Dermoscopic Findings of Rosacea and Demodicosis.

BACKGROUND: Rosacea is a common chronic inflammatory disorder affecting the facial skin.
OBJECTIVES: Dermoscopy is a noninvasive procedure that is commonly used for the diagnosis of dermatological diseases. This article aims to determine the clinical and dermoscopic manifestations of the rosacea patients and the presence of the accompanying Demodex.
MATERIALS AND METHODS: The study evaluated 23 patients who were diagnosed with rosacea through clinical and dermoscopic findings. The patients were clinically and dermoscopically photographed and were classified according to the rosacea classification. The presence of Demodex was demonstrated both dermoscopically and through biopsy.
RESULTS: There were a total of 23 participants (17 females and 6 males). The ages of the participants ranged between 28 and 75, with an average of 49. Among the 23 participants, 14 were erythematotelangiectatic, 7 were papulopustular, and 2 were rhinophyma. A total of 12 participants (4 males and 8 females) had ocular involvement. The most common dermoscopic finding was a linear vascular structure. A total of 15 patients (11 females and 4 males) had the demodicosis finding.
CONCLUSION: The diagnosis of rosacea and demodicosis through dermoscopic findings is as reliable as a biopsy and it has the advantage of being noninvasive. Copyright:

Introduction

Rosacea is a skin disease that is characterized by erythema of the central face.[1] The most common clinical manifestations include erythema, edema, telangiectasia, cutaneous findings (papules, pustules, and rhinophyma), and ocular involvement.[2] Rosacea is a chronic condition that prognoses with inflammations and remissions. Although it is more common among women, it is usually more severe among men. The prevalence is 1.2%–5.4% for the population aged over 50.[3] It typically develops after 30; however, it can be seen among children, adolescents, and young adults.[4] The latest classification of rosacea has four subtypes: Erythematotelangiectatic (vascular) rosacea (ETR), papulopustular rosacea, rhinophyma (sebaceous hyperplasia), and ocular rosacea.[4]

The physiopathology of rosacea is still not entirely clear. The main cause of pathogenesis is thought to be the increased vascular permeability due to increased vasomotor activity.[5] The etiology indicated that the vasoactive intestinal polypeptide is increased for these patients. This, together with increased secretion of angiogenic factors from mast cells (heparin, histamine, tumor necrosis factor-alpha, etc.) may lead to the pathogenesis of the disease.[6] It is also argued that other independent lesions may lead to inflammatory infiltrations of the hair follicle mites (Demodex folliculorum).[7] The hair follicle mites are more common among rosacea patients, compared to healthy individuals. It is possible that these mites are not pathogenetic factors, but they increase the severity of the disease.[8]

Dermoscopy has become increasingly common as a tool for dermatological diagnosis and monitoring. The specific dermoscopic patterns can be used to diagnose rosacea, especially demodicosis. The aim of this study was to dermoscopically identify the clinical manifestations of rosacea of 23 patients and to emphasize that the presence of demodicosis can be determined singularly through dermoscopy (without the requirement of skin biopsy).

Materials and Methods

This was a prospective, controlled clinical trial demonstrating the advantages of dermoscopy for rosacea and Demodex mites. The data were collected between November 2017 and March 2018 in the dermatology clinics of one private and one public hospital in Turkey. The study was approved by the ethical committee and was conducted in accordance with the principles of the Declaration of Helsinki. All the patients have signed informed consent forms.

The subjects

The study includes a total of 23 rosacea patients, who were diagnosed through clinical manifestations and dermoscopic imaging. The patients’ clinical facial lesions were both photographed and dermoscopically imaged [Figures 1-3]. The diagnosis was confirmed through biopsy examinations for some of the participants. For every participant, the presence of Demodex was investigated with superficial biopsies [Figure 4]. The patients who had used corticosteroids in the last 6 months before the dermoscopic examinations and the pregnant patients were excluded from the study.

Figure 1

Dermoscopic pictures: (1) Demodex tails (rectangle), follicle opening, (2) Demodex tails (circle), follicle plugs (rectangle), (3) Demodex tails, follicle opening (circle), superficial scales (arrow), (4) follicle plug (arrow), superficial scales (circle), (5) Demodex tail (circle), superficial scales (rectangle), (6) follicle opening (circles), linear vessels (arrows), (7) Demodex tail, follicle opening (circles) linear vessels (arrows), (8) arborizing vessels (arrows), follicle plugs (circle), (9) linear vessels (arrows), follicle opening (circles)

Figure 3

Dermoscopic pictures: 19-superficial scales (circle), polygonal network, (20) follicle plug (circle), (21) follicle opening (circle), linear vessels (arrows), (22) pigmentation structures (circle), linear vessels (arrows), follicle opening (rectangle), (23) follicle plug (circle)

Figure 4

Standardized skin surface biopsy. The appearance of 5 or more live parasites in a 1 cm2 area among patients with Demodex folliculorum (×40)

DermLite DL4 dermatoscope (3Gen) ×10 device was used for the evaluation of the central facial lesions, as this device applies the epiluminescence imaging technique, and the vascular and pigment webs can be more clearly observed. A sterile IceCap™ was used for the dermoscopic examination of every patient to prevent contact infections.

The dermoscopic evaluation was conducted in compliance with the current literature. The evaluated items were as follows: linearly arborizing vessels, vascular polygons, orange-yellowish area, follicle plug, dilated follicles, pigmented areas, and white and yellow squama. The dermoscopic changes were quantitatively analyzed.

Results

A total of 23 rosacea patients were included in the study (17 females and 6 males). The mean age of the patients was 49 (28–75) years. The patients were classified according to their demographic properties and the rosacea subtypes [Table 1]. The dermoscopic findings regarding the vascular structures, follicle dilatation and plug, white and yellow scabbing, and Demodex tail properties are presented in Table 2 [the results of dermoscopic analysis are presented in Table 2]

Table 1

Patients’ demographic characteristics

	n/gender
	Male	Female
Erythematotelangiectatic	3	11
Papulopustular	2	5
Phymatous	1	1
Ocular	4	8

Table 2

Frequency of dermoscopic criteria in rosacea patients

	n (%)
Polygonal network	12 (52.17)
Linear vessels	20 (86.95)
Arborizing vessels	3 (13.04)
Follicle plug	10 (43.47)
Follicle opening	11 (47.82)
Superficial scales	5 (21.73)
Pigmentation structures	6 (26.08)
Demodex tail	15 (65.21)

The ages of the participants ranged between 28 and 75, with an average of 49. Among the 23 participants, 14 were erythematotelangiectatic (ETR) (11 females and 3 males), 7 were papulopustular (5 females and 2 males), and 2 were rhinophyma (1 female and 1 male). A total of 12 participants had ocular involvement in the form of blepharitis or xerophthalmia. There was ocular involvement in 5 ETR patients, 5 papulopustular patients, and 2 rhinophyma patients. The most common dermoscopic finding was a linear vascular structure (20 participants). The most common vascular formation was a polygonal network (12 patients). In the cases where the dermoscopy suggested Demodex, the patients were evaluated with the superficial skin biopsy technique. The presence of 5 or more live parasites in a 1 cm2 area indicated demodicosis [Figure 2]. Fifteen participants had demodicosis: 8 ETR patients (6 females and 2 males) and 7 papulopustular patients (5 females and 2 males). The difference between the prevalence of Demodex in the ETR and papulopustular groups was not statistically significant.

Figure 2

Dermoscopic pictures: (10) linear vessels (arrow), follicle plug (circle), (11) follicle opening (circles), (12) linear vessels (arrows), (13) follicle plugs (rectangle), follicle opening (circles), (14) white-yellow scales (circle), Demodex tails (rectangle), (15) arborizing vessels (arrows), (16) linear vessels (arrows), pigmented structures (circle), (17) follicle plug (rectangle), Demodex tails (circles), (18) linear vessels (arrows), comma-like vessels (circles)

Discussion

Rosacea is a multifactorial disorder with a prominent vascular pathogenesis. It is characterized by temporary permanent erythema, papules, pustules, telangiectasia, and connective tissue hyperplasia; which develop due to the physiologic innervation and vascular reactivity of the sebaceous gland in the central part of the face.[5] Rosacea is diagnosed by medical history and physical examination. The diagnosis may be difficult due to the clinical manifestations’ similarities to several skin diseases conditions such as acne vulgaris, seborrheic dermatitis, contact dermatitis, and photodermatitis.[6] In such cases, dermoscopy can be a useful, noninvasive, and practical tool for the submacroscopic diagnostic evaluation.[9] Dermoscopy is a relatively new imaging technique. Currently, it is being used for the examinations of hair (trichoscopy), nail (onicoscopy), cutaneous infestations (entomodermoscopy), and inflammatory dermatoses (inflammoscopy).

The primary causes in the rosacea pathogenesis are vascular dilatation, increased vascular permeability, abnormal vasomotor response, and the accompanying hair follicle mites. The clear examination of the vascular pattern is critical for the diagnosis and monitoring of the treatment response.[91011] However, there are only a few studies available in the literature that concern this subject. That is why we wanted to investigate whether the dermoscopic examination can be a prominent tool for the rosacea patients. It was also aimed to determine whether this method would be useful for the determination of the presence of Demodex and the subsequent decision for a treatment. The main clinical finding in rosacea is the presence of polygonal vascular structures made up of linear blood vessels. The superficial scale and follicle openings may indicate the presence of Demodex.[1012] The dermatologic examination is not sufficient to discriminate the polygonal vasculature in the case of papulopustular rosacea, whereas papules and pustules are seen clearly with dermoscopy. Follicle plug, comedones, and dilated follicles are more prominent in papulopustular subtype of rosacea.[12] In the case of rhinophyma rosacea, follicle abnormalities may be accompanied by structureless reddish-yellowish masses.[10] Demodicosis is a common manifestation of the face and scalp and should be considered a method for the differential diagnosis of resistant rosacea, seborrheic dermatitis, or perioral dermatitis. It is usually in the form of roughness of skin, erythema, papules, and pustules, often accompanied by burning and itching sensation. The increased protease activity due to expression of epidermal TLR2 and the abnormal pro-inflammatory cathelicidin peptides stimulates immune response. Thus, hair follicle plugs are much more common among rosacea patients, compared to healthy individuals.[13] The dermoscopic findings are compatible with the microscopic findings in demodicosis cases. Thus, it is more advantageous as it is faster, more practical, and noninvasive.[14] In the case of demodicosis, the dermoscopic examination reveals a “Demodex tail” that protrudes from the follicle orifice, which is surrounded with a “Demodex follicle opening” that appears as a gray circle 1–3 mm in length. It is often confused with open comedones, but the open comedones can be seen with the naked eye, and they are more brownish and surrounded by a thin, hyperpigmented ring.[14]

In our study, we have found that the linear vasculature in the form of polygonal networks was a common finding among the ETR patients, whereas follicle plugs and superficial scales were observed more frequently in the papulopustular participants. These findings are compatible with the literature. The prevalence of Demodex was also compatible with the literature: There were 15 patients who had developed Demodex. These findings were confirmed through the microscopic examinations. Our primary purpose was to evaluate the dermoscopic findings of rosacea and the accompanying demodicosis. We suggest that the diagnosis of Demodex should be investigated with further studies. Our findings indicate that the dermoscopic method can be used as a reliable noninvasive method for the diagnosis of rosacea and the accompanying demodicosis. Our study is one of the few studies that demonstrate the contributions of a dermoscopic examination in the subjective assessment of whether the erythema has a vascular component, in the treatment and monitoring of rosacea, and the determination of demodicosis.

The limitations of our study include the small sample size and the relatively small literature which limits the ability to benchmark. As dermoscopy is a fast, inexpensive, and noninvasive method, it can be used for the diagnosis and monitoring of inflammatory dermatoses (such as rosacea). However, further research is required for the confirmation of its efficacy.

Conclusion

The dermoscopic feature of the Demodicosis is specific and ıt can be diagnosed without superficial surface biopsy. Demodex mites must be investigated in drugresistant Rosacea.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.