10.5826/dpc.1302a109
Introduction: There is growing evidence of the potential uses of dermoscopy in diagnostics of demodicosis. No previous studies have analyzed dermoscopic features in patients with ocular demodicosis.
Objectives: To evaluate the potential usefulness of videodermoscopy in diagnostics of ocular demodicosis.
Methods: It was a single-center prospective observational study in which results of videodermoscopic examination of the eyelids were compared to the results of classic microscopic examination in patients with suspected ocular demodicosis and healthy volunteers.
Results: Study group included 16 women and 15 men. In fifteen (48.4%) patients, microbiological examination of epilated eyelashes was positive. The results of forms filled by the patients concerning known subjective clinical symptoms of ocular demodicosis revealed no significant differences between the group with positive and negative results of microscopic examination. The presence of Demodex tails and madarosis observed during dermoscopic assessment correlated positively with positive results of microscopic examination. At least one Demodex tail was found in 86.7% (13/15) cases with positive results of microscopic examination. In the two remaining cases microscopic evaluation showed the presence of Demodex brevis. In 37.5% (6/16) of patients with negative results of microscopic examination, videodermoscopy showed the presence of Demodex tails.
Conclusions: Videodermoscopy may facilitate the diagnostics of ocular demodicosis. Patients reporting clinical symptoms suggesting ocular demodicosis but negative results of videodermoscopic examination should be referred to classical microscopic examination to exclude the presence of Demodex brevis. In patients with negative microscopic examination results and symptoms suggesting ocular demodicosis, dermoscopy-guided microscopic re-evaluation could be considered.
text/xml
2160-9381
2786
en
Michał Sobjanek
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
videodermoscopy
Videodermoscopy in the Assessment of Patients with Ocular Demodicosis
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-04-29
2022-08-28
2023-04-29
2023-05-31
e2023109
Dermatol Pract Concept
Introduction: There is growing evidence of the potential uses of dermoscopy in diagnostics of demodicosis. No previous studies have analyzed dermoscopic features in patients with ocular demodicosis.
Objectives: To evaluate the potential usefulness of videodermoscopy in diagnostics of ocular demodicosis.
Methods: It was a single-center prospective observational study in which results of videodermoscopic examination of the eyelids were compared to the results of classic microscopic examination in patients with suspected ocular demodicosis and healthy volunteers.
Results: Study group included 16 women and 15 men. In fifteen (48.4%) patients, microbiological examination of epilated eyelashes was positive. The results of forms filled by the patients concerning known subjective clinical symptoms of ocular demodicosis revealed no significant differences between the group with positive and negative results of microscopic examination. The presence of Demodex tails and madarosis observed during dermoscopic assessment correlated positively with positive results of microscopic examination. At least one Demodex tail was found in 86.7% (13/15) cases with positive results of microscopic examination. In the two remaining cases microscopic evaluation showed the presence of Demodex brevis. In 37.5% (6/16) of patients with negative results of microscopic examination, videodermoscopy showed the presence of Demodex tails.
Conclusions: Videodermoscopy may facilitate the diagnostics of ocular demodicosis. Patients reporting clinical symptoms suggesting ocular demodicosis but negative results of videodermoscopic examination should be referred to classical microscopic examination to exclude the presence of Demodex brevis. In patients with negative microscopic examination results and symptoms suggesting ocular demodicosis, dermoscopy-guided microscopic re-evaluation could be considered.
Michał Sobjanek
2023/04/29
10.5826/dpc.1302a109
e2023109
Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
2160-9381
videodermoscopy
en
e2023109
Sachdeva S, Prasher P. Madarosis: a dermatological marker. Indian J Dermatol Venereol Leprol. 2008;74(1):74-76. doi:10.4103/0378-6323.38426.
Videodermoscopy in the Assessment of Patients with Ocular Demodicosis
https://dpcj.org/index.php/dpc/article/download/2786/2071
     Videodermoscopy in the Assessment of Patients
              With Ocular Demodicosis
      Martyna Sławińska1, Karolina Jaworska1,2, Adam Wyszomirski3, Katarzyna Rychlik1,
                         Roman Janusz Nowicki1, Michał Sobjanek1


1 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
2 Department of Ophthalmology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
3 Department of Adult Neurology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland



Key words: dermoscopy, videodermoscopy, demodicosis, eye
Citation: Sławińska M, Jaworska K, Wyszomirski A, Rychlik K, Nowicki RJ, Sobjanek M. Videodermoscopy in the assessment of patients
with ocular demodicosis. Dermatol Pract Concept. 2023;13(2):e2023109. DOI: https://doi.org/10.5826/dpc.1302a109
Accepted: October 24, 2022; Published: April 2023
Copyright: ©2023 Sławińska et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Martyna Sławińska, MD, PhD, Mariana Smoluchowskiego 17, 80-214 Gdańsk. Phone number: +48 58 584 40 14;
fax number: +48 58 584 40 10 E-mail address: mslawinska@gumed.edu.pl




  ABSTRACT             Introduction: There is growing evidence of the potential uses of dermoscopy in diagnostics of demod-
                       icosis. No previous studies have analyzed dermoscopic features in patients with ocular demodicosis.
                       Objectives: To evaluate the potential usefulness of videodermoscopy in diagnostics of ocular
                       ­demodicosis.
                       Methods: It was a single-center prospective observational study in which results of videodermoscopic
                       examination of the eyelids were compared to the results of classic microscopic examination in patients
                       with suspected ocular demodicosis and healthy volunteers.
                       Results: Study group included 16 women and 15 men. In fifteen (48.4%) patients, microbiological
                       examination of epilated eyelashes was positive. The results of forms filled by the patients concerning
                       known subjective clinical symptoms of ocular demodicosis revealed no significant differences between
                       the group with positive and negative results of microscopic examination. The presence of Demodex
                       tails and madarosis observed during dermoscopic assessment correlated positively with positive results
                       of microscopic examination. At least one Demodex tail was found in 86.7% (13/15) cases with pos-
                       itive results of microscopic examination. In the two remaining cases microscopic evaluation showed
                       the presence of Demodex brevis. In 37.5% (6/16) of patients with negative results of microscopic
                       examination, videodermoscopy showed the presence of Demodex tails.




Original Article | Dermatol Pract Concept. 2023;13(2):e2023109                                                                       1
                      Conclusions: Videodermoscopy may facilitate the diagnostics of ocular demodicosis. Patients report-
                      ing clinical symptoms suggesting ocular demodicosis but negative results of videodermoscopic exam-
                      ination should be referred to classical microscopic examination to exclude the presence of Demodex
                      brevis. In patients with negative microscopic examination results and symptoms suggesting ocular
                      demodicosis, dermoscopy-guided microscopic re-evaluation could be considered.




Introduction                                                     and did not wear make-up at the time of examination were
                                                                 included. Current or previous (within 6 months) history
There is growing evidence on the potential role of dermos-       of demodicosis/rosacea treatment and age under 18 were
copy in diagnosis of demodicosis [1-6]. Dermoscopy proved        ­exclusion criteria.
to be an effective diagnostic tool and to correlate with stan-       Clinical and dermoscopic pictures were made using
dard skin surface biopsy results in cases of facial, scalp and   FotoFinder videodermoscope (non-polarized dermoscopy;
truncal disease [4,7,8]. Demodex tails and Demodex follicu-      video camera Medicam 800HD) with no immersion fluid
lar openings visualized in dermoscopy have been found to be      (x20 magnification; open front cap). Two dermoscopic
highly specific diagnostic features. Some reports also showed    pictures of the upper eyelid margin were performed with a
the utility of dermoscopy in the treatment monitoring [9].       closed eye to include the whole eyelid margin; in each stud-
Although ocular demodicosis may affect patients with facial      ied person, both eyelids were evaluated.
demodicosis, no previous studies have analyzed dermoscopic           Classical microscopic examination was performed with
features in this group of patients. Standardized skin surface    an MB-100 microscope equipped with a camera. Six upper
biopsy, which is currently a gold diagnostic standard of fa-     eyelid eyelashes and six lower eyelid eyelashes were col-
cial demodicosis, cannot be used to examine the eyelid mar-      lected from each patient (after clinical assessment from the
gin and currently there is no diagnostic standard for ocular     areas with visible erythema/scaling or randomly when no
demodicosis [2,10].                                              such symptoms were observed). Eyelashes were placed on
                                                                 a coverslip with a mixture of dimethyl sulfoxide and 20%

Objectives                                                       potassium hydroxide. A criterion for positive result was at
                                                                 least one Demodex mite visible under the microscope (x100
The aim of the study was to evaluate clinical and dermo-         magnification).
scopic features of patients with ocular demodicosis and              Clinical and dermoscopic pictures were evaluated by
compare these findings with results of classical microscopic     consensus of two experienced dermoscopists, blinded to the
evaluation.                                                      results of the classical microscopic evaluation, for predefined
                                                                 criteria (Table 1). In case of discrepancy, the final score for
                                                                 a particular case and structure was obtained based on the
Methods
                                                                 decision of the third evaluator. The Mann–Whitney U test
This was a single-center, prospective study performed in the     for comparison of the age distribution between unpaired
Department of Dermatology and Dermatology Outpatient             two groups was applied, and the chi-square test was ap-
Clinic, Medical University of Gdańsk (Poland) which con-         plied to compare categorical data. The two-tailed tests were
cerned patients referred to a dermatology outpatient clinic      carried out at a significance level of P ≤ 0.05. All statisti-
with suspected ocular demodicosis. Before classical mi-          cal analyses were performed using the R statistical package
croscopic assessment, videodermoscopic examination was           (version 3.6.3; https://www.r-project.org/). The study was
performed. The same assessment was performed in gener-           approved by the Ethics Committee, Medical University of
ally healthy volunteers who presented to the dermatology         Gdańsk (NKBBN/606/2018; NKBBN/606-675/2020) and all
outpatient clinic for dermoscopic evaluation of nevi, with       study participants gave informed consent before participa-
no previous history/clinical signs of demodicosis. All study     tion in the study.
participants filled in a previously prepared form concerning
clinical symptoms and were assessed clinically and dermo-
                                                                 Results
scopically by the same dermatologist. In the second step clas-
sical microscopic evaluation of the eyelashes was performed      Study group included 16 women and 15 men. In fifteen
by the same laboratory assistant. Only patients who did not      patients (48.4%), microscopic examination of epilated
wash their face and eyelid area for the previous 12 hours        eyelashes was positive (10 male, 5 female). Mean age was



2                                                                    Original Article | Dermatol Pract Concept. 2023;13(2):e2023109
            Table 1. Clinical and dermoscopic features in patients with positive and negative result
                                         of microscopic evaluation.
                                                                        Patients with a        Patients with a
                                                                      positive result of     negative result of
                                                                    microscopic evaluation microscopic evaluation                  P
    Data obtained from patients history
    Gender, N (%)                                                     female versus males            female versus males         0.049
                                                                        5 (33.3%) versus              11 (68.8%) versus
                                                                           10 (66.7%)                     5 (31.2%)
    Age (mean/median), years                                                64.5/68.0                     49.5/53.5              0.009
    Feeling of dry eyes/gritty sensation, N (%)                             7 (50.0%)                     6 (37.5%)              0.491
    Burning/itching within the eyes, N (%)                                  9 (60.0%)                     5 (31.2%)              0.108
    Epiphora, N (%)                                                         4 (26.7%)                     6 (37.5%)              0.519
    Conjunctivitis treatment in the previous 6 months, N (%)               14 (93.3%)                   16 (100.0%)              0.294
                                                                                        a                             b
    Eye disease, N (%)                                                     6 (40.0%)                     3 (18.8%)               0.193
    History of skin disease, N (%)                                         6 (40.0%) c                   9 (56.2%) d             0.366
    Tendency to blush easily, especially after eating, under the            2 (13.3%)                     3 (18.8%)              0.682
    influence of temperature, or drinking alcohol, N (%)
    Diabetes, N (%)                                                         4 (26.7%)                      1 (6.2%)              0.122
    Dermoscopic features
    Demodex tails (at least 1), N (%)                                      13 (86.7%)                     6 (37.5%)              0.005
    Demodex tails (median/mean)                                               6/12.8                       0/2.750               0.002
    Demodex follicular openings (gray dots), N (%)                          3 (20.0%)                      1 (6.2%)              0.254
    Follicular hypertrophy, N (%)                                          11 (73.3%)                     7 (43.8%)              0.095
    Follicular annular pigmentation, N (%)                                       0                             0                    -
    Yellow dots, N (%)                                                           0                             0                    -
    Red dots, N (%)                                                              0                             0                    -
    Scale, N (%)                                                           13 (86.7%)                     9 (56.2%)              0.062
    Pustules, N (%)                                                         1 (6.7%)                       0 (0.0%)              0.294
    Madarosis, N (%)                                                        6 (40.0%)                      1 (6.2%)              0.025
    Poliosis, N (%)                                                              0                             0                    -
a
 [cataract, epiretinal membrane, floaters suspected, macular degeneration, myopia, retinal cyst]; b [glaucoma] c [acne, atopic dermatitis,
chronic eczema, previous history of BCC, previous history of melanoma]; d [acne, atopic dermatitis, psoriasis, previous history of BCC,
previous history of melanoma].




significantly higher in the group with positive microscopic            P = 0.025), respectively). At least one Demodex tail was
examination results (64.5 versus 49.5 years, P = 0.009). The           found in 86.7% (13/15) of cases with positive results from
results of forms filled in by the patients concerning known            the microscopic examination. In the two remaining cases,
subjective clinical symptoms of ocular demodicosis, revealed           microscopic evaluation showed the presence of Demodex
no significant differences between the group with positive             brevis (D. brevis). These two patients reported symptoms
and negative results of microscopic evaluation. Previously             such as burning/itching within the eyes as well as a feeling of
diagnosed eye disease, skin disease and diabetes also did not          dry eyes/gritty sensation.
correspond with microscopic diagnosis of ocular demodi-                    In 37.5% (6/16) of patients with negative results of mi-
cosis. Table 1 presents details of the evaluated variables in          croscopic examination, videodermoscopy showed the pres-
patients with positive and negative results of microscopic             ence of Demodex tails. In these patients, the most common
evaluation and Figure 1 depicts details of videodermoscopic            clinical symptom was epiphora (present in 3/6 patients), fol-
assessment.                                                            lowed by burning/itching within the eyes (1 patient) as well
      The presence of Demodex tails and madarosis observed             as a feeling of dry eyes/gritty sensation (1 patient).
during dermoscopic assessment correlated positively with                   No significant correlation was found for other ana-
positive results of microscopic examination (P = 0.042 and             lyzed dermoscopic features (Demodex follicular openings,



Original Article | Dermatol Pract Concept. 2023;13(2):e2023109                                                                           3
    Figure 1. Dermoscopic assessment of the upper eyelid region may facilitate the assessment of a patient with clinical suspicion of ocular
    demodicosis. (A) Dermoscopic presentation in a healthy person – no signs of the presence of Demodex spp. (B) Dermoscopy shows two
    Demodex tails (black arrows) and mild madarosis. (C) Dermoscopy shows areas of madarosis (white arrow) as well as the presence of
    Demodex tails. (D) Dermoscopy shows the presence of multiple Demodex tails (black arrows), mild madarosis and follicular hypertrophy
    (white circles) (all pictures made with FotoFinder, Medicam 800HD, x20 magnification, no immersion fluid).



follicular hypertrophy, follicular annular pigmentation,                  assessment with an open front cap provides precise and
scales, pustules, poliosis).                                              non-contact evaluation of the eyelid region [13].
                                                                              We have found two dermoscopic features that have been
                                                                          observed significantly more often in patients with positive
Conclusions
                                                                          microscopy, namely Demodex tails and madarosis.
Patients with suspected/confirmed facial demodicosis should                   Demodex tail is defined as a gelatinous, whitish, creamy
be assessed for ocular demodicosis. Clinical symptoms that                thread, 1–3 mm in length, indicating a mite protruding from
may indicate involvement of the ocular region include eye-                the follicular orifice [14]. It has been previously identified as
lid erythema, eyelid itching, eyelid burning sensation, ocular            a feature typical of demodicosis on the face, scalp and trunk
foreign body sensation, conjunctival injection, epiphora, dry             and found in 20-100% of patients with a positive result of
eye sensation, increased sensitivity to light, smoke and dust,            microscopic examination [2,4,6,9,14,15].
mucus discharge and contact lens intolerance [1,11].                          As mentioned previously, in two patients from our study
      Most patients in the studied group reported at least                in whom dermoscopic assessment did not show the presence
one symptom and the frequency of the reported symptoms                    of Demodex tails, D. brevis could be found in microscopic
did not differ between groups of patients with positive and               evaluation. According to the literature, this species is smaller
negative results of microscopic examination. Therefore, the               in size (about 190 micrometers), compared to D. folliculo-
decision to refer to microscopic examination based only on                rum (about 290 micrometers) [16]. Therefore, when present
clinical symptoms may be difficult. The authors hypoth-                   in deep parts of the sebaceous glands, can potentially be in-
esized that videodermoscopy could be helpful in initial                   visible on the body surface and therefore beyond the scope
evaluation of patients and in some cases could be an al-                  of videodermoscopic assessment. Both species can be present
ternative method used to confirm the diagnosis of ocular                  in the same patient. None of the previous studies assessed the
demodicosis.                                                              correlation between dermoscopic presentation and D. brevis.
      Evaluation of the eyelid margin with a classical dermoscope         In microscopic studies, D. brevis was found to be the only
is possible, unless the front cap is too wide. Videodermoscopic           species in 0.7%–31.7% of patients [17,18].




4                                                                              Original Article | Dermatol Pract Concept. 2023;13(2):e2023109
    Based on that, it can be concluded that the patients report-     2. Karadağ Köse Ö, Borlu M. Definition of videodermoscopic fea-
ing clinical symptoms suggesting ocular demodicosis with                tures of demodicosis. Int J Dermatol. 2019;58(10):1153-1159.
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negative results of microscopic examination upon videoder-           4. Serarslan G, Makbule Kaya Ö, Dirican E. Scale and Pustule on
moscopic examination showed the presence of Demodex tails.              Dermoscopy of Rosacea: A Diagnostic Clue for Demodex Species.
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                                                                     5. Sonthalia S, Agrawal M, Bhatia J, et al. Entodermoscopy
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case of persisting clinical symptoms. An ideal scenario would            2021;12(2):220-236. DOI:10.4103/idoj.IDOJ_559_20. PMID:
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6                                                                               Original Article | Dermatol Pract Concept. 2023;13(2):e2023109
