Med Journal December 2020_ | Page 14

DERM DILEMMA by Austin Morgan by austin

, UAMS morgan class of
; Christopher 2021 ; Chris Schach
Schach , MD MD
Case
A 33-year-old Caucasian male presents to clinic with complaints of red , burning skin and pimple-like bumps on his forehead that have appeared within the past year . The patient states that his symptoms seem to wax and wane in severity , and he notices that they get noticeably worse after he eats spicy food or has been in the sunlight for an extended period of time . His past medical history is otherwise non-contributory .
On physical exam , the patient is found to have multiple erythematous papules and pustules distributed symmetrically across the forehead , glabellum , nose and cheeks . The attending physician decides to perform a scraping of the lesion with mineral oil preparation to ascertain a possible etiology . The mineral oil scraping is subsequently examined under the microscope and reveals the following organism .
Which of the following is the most likely diagnosis and associated organism ?
A .) This is likely periorificial scabies ; the culprit organism is Sarcoptes scabiei .
B .) These lesions are representative of rosacea ; the associated organism is Demodex folliculorum .
C .) This patient has extensive seborrheic dermatitis ; the organism is Malassezia species .
D .) This is gamasoidosis ( bird mite dermatitis ); the causative organism is Dermanyssus gallinae .
Answer : B . Rosacea ; Demodex folliculorum
Discussion
Acne rosacea , or simply rosacea , is an inflammatory skin condition that traditionally presents with erythematous papules and pustules , flushing , telangiectasias , burning , stinging and dryness distributed on the central third of the face . Those afflicted may also experience an irritated , gritty sensation of the eyes , or an enlarged , bulbous nose ( rhinophyma ). It is usually seen in middle aged individuals ranging from 30 to 60 years of age and can be sub-divided into four main types based upon the predominate symptomology : erythematotelangectactic , papulopustular , phymatous , and ocular . Classically , patients with rosacea will experience worsening of their symptoms with certain triggers , which include alcohol , caffeine , spicy foods , exposure to sunlight , stress and heat exposure .
There are many postulated causes of rosacea , and the disease seems to arise from a complicated interplay between genetic predisposition , combined with vascular anomalies , environmental triggers and inflammatory factors . Of note , studies as early as 1932 ( Ayres and Ayres ) have suggested a possible influence of Demodex folliculorum on the development of rosacea , and subsequent studies have been performed that have corroborated this hypothesis .
The demodex mite is a normal inhabitant of the skin fauna but is often seen in higher concentrations in the pilosebaceous units and hair follicles in conditions such as rosacea . Specifically , multiple studies have shown that > 5 mites per follicle or 5 mites / cm2 might play a role in the development of rosacea lesions . As of yet , it is unclear what impact this higher concentration of mites specifically has on the skin of affected individuals , but it is thought that the higher mite burden might trigger inflammatory cascades , either through physical blockage of the follicles , acting as vectors for bacteria that drive the disease process , or by some other process yet to be elucidated . In addition to rosacea , it has also been postulated that Demodex may contribute to the production of other , similar disease processes , such as acne vulgaris ,
pityriasis folliculorum , pustular folliculitis , and perioral dermatitis .
Treatment of rosacea can be difficult , and one of the most effective measures is simple avoidance of triggers . Other therapies include both topical and oral therapy , such as topical Metronidazole cream and oral doxycycline , depending on the severity of the disease process , as well as the subjective physical and emotional discomfort experienced by the patient . Demodex is now being specifically utilized as a therapeutic target . In fact , recent clinical trials have shown promising results with newer agents specifically targeted at the elimination or reconstitution of normal levels of Demodex on the skin surface of rosacea
134 • The Journal of the Arkansas Medical Society www . ArkMed . org