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Small itchy white bump appeared under skin on face. How to treat this?

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Practicing since : 2006
Answered : 2015 Questions
Hi I have an infestation of tiny white pin like worms (very slim, and very short, look like tiny white dots) on my face under my skin.
It feels very itchy, it moves, and I experience regular outbreaks on my face.
What can I do to treat them?
Posted Fri, 26 Apr 2013 in Skin Hair and Nails
Answered by Dr. Kalpana Pathak 1 hour later
Thanks for writing to us.
I have gone through the image attached. It was not clear to pin point the possibility.
From the description provided, I can think of two possibilities:
1) Demodex folliculitis- a mite infestation which can cause itching crawling sensation with redness and pimple like lesions over face
2) Cutaneous larva migrans- worm infestation of skin which produces itchy creeping sensation with visible linear tracts over skin along with small elevated skin lesions.

The treatment of both of these vary, cutaneous larva migrans requires either oral albendazole or thiabendazole. Topical application if thiabendazole tablet crushed and mixed in Vaseline helps too. Demodex folliculitis requires oral ivermectin with topical application of permethrin or crotamiton.

As you can see, treatment of both these conditions vary , hence a visit to dermatologist nearby is advised to get the diagnosis confirmed and start with specific treatment. Moreover, above mentioned drugs are prescription drugs for which a doctor's visit is mandatory.

Let me assure you that both the conditions are treatable if early treatment is undertaken.

Hope that helps. Should there be any other query, feel free to write back.

Take care.
Above answer was peer-reviewed by
Follow-up: Small itchy white bump appeared under skin on face. How to treat this? 10 hours later
Hi doctor,
Thank you very much for your answer. I personnally believe it is Demodex folliculitis, because there are no visible linear tracts over my skin.
I saw doctor Joshen in rancho mirage this morning and he believes that what you saw on the picture is just dead skin (!!!). He believes I am "delusional" about the itching and the picture. He said bad things about your email that I had him read, but I really think you are right.
I insisted that he do a biopsy on my skin on a spot where a "little head" was showing at the time of the appointment. He also agreed to have the samples that I collected in a little plastic box to be analyzed.
I collected in that box what I think are Demodex (extremely thin), but also bigger, round shaped "things" that I believe are a different type of possibly "mite", which did not show on the picture at the time, but many of which came up last week end when I applied a lot of tea tree oil on my face to try to alleviate the itching (I did the facial that revealed numerous thin worms only yesterday)
I saw some little worms moving, even one jumping, so there is no doubt in my mind that your diagnosis based on the picture seems to be correct.
I live in La Quinta California (near Palm Springs/Indian wells), could you let me know if by any chance you would be in the area, or if you know a dermatologist who knows how to treat demodex like you seem to know very well.
Please doctor, don't let me down, I really need your help, I am afraid to be disfigured if I don't address this issue correctly, and have a miserable remainder of my life.
I will have the results of the biopsy, and samples I collected, in about 2 weeks or less. I hope that people who will analyse them will be competent. Do you think, from your experience that they will definitely recognize what it is, if it is confirmed to be demodex or some type of worm?
Thank you so much for your help.
Answered by Dr. Kalpana Pathak 10 hours later
Thanks for writing back.
I partly agree with your consulting doctor.
Itching, crawling sensation along with redness and persistent pimple like outbreaks or irregular sandpaper like feeling on face, rosacea may occur in demodex folliculitis. The same can be confirmed by skin biopsy and if positive can be treated with application of 5 percent permethrin or crotamiton. Many a times doctors may misdiagnose demodex and feel that the patient is delusional .
Having said this few of the complaints that you have emphasised upon seems unlikely like collecting mites in the box, moving or jumping mites etc. demodex mites are too small to be visible to naked eye( 0.2 mm in size)
Right now I would advise that you may take tablet cetirizine to alleviate itching and may apply 5 permethrin cream or crotamiton cream over face. If not helpful it won't be harmful in any way.
However if your biopsy comes negative then a consultation with a psychiatrist or counsellor is required for delusional parasitosis.

The link to this site might be useful in understanding demodex
But I am neither endorsing the product neither do I confirm that you have demodex mite induced skin eruptions. You need to wait for biopsy for confirmation.
Hope that helps.
Take care
Above answer was peer-reviewed by
Follow-up: Small itchy white bump appeared under skin on face. How to treat this? 2 hours later
Hi doctor,
Thank you so much for your advice.
The worms are normally barely noticeable to the naked eyes, but when I apply 70% rubbing alcohol on them, they seem to pretty much die on contact or pretty close to it, and they become much longer after getting in contact with the alcohol. This is why we were able to see them pretty well on the picture.
I noticed tonight that when I apply softly 70% rubbing alcohol with a Kleenex on my chin (the least sensitive part of my lower face), after only two or three times, the worms start to come out and seem to die, and they are longer than what you said because of the alcohol.
I kept on rubbing my chin off and on for about 15 minutes tonight with alcohol, and tens of tiny worms were still coming out, occasionally in a rather "jumpy" way, meaning that sometimes they fall or almost jump directly in the sink over which I am bent. The flow seems endless. Then I had to apply water several times to stop the process of them coming out, otherwise I would keep visible traces of them on my chin.
Doctor, I guarantee you that the biopsy will come out positive.
Now, is it Demodex or something similar remains to be seen, but Demodex seems likely given what you said and what I read and saw for myself.
If the results were to come negative, then I would seriously consider going to a psychatrist; such an event is in my opinion nearly impossible because of what I see and experience.
I just wish you had a practice somewhere in the area where I live, which would make things much more simple for me. Right now, I feel I need to educate my doctor, and he doesn't even know how to treat my condition by the way, for which he is in total denial, or "desilusion" .
You on the contrary seem to really know how to address my issue.
I thank you so very much, and I am going to get the products you pointed at this morning, waiting for the biopsy results.
sent a picture of my face taken yesterday with barely noticeable worms, before application of the alcohol.
As I said, they get bigger with the alcohol.
Have a wonderful week end.
Answered by Dr. Kalpana Pathak 21 hours later
Apologies for the delayed response.
I have gone through the images attached. If those thread like structures are really worms, then it could not be demodex folliculitis. In that case we have to think on lines of worm infestation like thread worm or pin worm. But cases of worms coming out from face are rare. Honestly I have not encountered a case like yours till now and most of the dermatologists too would not have seen such a case. If that is really the case, you should be having some systemic symptoms like abdominal pain, nausea, anal itching etc too. A microbiologist would be the right expert to clear your doubts and concern.
Hope that helps
Above answer was peer-reviewed by
Follow-up: Small itchy white bump appeared under skin on face. How to treat this? 7 hours later
Hi Doctor Pathak,
Yesterday morning, after receiving your extremely important emails, and experiencing the itching, with the trauma of seing a multitude of worms coming out every time I applied alcohol, plus Dr Joshen denying what is an obvious massive infestation, I was truly desperate and could not stand physically and mentally having to wait for two weeks for a biopsy.
My wife and I went to see an urgent care doctor, as I managed to convince my wife I was indeed infected (she had believed Dr Joshen I was delusional), asking him in advance if he knew what a Demodex infestation was and if he could potentially give a prescription. The answer through his secretary was positive. So I saw him, explained everything and he only prescribed Ivermectin (1 pill now, 1 pill in a week).
Last night, the worms started to be paralysed and a multitude (hundreds, more likely a few thousands) started coming out of my face (bottomhalf of my face from my temples down to the upper part of my throat) and to my knowledge nowhere else on my body.
I feel much better, very tired due to the medication.
I am as thankful to you as for Dr Scherwin whom I saw yesterday, and took a risk because he wasn't sure exactly what it was, but knew the infectation was real.
I am still concerned in many ways of course:
1. We need to wait for the biopsy to know what it is exactly, including the reproduction cycle of what is infecting me, to know how and when other doses of Ivermectin will be needed to kill the eggs when they will hatch.
2. My wife seems not to be infected (she thinks she is not), but I am in fear for her.
3. I am an artist, but currently work as a security officer as well, and I share a vehicle with 6 coworkers; my condition could be of great danger to them, and I may have caught it at work as well.
4. What can we do to ensure that the house is safe as we have carpet throughout (major cleaning and desinfection took place yesterday when we came back home).
5. Should I go back to work on Sunday or wait until we get to the bottom of this?
And more issues of course.
So thank you a million times again, I have hope again, and I am ready to fight to find a solution.
You are probably right regarding a microbiologist, I think I need the results of the biopsy first.
Have a great day.

Answered by Dr. Kalpana Pathak 20 hours later
If you think the medication has worked, there is no need to worry. You may not spread infection to others. You may resume your work. However keep your towels and clothes separately. I would still emphasise that you XXXXXXX a microbiologist or parasitologist to confirm the diagnosis as looking at the images I still doubt that these are demodex mites. Secondly if nothing comes out to be positive from biopsy and medication, do visit a counsellor.
Hope that helps.
Wish you a speedy recovery and good health.
Above answer was peer-reviewed by
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