DR Unilateral demodicidosis of face mimicking Hansens disease Deepak Vashisht,1 Jatinder Singh,1 Sukriti Baveja,1 Rohit Tiwari,2 Anuj Bhatnagar1 Departments of 1Dermatology and 2Pathology, Armed Forces Medical College, Pune, India Abstract Demodicosis is a common parasitic infec- tion of the hair follicles and the pilosebaceous unit by the Demodex mites viz. Demodex fol- liculorum and Demodex brevis. Infection by this parasite is common among immunocom- promised and elderly. We report a case of facial Demodicosis which presented like atypical rosacea with a gradually progressing swelling and redness on right side of face which was initially diagnosed as a case of Hansen’s dis- ease. Skin biopsy revealed follicular dilatation with presence of Demodex mite along with intense perifollicular lymphomononuclear infiltrate. Patient was treated with oral tab Ivermectin 12 mg stat along with topical gel metronidazole twice daily to which he respond- ed favourably. Introduction Mite Demodex is an ectoparasite infesting the areas of face rich in pilo-sebaceous units and less commonly other seborrheic sites like upper and medial region of chest and back are also involved.1,2 Majority of the patients are immune-compromised though immunocompe- tent are not spared, nevertheless atypical pre- sention in immunocompetent individuals is a rarity. We report a case with atypical presenta- tion which posed diagnostic dilemma due to confusing clinical picture. Case Report A 32-year-old male presented with gradual onset swelling and redness on right side of face associated with minimal itching for past six months. It started as a pea-sized red raised flat lesion, which increased in size to involve 1/3 rd of right cheek, adjoining nasolabial fold and lower eye-lid. There was modest increase in redness and pruritus of the lesions on sun- exposure, however hot spicy meals, alcohol or emotional stress did not aggravate his symp- toms. There was no history of cough, chest pain, fever, weight loss or any constitutional or systemic symptoms. Patient denied using any local or systemic medication. There was no history of pets in the house. Patient reported to a dermatologist about a month back, where he was diagnosed as Hansen’s disease in view of equivocal hypoaesthesia and solitary indurated plaque on face. He underwent skin biopsy which revealed non-specific inflammation. He was empirically started on multi drug treat- ment (MDT) multi bacillary for Hansens dis- ease. After about four weeks of MDT, patient reported to our hospital with no clinical improvement and persistence of symptoms. His general physical and systemic examina- tions were within normal limits. Dermatological examination revealed involve- ment of right malar region, nasolabial fold and adjacent parts of nasal bridge and lower eyelid in the form of edema, erythema and follicular dilatation (Figure 1). There was no hypoesthe- sia or thickened peripheral nerves. Laboratory investigations revealed complete blood count, erythrocyte sedimentation rate (ESR), liver and renal function tests, serum ACE levels, were normal. Screening for hepatitis B, hepa- titis C and human immunodeficiency virus, as well as serology for antinuclear antibodies (ANA) were negative. Chest X-ray showed no abnormality and KOH mount of scrapings did not reveal any pathology. Repeat skin biopsy from medial end of the swelling along nasolabial fold showed mild epidermal ortho- hyperkeratosis. The dermis showed intense follicular and perifollicular lymphocytic inflam- matory infiltrate along with dense lichenoid lymphomononuclear infiltrate. There was fol- licular dilatation with presence of Demodex sp.mite with surrounding homogenous eosinophilic material (Figure 2). Patient was managed with oral ivermectin 12 mg stat and topical metronidazole gel locally twice a day. The eryhthema and swelling start- ed regressing within few days and after 03 weeks had near complete resolution of symp- toms (Figure 3). Discussion and Conclusions Demodex are parasitic mites that live in hair follicles and pilosebaceous units, accord- ingly maximum density is found in seborrheic sites. Besides humans they also cause signifi- cant infestation in canines and felines.3 Human infestation is very common and varies between 23-100% as per different authors.4,5 This infestation is usually asymptomatic, but when and how it becomes pathogenic is poorly understood.6 Primary or secondary suppres- sion in immunity plays a major role in Demodex proliferation and resultant der- matoses. Cutaneous disorders attributed to this mite include, rosacea, pustular folliculitis, perioral dermatitis, Lupus miliaris dissemina- tus faciei, Madarosis, non-specific facial der- matitis etc.7 Our patient presented with non- specific facial dermatitis affecting only right Dermatology Reports 2016; volume 8:6891 Correspondence: Deepak Vashisht, Department of Dermatology, Armed Forces Medical College, Pune, Maharasthra, 411040 India. Tel.: +91.9419021643. E-mail: deepak3975@gmail.com Key words: Demodicosis, atypical rosacea, Hansen’s Disease. Contributions: the authors contributed equally. Conflict of interest: the authors declare no poten- tial conflict of interest. Received for publication: 16 September 2016. Accepted for publication: 18 November 2016. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). ©Copyright D. Vashisht et al., 2016 Licensee PAGEPress, Italy Dermatology Reports 2016; 8:6891 doi:10.4081/dr.2016.6891 Figure 1. A) Partially defined edematous and erythematous plaque on right malar region, nasolabial fold and lower eyelid with follicular dilatation. B) Comparisson of the lesion with contralateral normal site. [Dermatology Reports 2016; 8:6891] [page 13] A B No n c om me rci al us e o nly [page 14] [Dermatology Reports 2016; 8:6891] side of the face. Patient had no evidence of pri- mary or secondary immune suppression. There was no local or systemic risk factor sug- gestive of Demodex infestation. Unilateral, indurated, erythematous plaque on face with equivocal hypoaesthesia resulted in initial misdiagnoses. Earlier it has also been reported to present with facial sclera-oedema and ble- pharoedema which mimicked cutaneous lym- phoma.8 This case is being reported for its uni- lateral atypical presentation. Further demodi- cidosis should also be considered in patients presenting even with unilateral lesions in seb- orrheic areas. References 1. Aylesworth R, Vance C.Demodex folliculo- rum and Demodex brevis in cutaneous biop- sies. J Am Acad Dermatol 1982;7:583-9. 2. Basta- Juzbasic A, Subic JS, Ljubojevic S. Demodex folliculorum in development of dermatitis rosaceiformis steroidica and rosacea-related diseases. Clin Dermatol 2002;20:135-40. 3. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Skin diseases of the dog and cat: clinical and histopathologic diagnosis. Oxford: Blackwell Science Ltd; 2008. pp 932 4. Norn MS. Demodex folliculorum. Incidence, regional distribution, patho- genicity. Dan Med Bull 1971;18:14-7. 5. Rufli T, Mumcuoglu Y. The hair follicle mites Demodex folliculorum and Demodex brevis: biology and medical importance. A review. Dermatologica 1981;162:1-11. 6. Temnikov VE. The peculiarity of immune status in rosacea. Nigniy Novgorod 1991;1:86-8. 7. Rather PA, Hassan I. Human demodex mite: the versatile mite of dermatological importance. Indian J Dermatol 2014;59:60- 6. 8. Kito Y, Hashizume H, Tokura Y. Rosacea- like demodicosis mimicking cutaneous lymphoma. Acta Derm Venereol 2012;92:169-70. Case Report Figure 2. Section through skin biopsy showing multiple follicular infundibula showing Demodex mites (horizontal arrow). The perifollicular tissue shows lymphomononuclear inflammation (H&E, 100×). Inset: Demodex mite in the infundibulum(horizontal arrow) (H&E, 400×). Figure 3. Almost completed resolution of the plaque on right malar region. No n c om me rci al us e o nly