pinpoint crusted excoriations were noted. A sample was taken from the papules and pustules using a #15 blade and submitted for examination.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Rosacea with Demodex mites
Under light microscopy, the scraping revealed Demodex mites (FIGURE 2). It has been proposed that these mites play a role in the inflammatory process seen in rosacea, although studies have yet to determine whether the inflammatory symptoms of rosacea cause the mites to proliferate or if the mites contribute to the initial inflammatory process.1,2
Demodex folliculorum and D brevis are part of normal skin flora; they are found in about 12% of all follicles and most commonly involve the face.3 They often become abundant in the presence of numerous sebaceous glands. Men have more sebaceous glands than women do, and thus run a greater risk for infestation with mites. An abnormal proliferation of Demodex mites can lead to demodicosis.
Demodex mites can be examined microscopically via the skin surface sampling technique known as scraping, which was done in this case. Samples taken from the papules and pustules utilizing a #15 blade are placed in immersion oil on a glass slide, cover-slipped, and examined by light microscopy.
Rosacea is thought to be an inflammatory disease in which the immune system is triggered by a variety of factors, including UV light, heat, stress, alcohol, hormonal influences, and microorganisms.1,4 The disease is found in up to 10% of the population worldwide.1
The diagnosis of rosacea requires at least 1 of the 2 “core features”—persistent central facial erythema or phymatous changes—or 2 of 4 “major features”: papules/pustules, ocular manifestation, flushing, and telangiectasias. There are 3 phenotypes: ocular, papulopustular, and erythematotelangiectatic.5,6
Continue to: The connection
The connection. Papulopustular and erythematotelangiectatic rosacea may be caused by a proliferation of Demodex mites and increased vascular endothelial growth factor production.2 In fact, a proliferation of Demodex is seen in almost all cases of papulopustular rosacea and more than 60% of cases of erythematotelangiectatic rosacea.2
Patient age and distribution of lesions narrowed the differential
Acne vulgaris is an inflammatory disease of the pilosebaceous units caused by increased sebum production, inflammation, and bacterial colonization (Propionibacterium acnes) of hair follicles on the face, neck, chest, and other areas. Both inflammatory and noninflammatory lesions can be present, and in serious cases, scarring can result.7 The case patient’s age and accompanying broad erythema were more consistent with rosacea than acne vulgaris.
Seborrheic dermatitis is a common skin condition usually stemming from an inflammatory reaction to a common yeast. Classic symptoms include scaling and erythema of the scalp and central face, as well as pruritus. Topical antifungals such as ketoconazole 2% cream and 2% shampoo are the mainstay of treatment.8 The broad distribution and papulopustules in this patient argue against the diagnosis of seborrheic dermatitis.
Systemic lupus erythematosus is a systemic inflammatory disease that often has cutaneous manifestations. Acute lupus manifests as an erythematous “butterfly rash” across the face and cheeks. Chronic discoid lupus involves depigmented plaques, erythematous macules, telangiectasias, and scarring with loss of normal hair follicles. These findings classically are photodistributed.9 The classic broad erythema extending from the cheeks over the bridge of the nose was not present in this patient.
Treatment is primarily topical
Mild cases of rosacea often can be managed with topical antibiotic creams. More severe cases may require systemic antibiotics such as tetracycline or doxycycline, although these are used with caution due to the potential for antibiotic resistance.
Ivermectin 1% cream is a US Food and Drug Administration–approved medication that is applied once daily for up to a year to treat the inflammatory pustules associated with Demodex mites. Although it is costly, studies have shown better results with topical ivermectin than with other topical medications (eg, metronidazole 0.75% gel or cream). However, metronidazole 0.75% gel applied twice daily and oral tetracycline 250 mg or doxycycline 100 mg daily or twice daily for at least 2 months often are utilized when the cost of topical ivermectin is prohibitive.10
Our patient was treated with a combination of doxycycline 100 mg daily for 30 days and
1. Forton FMN. Rosacea, an infectious disease: why rosacea with papulopustules should be considered a demodicosis. A narrative review. J Eur Acad Dermatol Venereol. 2022;36:987-1002. doi: 10.1111/jdv.18049
2. Forton FMN. The pathogenic role of demodex mites in rosacea: a potential therapeutic target already in erythematotelangiectatic rosacea? Dermatol Ther (Heidelb). 2020;10:1229-1253. doi: 10.1007/s13555-020-00458-9
3. Elston DM. Demodex mites: facts and controversies. Clin Dermatol. 2010;28:502-504. doi: 10.1016/j.clindermatol.2010.03.006
4. Erbağci Z, OzgöztaŞi O. The significance of demodex folliculorum density in rosacea. Int J Dermatol. 1998;37:421-425. doi: 10.1046/j.1365-4362.1998.00218.x
5. Tan J, Almeida LMC, Criber B, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-438. doi: 10.1111/bjd.15122
6. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78:148-155. doi: 10.1016/j.jaad.2017.08.037
7. Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet. 2012;379:361-372. doi: 10.1016/S0140-6736(11)60321-8.
8. Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91:185-190.
9. Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol. 1996;135:355-362.
10. Raedler LA. Soolantra (ivermectin) 1% cream: a novel, antibiotic-free agent approved for the treatment of patients with rosacea. Am Health Drug Benefits. 2015;8(Spec Feature):122-125.
1. Forton FMN. Rosacea, an infectious disease: why rosacea with papulopustules should be considered a demodicosis. A narrative review. J Eur Acad Dermatol Venereol. 2022;36:987-1002. doi: 10.1111/jdv.18049
2. Forton FMN. The pathogenic role of demodex mites in rosacea: a potential therapeutic target already in erythematotelangiectatic rosacea? Dermatol Ther (Heidelb). 2020;10:1229-1253. doi: 10.1007/s13555-020-00458-9
3. Elston DM. Demodex mites: facts and controversies. Clin Dermatol. 2010;28:502-504. doi: 10.1016/j.clindermatol.2010.03.006
4. Erbağci Z, OzgöztaŞi O. The significance of demodex folliculorum density in rosacea. Int J Dermatol. 1998;37:421-425. doi: 10.1046/j.1365-4362.1998.00218.x
5. Tan J, Almeida LMC, Criber B, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-438. doi: 10.1111/bjd.15122
6. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78:148-155. doi: 10.1016/j.jaad.2017.08.037
7. Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet. 2012;379:361-372. doi: 10.1016/S0140-6736(11)60321-8.
8. Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91:185-190.
9. Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol. 1996;135:355-362.
10. Raedler LA. Soolantra (ivermectin) 1% cream: a novel, antibiotic-free agent approved for the treatment of patients with rosacea. Am Health Drug Benefits. 2015;8(Spec Feature):122-125.
