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Abstract:
Rosacea is a chronic dermatological disorder characterized by persistent symmetrical erythema, edema, telangiectasia, papules and pustules on the face, especially on the nose, cheeks, chin and forehead. There are a limited therapeutic options for recalcitrant cases of papulopustular rosacea. Demodex folliculorum is the most common saprophytic mite of the pilosebaceous unit. This paper reports a case of a 35 -year-old man presented to the outpatient clinic of Qassim University with man presented with severe papulopustular rosacea recalcitrant to multiple therapies, including oral doxycycline, oral isotretinoin, topical metronidazole gel and topical tacrolimus. Histological examination of a biopsy specimen from the affected area revealed numerous mites within the folliculosebaceous unit. The patient was treated with oral ivermectin and topical permethrin resulting in complete and rapid clearing of his symptoms.
Keywords: Papulopustular rosacea, Oral ivermectin, Topical permethrin
Introduction
Rosacea is a highly predominant, chronic inflammatory skin condition. Rosacea mainly affects adults around 30 years of age, and classically predominates in females and increases with age. (1)
The pathogenesis of rosacea is not yet completely understood. Its a etiology is multifactorial and in addition to exogenous factors including UV light, it may be secondary to parasitic involvement (particularly Demodex folliculorum mites). (2)
Demodex folliculorum is the most common ectoparasite of man and a saprophytic mite of the pilosebaceous unit. It is an elongated transparent worm-like parasite with an obvious head, neck, and a body-tail part, of which the former has four pairs of stumpy legs measuring about 0.35–0.4 mm in length; it has protruding stumpy sharp mouth parts. (3)
Case Report
A 35 -year-old white man presented to the outpatient dermatology clinic, College of Medicine, Qassim University, Saudi Arabia with 5 years history of of a slowly progressive and pruritic facial eruption.
Physical examination, there was a diffuse erythema, telangiectasia, severe papules and pustules localized on the cheeks, nose, chin, and forehead. The retroauricular region, neck, and chest were not affected. The patient noted moderate to severe pruritus in the affected regions. Otherwise, he is healthy with no significant history for skin or any associated systemic manifestations. Additionally, there was no significant history of recurrent skin or systemic infections. There was also no history of any other significant and relevant skin or systemic illness in the family.
Laboratory examination, including routine blood counts, liver function, kidney function, lipid profile revealed no abnormalities. A 10% potassium hydroxide (KOH) preparation of pustule scrapings from the cheek revealed several Demodex folliculorum mites.
Previous Therapy: the patient treated with doxycycline, 100 mg/d, and topical steroid for 3 months and achieved a temporary improvement in the skin lesions. A flare 5 weeks after discontinuing doxycycline and topical steroid and the treatment did not result any improvement. He treated with oral isotretinoin, 0.5 mg/kg/d, for 6 months and achieved a temporary improvement in the skin lesions. A flare 6 weeks after discontinuing isotretinoin and the treatment result very mild improvement. He started using topical tacrolimus. There was some improvement in the skin lesions; however, when he stopped treatment clinical picture were worse
Because of the long list of previous unsuccessful treatment attempts the patient
Ethical considerations
Written informed consent was taken from the patient for publication of the manuscript. The authors declare that there is no conflict of interest regarding the publication of this paper.
Conflict of interest: The author hereby declared no conflict of interest. The author declares no conflict of interest.
Acknowledgement: The authors acknowledge the imperative contributions of many individuals to this study. Medical and nursing staff members in the dermatology clinic and, laboratory department for their scientific technical support.