10.5826/dpc.1203a113
Introduction: The relationship between facial dermatoses and blepharitis has been known for along time.Objectives: We aimed to investigate the frequency of accompanying facial dermatoses in patients withblepharitis and their relationship with the severity of blepharitis.Methods: In this cross-sectional study, 95 patients with blepharitis were examined for attending facialdermatoses. The type of blepharitis, the severity of blepharitis, and the degree of dry eye weredetermined in the patients. Dermoscopic and microscopic examinations were used in the diagnosis offacial dermatoses. The history of allergic rhinitis was questioned because Demodex species frequentlyaccompany blepharitis, facial dermatoses, and allergic rhinitis patients. Mann-Whitney U test wasused compare 2 independent groups. In comparing categorical variables, Pearson chi-Squared, FishereExact, and Fisher-Freeman-Holton tests were used.Results: At least 1 facial dermatosis was detected in 84.2% patients, and we did not see any facialdermatosis in 15.8% ones. No patients had acne, which is one of the most common facial dermatoses.The most common facial dermatosis detected in our patients was facial demodicosis (57.9%). It wasfollowed by seborrheic dermatitis (22.1%) and rosacea (12.6%), respectively. In addition, 2.1% of thepatients had atopic eyelid dermatitis, 23.2% had a history of allergic rhinitis, and 63.2% had oculardemodicosis.Conclusions: It is essential to perform dermatological examinations of all patients with blepharitis interms of accompanying facial dermatoses and their early diagnosis.
text/xml
2160-9381
2085
en
Şafak  Çulfa
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
seborrheic dermatitis
Facial dermatoses in patients with blepharitis: a cross-sectional prospective analysis.
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-10-04
2022-07-28
2022-09-15
e2022113
Dermatol Pract Concept
Introduction: The relationship between facial dermatoses and blepharitis has been known for along time.Objectives: We aimed to investigate the frequency of accompanying facial dermatoses in patients withblepharitis and their relationship with the severity of blepharitis.Methods: In this cross-sectional study, 95 patients with blepharitis were examined for attending facialdermatoses. The type of blepharitis, the severity of blepharitis, and the degree of dry eye weredetermined in the patients. Dermoscopic and microscopic examinations were used in the diagnosis offacial dermatoses. The history of allergic rhinitis was questioned because Demodex species frequentlyaccompany blepharitis, facial dermatoses, and allergic rhinitis patients. Mann-Whitney U test wasused compare 2 independent groups. In comparing categorical variables, Pearson chi-Squared, FishereExact, and Fisher-Freeman-Holton tests were used.Results: At least 1 facial dermatosis was detected in 84.2% patients, and we did not see any facialdermatosis in 15.8% ones. No patients had acne, which is one of the most common facial dermatoses.The most common facial dermatosis detected in our patients was facial demodicosis (57.9%). It wasfollowed by seborrheic dermatitis (22.1%) and rosacea (12.6%), respectively. In addition, 2.1% of thepatients had atopic eyelid dermatitis, 23.2% had a history of allergic rhinitis, and 63.2% had oculardemodicosis.Conclusions: It is essential to perform dermatological examinations of all patients with blepharitis interms of accompanying facial dermatoses and their early diagnosis.
Şafak  Çulfa
2022/07/28
10.5826/dpc.1203a113
e2022113
Department of Ophthalmology, Medical Faculty, Bezmialem Vakif University, Adnan Menderes Bulvarı, Fatih/Istanbul, Turkey
2160-9381
seborrheic dermatitis
en
e2022113
Facial dermatoses in patients with blepharitis: a cross-sectional prospective analysis.
https://dpcj.org/index.php/dpc/article/download/2085/1671
                    Dermatology Practical & Conceptual


       Facial Dermatoses in Patients With Blepharitis:
           a Cross-sectional Prospective Analysis
                                                  Semih Güder1, Şafak Çulfa2


1 Department of Dermatology, Medical Faculty, Bezmialem Vakif University, Adnan Menderes Bulvarı, Fatih/Istanbul, Turkey
2 Department of Ophthalmology, Medical Faculty, Bezmialem Vakif University, Adnan Menderes Bulvarı, Fatih/Istanbul, Turkey



Key words: facial dermatoses, blepharitis, demodicosis, rosacea, seborrheic dermatitis
Citation: Güder S, Çulfa S. Facial dermatoses in patients with blepharitis: a cross-sectional prospective analysis.
Dermatol Pract Concept. 2022;12(3):e2022113. DOI: https://doi.org/10.5826/dpc.1203a113
Accepted: November 23, 2021; Published: July 2022
Copyright: ©2022 Güder 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: Conceptualization: S.G.; Ş.Ç.; Data collection: Ş.Ç, S.G.; Writing of the manuscript: S.G., Ş.Ç.; Manuscript editing and
revision: S.G., Ş.Ç.
Corresponding author: Semih Güder, MD, Department of Dermatology, Medical Faculty, Bezmialem Vakif University, Adnan Menderes
Bulvarı, Fatih/Istanbul, Turkey. E-mail: semihguder@gmail.com Tel: +905056655518




  ABSTRACT              Introduction: The relationship between facial dermatoses and blepharitis has been known for a
                        long time.
                        Objectives: We aimed to investigate the frequency of accompanying facial dermatoses in patients with
                        blepharitis and their relationship with the severity of blepharitis.
                        Methods: In this cross-sectional study, 95 patients with blepharitis were examined for attending fa-
                        cial dermatoses. The type of blepharitis, the severity of blepharitis, and the degree of dry eye were
                        determined in the patients. Dermoscopic and microscopic examinations were used in the diagnosis of
                        facial dermatoses. The history of allergic rhinitis was questioned because Demodex species frequently
                        accompany blepharitis, facial dermatoses, and allergic rhinitis patients. Mann-Whitney U test was
                        used compare 2 independent groups. In comparing categorical variables, Pearson chi-Squared, Fishere
                        Exact, and Fisher-Freeman-Holton tests were used.
                        Results: At least 1 facial dermatosis was detected in 84.2% patients, and we did not see any facial
                        dermatosis in 15.8% ones. No patients had acne, which is one of the most common facial dermatoses.
                        The most common facial dermatosis detected in our patients was facial demodicosis (57.9%). It was
                        followed by seborrheic dermatitis (22.1%) and rosacea (12.6%), respectively. In addition, 2.1% of the
                        patients had atopic eyelid dermatitis, 23.2% had a history of allergic rhinitis, and 63.2% had ocular
                        demodicosis.
                        Conclusions: It is essential to perform dermatological examinations of all patients with blepharitis in
                        terms of accompanying facial dermatoses and their early diagnosis.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022113                                                                         1
Introduction                                                            The parasitic infection Demodex blepharitis is a chronic
                                                                     inflammatory disease caused by Demodex mites, affecting the
Blepharitis is a multifactorial inflammatory condition of the        eyelid margin and ocular surface. The worldwide incidence of
eyelids that occurs in less than 1% of the general population.       ocular Demodex infestation is around 13%-70%. In addition,
It is classified as anterior blepharitis and posterior blepharitis   the presence of Demodex in the eyelashes of 18% of healthy
according to the eyelash margin of the affected area. Affected       individuals in the 2nd and 3rd decades is reported [5,14]. The
individuals may complain of irritation as eyelid itching,            rate of Demodex infestation increases with age and is seen in
burning sensation, watering-epiphora, eyelid crusting, for-          almost all people over 70 years of age [13,15-17].
eign-body sensation, a feeling of heavy eyelids, and photo-             Demodex mites have also been hypothesized to play a role
phobia and blurring vision. Rarely blepharitis may lead to           in the etiology of posterior blepharitis [18]. Infestation along
keratopathy, corneal ulceration, permanent changes of eye-           the posterior margin is a reason for obstruction of gland orifices
lid morphology, and result in decreased vision. Blepharitis          [15]. Demodex’s nutritional source is follicular and glandular
is commonly categorized by anatomical location. Anterior             epithelial cell sebum [19]. Demodex folliculorum infestation
blepharitis may occur in seborrheic or non-seborrheic types          causes anterior blepharitis. Mites deposit their eggs on the
and is associated with increased eyelid commensals such as           base of the eyelashes, and keratin and epithelial cell deposits
Staphylococcus epidermidis and Staphylococcus aureus [1,2].          accumulate, forming cylindrical dandruff, the pathognomonic
    However, posterior blepharitis is secondary to structural        sign of demodicosis. Mites are in clusters around eyelashes and
changes and occlusion of the meibomian gland orifices [2,3].         skin [20,21]. Demodex brevis penetrate the meibomian glands
Blepharitis generally occurs due to underlying skin diseases         causing gland obstruction and dysfunction inducing marginal
such as seborrheic dermatitis (SD), atopic dermatitis (AD),          blepharitis. They are seen one by one in glands [21,22].
rosacea, or facial demodicosis (FD) [2,4,5].                            Demodex species are also a common etiological factor
    In anterior blepharitis, bacterial antigen, exotoxins, and       for AR and blepharitis. The frequency of facial Demodex,
delayed cell-mediated immune hypersensitivity leading to an          which is thought to be a facilitating factor in patients with
inflammatory cascade. Infectious blepharitis is characterized        AR, was found to be 40% on average [5, 3,24].
by hyperemia, edema, scaling, and telangiectasia of the an-             Dermoscopy is a good diagnostic tool in common facial
terior lid margin. Severe cases are complicated with poliosis,       dermatoses. Demodex tails and Demodex follicular openings
madarosis, eyelid hypertrophy, and corneal scars. Recurrent          are frequently observed in facial demodicosis. Dotted ves-
hordeola are often related to staphylococcal strains in infec-       sels and fine yellowish scales in seborrheic dermatitis, linear
tious blepharitis [6].                                               veins in a polygonal network, and follicular pustules in rosa-
    In posterior blepharitis cases, inflammation of the poste-       cea are diagnostic clues [25].
rior lid margin induces Meibomian gland dysfunction (MGD).
Terminal duct obstruction due to hype-rkeratinization re-
duces glandular secretion and causes tear film abnormalities.        Objectives
Evaporative tear disorders are mostly seen in patients with
                                                                     We planned this study to investigate the frequency of SD,
MGD and are reasons for patients complaints [7].
                                                                     AD, rosacea, and demodicosis, which are skin diseases that
    Seborrheic blepharitis more effecting sebaceous gland
                                                                     frequently affect the face and are thought to play an essen-
Zeis than meibomian glands has less inflammation than
                                                                     tial role in the etiology of blepharitis. We hypothesized that
staphylococcal blepharitis but is characterized by more oily
                                                                     performing dermatological examinations of all patients with
scaling. Some patients with seborrheic blepharitis show
                                                                     chronic blepharitis may be necessary for the early diagnosis
MGD [8].
                                                                     and treatment of facial dermatoses.
    Ocular complications such as eyelid dermatitis, blephari-
tis, conjunctivitis, cataract, keratoconus are seen in patients
with atopic dermatitis [2,9]. In the report of the North Amer-       Methods
ican contact dermatitis study group, the frequency of atopic
eyelid dermatitis was reported to be around 13% [10]. Every          The local ethics committee reviewed and approved the study
patient with blepharitis and conjunctivitis should be ques-          (protocol ID: 2021/900/88), and written informed consent
tioned about the history of atopy. Because it is common in           was obtained from all participants. The study was carried
these patients [11].                                                 out according to the principles in the Declaration of Helsinki.
    Rosacea is a progressive facial inflammatory dermatosis
that may be associated with systemic diseases. Ocular sur-           Patient Selection and Procedures
face changes such as blepharitis and conjunctivitis are seen         A total of 95 patients diagnosed with chronic blepharitis in
in patients with rosacea [12,13].                                    our ophthalmology clinic and undergoing dermatological



2                                                                        Original Article | Dermatol Pract Concept. 2022;12(3):e2022113
evaluation on the same day were included in the study. The        Demodicosis Classification and Evaluation
patients were examined for facial dermatoses, and a dermo-        of the Density of Facial Demodex
scopic examination was performed. The history of allergic         Demodicosis was classified as follows: rosacea-like demod-
rhinitis was questioned because Demodex species frequently        icosis, pityriasis folliculorum, Demodex dermatitis, spinulo-
accompany blepharitis, facial dermatoses, and allergic rhi-       sus of the face, and pustular folliculitis [29]. Skin samples
nitis patients. In terms of accompanying demodicosis, skin        were taken from the right cheek of the patients using the
scraping, standardized skin surface biopsy (SSSB), and eye-       SSSB method. A microscope slide with cyanoacrylate adhe-
lash sampling were performed. The duration of blepharitis         sive is pressed onto the lesion. After 30 seconds, the sample
and facial dermatoses, and the history of allergic rhinitis,      was removed from the skin. The sample was covered with a
were recorded.                                                    coverslip and examined by light microscopy at x10, x40, and
                                                                  x100 magnification in immersion oil. The total number of
Dermoscopic Evaluation                                            viable parasites in a sample was used to assess Facial Demo-
The dermoscopic evaluation was performed by using a               dex severity and density (FDS): 0-5 per cm2, 1+ density, 5-10
handheld dermoscope (DermLite DL200HR; 3Gen, Inc.) at             per cm2, 2+, 10-15 per cm2, 3+, 15-20 per cm2, 4+ and >20.5
×10 magnification (polarized light). Images were recorded         per cm2 was classified as 5+ [30].
directly by the smartphones attached magnetically to the
dermoscope. We performed dermoscopic examination with             Rosacea Classification and Evaluation
two methods. First, we performed a classical dermoscopic          of the Clinical Severity (RCS)
examination (Figure 1, A,B,C. In this method, we placed the       The classification and scoring system of the American
dermoscope probe vertically on the cheek skin. Second, our        National Rosacea Society (NRS) was used for the type and
new lateral dermoscopic technique; makes demodex tails            severity of rosacea [31].
more prominent. We put the dermoscope horizontally on the
cheek skin and then examined it by pinching between the           Bleraphyte Classification and Scoring of Severity
index finger and the dermoscope (Figure 1, D,E,F, Figure 2).
                                                                  The Uludağ Ocular Demodicosis Clinical Scoring system
                                                                  (UODS) was used to evaluate the severity of blepharitis.
Microscopic Eyelid Demodex Examination                            According to this score, if there is at least one stinging, burn-
Three eyelashes were taken from the eyelids of both eyes,         ing, itching, and pain complaint, 1 point is given; otherwise,
prepared by glycerine-type separation, and evaluated under        0 points were awarded. A score of 1 was given for anterior
a light microscope (Olympus,) at ×40 and ×100 magnifica-          or posterior blepharitis, and 2 points were given if both were
tion. At least 3 Demodex folliculorum in each eyelash was         present. One point for long-term use of drops containing
considered as Demodex infestation (Figure 3) [26].                preservatives (eg glaucoma drugs); 2 points were given if
                                                                  there was a systemic or local disease other than blepharitis
Evaluation of Tear Production                                     that would cause dry eye. It was given 1 point if there was
                                                                  an epithelial defect and 2 points if it presented with keratitis.
The Schirmer test was used to evaluate tear production in
                                                                  The presence of cylindrical dandruff was given 2 points [32].
patients. Test strips were designated “L” and “R” for the left
and right eyes, respectively. Afterward, each strip was bent at
a 90-degree angle. The patient was told to look up, and the       Statistical Analysis
lower eyelid of the patient was pulled down. The curved end       The SPSS 25.0 (IBM Corporation) program was used in the
of the test strip was placed between the palpebral conjunctiva    analysis of the variables. The conformity of univariate data
and the bulbar conjunctiva. This procedure was also done for      to normal distribution was evaluated with the Shapiro-Wilk
the other eye. After both strips were seated, the patient was     Francia test, while homogeneity of variance was assessed
asked to close their eyes for five minutes gently. After five     with the Levene test.
minutes, the test strips were removed. A score of more than          The Mann-Whitney U test was used together with Monte
10 mm was considered normal. A score between 5mm and              Carlo results to compare two independent groups with each
10mm was graded as mild insufficiency, and a score of less        other according to quantitative data. In the comparison
than 5mm was graded as severe insufficiency [27].                 of more than two groups according to quantitative data,
                                                                  Kruskal-Wallis H test and Jonckheere-Terpstra test were
Evaluation of the Severity of Seborrheic Dermatitis               used together with Monte Carlo results, and Dunn tand
The Seborrheic Dermatitis Area and Severity Index (SEDASI)        Tukey tests were used for post-hoc analyses. Kendall tau-b
scale developed by Micali et al. were used to assess the sever-   and Spearman rho tests were used to examining the correla-
ity of seborrheic dermatitis [28].                                tions of the variables with each other.



Original Article | Dermatol Pract Concept. 2022;12(3):e2022113                                                                   3
    Figure 1. Dermoscopic findings of facial demodicosis (FD). (A)Pityriasis folliculorum on the right cheek area of a young
    man. The white yellowish structures are Demodex tails (arrows). (B) Cheek area of middle-aged woman. The white yellowish
    structures are Demodex tails (arrows), and Demodex follicular openings (black circles) are seen. Reticular dilated vessels are
    remarkable in the patient with a history of intermittent steroidal cream use. (C) Diffuse eyelash demodicosis in an elderly
    man; white yellowish structures are Demodex tails (arrows); increased vascularity less pronounced possibly due to age-related
    atrophy. (D and E) Dermoscopy of the cheek region of 2 different patients, lateral dermoscopic examination technique. In the
    patient on the left, Demodex follicular openings (black circles) and reticular dilated vessels are observed in addition to Demo-
    dex tails (arrows). (F) Lateral dermoscopic technique for FD.




4                                                                          Original Article | Dermatol Pract Concept. 2022;12(3):e2022113
Figure 2. Dermoscopic findings of seborrheic dermatitis (SD). (A) Interfollicular pale erythema (red circle) and oily scale (black circle) in the
scalp region. (B) Oily scale on eyebrows (circle) (C) Eyelash of the patient with SD. Thin scales (white circles) attached to the eyelashes are
seen (no accompanying Demodex). (D) Eyelash demodicosis in a patient with SD. The white yellowish structures are Demodex tails (arrows),
and dilated, and arborized vessels are visible. (E) A dermoscopic view of the nasolabial fold. Fine white nonspecific scales are seen (circles).
(F) Dermoscopic view of the cheek of a patient with SD accompanied by facial demodicosis. Demodex follicular openings (circles) and
Demodex tails (arrows) are visible.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022113                                                                                 5
Figure 3. The appearance of eyelid and eyelashes of a patient with atopic eyelid dermatitis and allergic rhinoconjunctivitis; microscopic
views of facial and ocular demodicosis. (A) A middle-aged man with atopic eyelid dermatitis, presumably secondary to scratching trauma.
Prominent skin lines (red circle) and polypoid structures (black circles) are seen. (B) Eyelashes of the patient with allergic rhinoconjuncti-
vitis. The white yellowish structures are Demodex tails (arrows). Thin white scales wrapped around the lashes are also observed (circles).
(C) Microscopic view of Demodex folliculorum (black circles) and its larvae (red circles) appear on standardized skin surface biopsy (SSSB)
(×40). (D) Microscopic view of the eyelash: Demodex folliculorum eggs (black circle) and larvae (red circle) (×40).



    In comparing categorical variables, Pearson chi-Squared,             (±22.49) months. Ninety-one (95.8%) patients had anterior
Fisher exact, and Fisher-Freeman-Holton tests were tested                blepharitis, 22 (23.2%) had posterior blepharitis, and 18
with the Monte Carlo simulation technique, and column ra-                (18.9%) had compound blepharitis. The mean UODS were
tios were compared with each other and expressed according               4.23 (±2.39). All our patients had at least 1 of the symptoms
to Benjamini-Hochberg corrected P value results.                         of eyelid itching, burning sensation, watering, eyelid crust-
    Quantitative variables were expressed as mean (± standard            ing, feeling of heavy eyelids, and photophobia. We did not
deviation), median (minimum/maximum), and median (per-                   find keratitis in any of the patients (Table 1).
centile 25° / percentile 75°) in the tables, while categorical               The mean Schirmer test values of the patients were 9.46
variables were shown as N (%). The variables were analyzed               for the right eye and 9.77 for the left eye, and more than
at 95% confidence level, and a P value less than 0.05 was                one-third of them had a severe dry eye (Table 1).
considered significant.                                                      At least one facial dermatosis was detected in 84.2%
                                                                         of our patients, and we did not see any facial dermato-
Results                                                                  sis in 15.8%. And none of our patients had acne, which
                                                                         is one of the most common facial dermatoses. The most
Demographic Data                                                         common facial dermatosis detected in our patients was FD
Thirty-two (33.7%) of our patients were males, and 68                    (57.9%). This was followed by SD (22.1%) and rosacea
(66.3%) were femalse. The mean age of our patients was                   (12.6%), respectively. In addition, 2.1% of the patients
46.58 (±14.78) years. The mean disease duration was 24.99                had atopic eyelid dermatitis (AED), 23.2% had a history

6                                                                             Original Article | Dermatol Pract Concept. 2022;12(3):e2022113
        Table 1. Blepharitis types and severity, Schirmer scores, facial dermatoses types, rates and severity, together with
                                                 demographic data in our patients
                                                                                      N                                 %
 Male                                                                                 32                             33.7%
 Female                                                                               63                             66.3%
 Schirmer right eye score
    Mild                                                                              29                             30.5%
    Moderate                                                                          24                             25.3%
    Severe                                                                            42                             44.2%
 Schirmer left eye score
    mild                                                                              33                             34.7%
    moderate                                                                          26                             27.4%
    Severe                                                                            36                             37.9%
 Facial demodicosis severity (FDS)
    0-5                                                                                4                              4.2%
    5-10                                                                               5                              5.3%
    10-15                                                                             16                             16.8%
    15-20                                                                             24                             25.3%
    >20                                                                                6                              6.3%
 Facial demodicosis                                                                   55                             57.9%
    Spinulosis of face                                                                28                             29.5%
    Pityriasis folliculorum                                                            6                              6.3%
    Rosacea like demodicosis                                                          21                             22.1%
 Positive eyelash microscopy for Demodex                                              60                             63.2%
 Ocular demodicosis                                                                   60                             63.2%
 Seborrheic dermatitis                                                                21                             22.1%
 Rosacea                                                                              12                             12.6%
 All facial dermatoses                                                                80                             84.2%
 Positive cheek microscopy for Demodex                                                55                             57.9%
 Demodex tails                                                                        55                             57.9%
 Demodex follicular openings                                                          35                             36.8%
 Demodex dilated capillaries                                                          30                             31.6%
 History of allergic rhinitis                                                         22                             23.2%
 Anterior blepharitis                                                                 91                             95.8%
 Posterior blepharitis                                                                22                             23.2%
 Compund belpharitis                                                                  18                             18.9%
 Cylindiric scale                                                                     52                             54.7%
 Droplet usage                                                                        17                             17.9%
 Different xerophthalmia cause and keratitis                                           0                              0.0%
 Epithelial defect                                                                     7                              7.4%
                                                                                      N                        Median (min/max)
 Age                                                                                  95                           43 (24 / 82)
 Blepharitis duration (m)                                                             95                           18 (2 / 96)
 UODS                                                                                 95                            4 (2 / 15)
 Seborrheic dermatitis duration (m)                                                   21                          60 (48 / 240)
 SEDASI                                                                               21                           16 (8 / 24)
 Rosacea duration (m)                                                                 14                           36 (24 / 72)
 Rosacea clinical severity                                                            14                             6 (6 / 9)
 Allergic rhinitis duration (m)                                                       22                          96 (60 / 360)
 Schirmer right eye                                                                   95                            8 (4 / 20)
 Schirmer left eye                                                                    95                           10 (5 / 20)

m = month; SD = Standard Deviation; SEDASI: Seborrheic Dermatitis Area and Severity Index; UODS = Uludağ Ocular Demodicosis Clinical Scor-
ing system.
of allergic rhinitis (AR), and 63.2% had ocular demodico-          and patients with SD in terms of dry eye degree (P > 0.05)
sis (OD) (Table 1).                                                (Table 3).
                                                                       However, there was a weak positive correlation between
Duration and Severity of Detected Facial                           the presence of FD with Schirmer scores of the right and
Dermatoses                                                         left eyes (r = 0.369 and 0.489, respectively), which was
The patients had not previously applied to the dermatology         statistically significant (P = 0.027 and 0.002, respectively)
outpatient clinic regarding this condition, and they had no        (Table 4).
complaints about this. Therefore, we could not calculate the           Anterior blepharitis was significantly higher in the FD
FD time. The FDS was as follows: + in 4 patients (4.2%),           group than in the SD and AR groups (P = 0.028) (Table 5).
++ in 5 patients (5.3%), +++ in 16 patients (16.8%), ++++              We examined the rate of FD in facial dermatoses we
in 24 patients (25.3%), 6 patients (6.3%) +++++ FD was             detected. We observed a higher rate of FD, especially in
present. The mean SD duration was 85.71 (±44.79) months.           patients with rosacea compared to other groups. FD was
The mean SEDASI was 14.48 (±5.06). The mean disease                present in 66.7% of patients with rosacea and 47.6%
duration of the patients with rosacea was 41.86 (±13.18)           of patients with SD. We found the incidence of FD to be
months, and the mean RCS was 7.29 (±1.54) (Table 1).               quite low (22.7%) in patients with AR than in patients
                                                                   without AR. This difference was statistically significant
Relationships Between Duration and Severity of                     (P < 0.001). We did not find a significant difference in the
Blepharitis and Duration and Severity of Facial                    incidence of FD in patients with or without SD and with
Dermatosis                                                         or without rosacea (respectively P = 0.280 and P = 0.510)
                                                                   (Table 6).
There was no correlation between blepharitis duration, ro-
sacea duration, SD duration, RCS score, SEDASI scores with
blepharitis severity (UODS) in our patients. There was only
                                                                         Table 2. Relationships between duration
a weak positive correlation between rosacea duration and
                                                                          and severity of facial dermatosis with
UODS and between FDS score and UODS (P = 0.002 and P
                                                                                   blepharitis severity.
= 0.013, respectively) (Table 2).
                                                                                                                    UODS
                                                                                                              r              P
Facial Dermatoses and History of Allergic Rhinitis
Compared with the Severity of Blepharitis and                       FDS                                     0.255           0.013
Degree of Dry Eye.                                                  RCS                                     0.149           0.566

In terms of the severity of blepharitis, the median value of        SD duration                             0.262           0.148
the UODS score in the FD group was greater than the me-             SEDASI                                  0.275           0.133
dian value of the allergic rhinitis group (P = 0.026) and           Rosacea duration                        0.706           0.002
the median value of the SD group (P = 0.001), and it was            Allergic rhinitis duration              0.111           0.518
statistically significant. There was no significant difference     Kendall tau b test, Spearman rho test.
in the severity of blepharitis between patients with allergic      FDS = facial demodicosis severity; r = Correlation Coefficient; RCS
                                                                   = Rosacea clinical severity; SD = seborrheic dermatitis; SEDASI =
rhinitis and patients with SD (P = 0.208). No significant          Seborrheic Dermatitis Area and Severity Index; UODS = Uludağ
correlation was found between patients with allergic rhinitis      Ocular Demodicosis Clinical Scoring system.




    Table 3. Relationships between facial dermatoses and history of allergic rhinitis with the severity
                                             of blepharitis.
                                                                                UODS
                                                                          Median (q1 / q3)                          P
                                                                                                                  0.001
 Allergic rhinitis (A)                                                          3 (2 / 4)                   P (A-B) = 0.208
 Seborrheic dermatitis (B)                                                      2 (2 / 3)                   P(A-C) = 0.026
 Facial demodicosis (C)                                                         4 (4 / 5)                   P(B-C) = 0.001

Kruskal-Wallis H test (Monte Carlo); Post Hoc test: Dun test.
AR = allergic rhinitis;FD = facial demodicosis; q1 = 25°percentile; q3 = 75° percentile;. SD = seborrheic dermatitis; UODS = Uludağ
Ocular Demodicosis Clinical Scoring System Blepharitis severity score.



8                                                                       Original Article | Dermatol Pract Concept. 2022;12(3):e2022113
     Table 4. Relationships between facial dermatosis and history of allergic rhinitis, with the degree
                                               of dry eye.
                                              Allergic Rhinitis               Seborrheic Dermatitis                     Facial Demodicosis
                                              r                  P                   r                  P                 r                  P
 Schirmer right eye score                   -0.204              0.466            0.324                 0,332            0.369              0.027
 Schirmer left eye score                    -0.312              0.257            0.324                 0.332            0.489              0.002
 SEDASI                                       -                   -              0.106                 0.757              -                  -
 FDS                                          -                   -                  -                     -           -0.080              0.643
FDS = facial demodicosis severity; r = Spearman rho test correlation coefficient; SEDASI = Seborrheic Dermatitis Area and Severity Index.



     Table 5. The relationship between blepharitis type and severity parameters and facial dermatoses.
                                           Allergic Rhinitis            Seborrheic Dermatitis                  Facial Demodicosis
                                               (N = 15)                       (N = 11)                               (N = 36)                    P
                                                  N (%)                             N (%)                            N (%)
 Anterior blepharitis                                                                                                                       0.028
                                                            C                               C
      None                                     2 (13.3)                        2 (18.2)                              0 (0.0)
      Yes                                      13 (86.7)                         9 (81.8)                         36 (100.0) AB
 Posterior blepharitis                                                                                                                      0.545
      None                                     10 (66.7)                         9 (81.8)                          29 (80.6)
      Yes                                         5 (33.3)                       2 (18.2)                           7 (19.4)
 Compound blepharitis                                                                                                                       0.280
      None                                     12 (80.0)                      11 (100.0)                           29 (80.6)
      Yes                                         3 (20.0)                       0 (0.0)                            7 (19.4)
 Cylindric scale                                                                                                                           <0.001
      None                                    12 (80.0) C                     10 (90.9) C                           9 (25.0)
      Yes                                         3 (20.0)                       1 (9.1)                          27 (75.0) AB
 Droplet usage                                                                                                                              0.019
      None                                        9 (60.0)                    11 (100.0) A                         31 (86.1) A
      Yes                                     6 (40.0) BC                        0 (0.0)                            5 (13.9)
 Different xerophthalmia cause                                                                                                                   -
      None                                    15 (100.0)                      11 (100.0)                           36 (100.0)
      Yes                                         0 (0.0)                        0 (0.0)                             0 (0.0)
 Epithelial defect                                                                                                                          0.368
      None                                    15 (100.0)                      11 (100.0)                           32 (88.9)
      Yes                                         0 (0.0)                        0 (0.0)                            4 (11.1)

Fisher freeman Halton test (Monte Carlo). A expresses significance according to AR group, B expresses significance according to SD group,
C
  expresses significance according to FD group, AB expresses significance according to AR and SD group, BC expresses significance according
to SD and FD group



     Table 6. Frequency of facial demodicosis in facial dermatoses and patients with allergic rhinitis.
                               Seborrheic Dermatitis                        Allergic Rhinitis                                  Rosacea
                               None                  Yes                  None                   Yes                 None                  Yes
                               N (%)                N (%)                N (%)                  N (%)               N (%)                N (%)
 Facial Demodicosis
 None                         29 (39.2)            11 (52.4)            23 (31.5)           17 (77.3)              36 (43.4)             4 (33.3)
 Yes                          45 (60.8)            10 (47.6)            50 (68.5)               5 (22.7)           47 (52.6)             8 (66.7)
 P                                        0.280 a                                <0.001     a                                  0.510 a

a: Pearson Chi-Square Test (Monte Carlo).



Original Article | Dermatol Pract Concept. 2022;12(3):e2022113                                                                                       9
Conclusions                                                       of patients with OD. Since this finding is often associated
                                                                  with D. folliculorum, which causes anterior blepharitis, we
This study aimed to investigate the frequency of accom-           may have seen anterior blepharitis possibly related to D.
panying facial dermatoses in patients with blepharitis and        folliculorum much more in our patients with OD [15, 20, 21].
whether there is a relationship between the severity of der-      Since SD involves the Zeis glands more frequently, and an-
matoses and the severity of blepharitis. As a result of our       terior segment findings can be expected [8]. Therefore, we
research, we found that patients with blepharitis mostly have     may have seen anterior blepharitis more frequently in our SD
facial inflammatory dermatosis.                                   patients, as expected.
     We detected at least one facial dermatosis in most of our       Main limitations of the study were thatthe information
wastes. This may suggest that a common factor plays a role        about the drugs used by the patients for blepharitis and their
in the etiopathogenesis of facial dermatoses and blepharitis.     other diseases was not recorded and the lack of a control group.
For example, many studies suggest that Demodex infesta-              We detected high rates of facial dermatosis in patients
tion, which plays a role in the etiology of facial dermatoses,    with blepharitis. For this reason, we think that it is essential
is associated with rosacea and SD [16,33,34].                     for all patients diagnosed with blepharitis to be examined in
     A similar immunopathogenesis in these disease groups         dermatology clinics for facial dermatoses. Thus, we predict
may also be responsible for the association of facial derma-      that the patient’s quality of life will increase with the treat-
toses and blepharitis. The presence of STAT-1 gene mutations      ment of an early-detected facial dermatosis. Furthermore, we
that cause a primary immunodeficiency, which is blamed es-        are becoming more and more aware that dermoscopy can be
pecially in the etiology of rosacea, Demodicosis, blepharitis,    a helpful tool in the diagnosis of periocular diseases besides
or the emergence of Demodicosis, SD and rosacea in second-        all skin diseases and facial dermatoses.
ary immunodeficiency cases may be a consociate etiopatho-
genetic factor [35-38].                                           References
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