Discrete and Coalescing Pustules Masking Severe Recalcitrant Rosacea Due to Demodex

CONTEXTRosacea is a frequent and often easily treatable condition in dermatological practice. The clinical manifestations of rosacea are hypothesized to be the result of a dysregulation of the innate immune system. The roles played by outside factors, such as the presence of Demodex or localized immunosuppression in the pathogenesis of rosacea, are under considerable debate. OBJECTIVEThe current study intended to examine the contribution of immunosuppression to a case of recalcitrant rosacea and the effects of nutritional status in the resolution of the skin disease. DESIGNThe research team designed a case study. SETTINGThe study took place at the dermatology clinic of the Department of Dermatology at Indiana University (Indianapolis, IN, USA). PARTICIPANTThe participant was a 36-y-old male patient at the clinic with a recalcitrant dermatosis of the face and neck. This patient's disease had persisted despite multiple standard treatments for facial dermatitis, rosacea, and granulomatous rosacea with a high Demodex burden. INTERVENTIONThe intervention included a tapering course of cyclosporin, 3 mg of ivermectin daily for 3 wk, 500 mg daily of ascorbic acid, 1000 units daily of cholecalciferol, and green smoothies. OUTCOME MEASURESThe study measured the patient's levels of immunoglobulin M (IgM), 25 hydroxyvitamin D, and ascorbic acid. RESULTSThe testing showed isolated IgM deficiency and low levels of 25 hydroxyvitamin D and ascorbic acid. The rash resolved following the tapering course of cyclosporin and vitamin repletion through supplements and dietary alteration. CONCLUSIONSThe case was one with multiple confounding variables: (1) the presence of Demodex, (2) iatrogenic immunosuppression due to prolonged systemic and topical steroid use, and (3) vitamin deficiency. The case demonstrates the multifactorial pathogenesis of a recalcitrant dermatosis of the face and neck, and the research team encourages providers to consider a holistic approach when patients do not respond to standard medical therapy.