Editorial

Dermatology 2011;222:128–130 Published online: January 11, 2011

DOI: 10.1159/000323009

Demodex Mites – Commensals, Parasites

or Mutualistic Organisms?
Noreen Lacey Síona Ní Raghallaigh Frank C. Powell 
UCD Clinical Research Centre and Regional Centre of Dermatology, Mater Misericordiae University Hospital,
Dublin, Ireland

The German dermatologist Gustav Simon is credited ated, he proposed that the life cycle of D. folliculorum
with the first description of Demodex mites [1]. He was mites was about 14.5 days. He also demonstrated that all
studying the microanatomical structure of acne vulgaris life stages of these mites were negatively phototaxic, that
lesions by examining material expressed from sebaceous is they were more mobile in a dark environment and rel-
follicles under the microscope. He noted structures with- atively inert when bright light was shone on them. How-
in this material and was able to identify a worm-like ob- ever, until optimal in vitro culture techniques and condi-
ject with a head, legs, and anterior and posterior body tions allow Demodex proliferation in the laboratory, the
parts that made him think this was ‘an animal’ of some true life cycle of Demodex remains uncertain. Mites are
sort. Suspicion became certainty when he pressed the ob- mobile and can travel at a speed of up to 16 mm/h [6].
ject gently between two slides and observed that ‘it Mites found from time to time on the skin surface suggest
moved’! The term Demodex was coined by Richard Owen that they emerge from follicles (probably at night to avoid
in 1843 for this genus [2], borrowing from the Greek the light exposure) and migrate across the surface of the fa-
words ‘demo’ (lard) and ‘dex’ (boring worm) to describe cial skin.
the form and location of preference of this organism. The Mites are known to contain lipase enzymes [7], to car-
anatomical details were subsequently described by Desch ry bacteria on the surface [6] and they may have endobac-
and Nutting [3, 4]. These included (for Demodex follicu- teria [8].
lorum) 4 pairs of articulated legs, complex mouth parts, Any potential role of these complex organisms in the
genital organs (either penis or vagina), a rudimentary biobalance of the skin has been largely ignored. They are
gastrointestinal tract but surprisingly no anus! regarded by most investigators as simple commensals
We now know that 2 mite species (Demodex brevis and benefiting from the human sebum in its sheltered eco-
D. folliculorum) inhabit normal adult human facial seba- logical follicular niche and without adversely affecting its
ceous follicles. Mites are not found in the skin of newborn host, but in animals the pathogenic potential of Demodex
infants. Sebaceous follicles are thought to become colo- species is well documented. Demodectic mange in dogs
nised during later childhood and early adult life by trans- is a potentially lethal condition, and goats can be simi-
fer from adult family members. The mites’ life cycle was larly affected. Both disorders are caused by a massive pro-
studied by Spickett [5] by histological and rudimentary liferation of the normal mite population [9]. In humans
in vitro experiments. From a synthesis of this data gener- there is mounting evidence that Demodex mites, like oth-

© 2011 S. Karger AG, Basel Frank C. Powell

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er cutaneous microflora, may be opportunistic patho- the canal under control without inducing an inflamma-
gens, that is they have the potential to change status from tory response. If mite numbers increase to a critical level
commensals to parasites (the mites benefit but cause (possibly causing physical distension of follicles with kera-
harm to the host) if the host cutaneous environment fa- tinocyte disruption), they possibly develop a pathogenic
cilitates their proliferation [10, 11]. role causing host ‘insult’. Thus, cytokine/chemokine re-
Demodex mite numbers have been repeatedly shown lease may be initiated, and a humoral immune inflamma-
to be increased in patients with rosacea, and a recent re- tory response ensues with clinically visible cutaneous
port using meta-analysis of previous studies has shown a changes. If the follicle is damaged to the point of rupture,
statistically significant association between Demodex a granulomatous ‘foreign-body’ type of reaction subse-
species infestation and the development of rosacea [12]. quently results.
Rosaceiform dermatitis has been reported following re- Several factors could allow proliferation of mites to
peated facial application of topical steroids and other im- this critical level. For example the particular physical
munomodulators with similarly increased numbers of barrier characteristics of an individual’s facial skin may
mites recorded [13]. Several other studies have shown that facilitate their increased population. Our preliminary
Demodex mite numbers are increased in immunosup- studies have shown that patients with papulopustular ro-
pressed patients, children with leukaemia receiving che- sacea have increased facial pH and reduced skin surface
motherapy [14], patients with HIV infection and AIDS hydration levels [20]. Papulopustular rosacea patients
[15, 16], patients undergoing phototherapy [17] and pa- also have abnormal fatty acid composition of their skin
tients on chronic dialysis [18]. surface lipid layer, with increased levels of linoleic acid
In this issue, Gerber et al. [19] introduce a new clinical and myristic acid, as well as reduced levels of specific sat-
setting in which Demodex numbers were found to be in- urated fatty acids [21]. This type of facial cutaneous mi-
creased. In their retrospective study these authors demon- croenvironment may prove conducive to mite prolifera-
strated increased numbers of D. folliculorum in the cheek tion. Alternatively, the aberrant innate immune response
region of patients presenting with papulopustular lesions as previously reported in rosacea patients [22] may facili-
induced by epidermal growth factor receptor inhibitor tate mite multiplication to the point where the humoral
following therapy for cancer. The authors propose that response is initiated and cutaneous inflammation results.
their findings suggest that epidermal growth factor recep- The role of suppression of the host immune response
tor inhibitor may reduce/impair cutaneous defence mech- in the facilitation of mite proliferation is suggested by the
anisms resulting in increased Demodex proliferation. studies cited above and the publication by Gerber et al.
Our present state of knowledge suggests that Demodex [19] in this issue.
mites normally have a symbiotic relationship with hu- Studies of Demodex mites and their role in healthy
mans. In usual circumstances they appear to live as com- skin as well as their potential to cause host damage have
mensals feeding on their host’s sebum. It is possible in this the potential to give insight into this complex and impor-
role that they may even confer a mutualistic host benefit tant area of cutaneous medicine. It may well be that De-
by ingesting bacteria or other organisms in the follicular modex mites, like some cutaneous microbes, take on dif-
canal. The host’s innate immune system appears to toler- ferent roles depending on host status [23], changing from
ate the presence of these mites (possibly being downregu- commensals (or even mutuals) to parasites as the host’s
lated by the mites themselves) but it may have a ‘culling’ or defences are altered.
inhibitory effect on mite proliferation keeping numbers in

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Demodex – Commensal, Parasitic or Dermatology 2011;222:128–130 129

Mutualistic?
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130 Dermatology 2011;222:128–130 Lacey/Ní Raghallaigh/Powell