Dear Doctors: I am a 29-year-old woman, and I am concerned that I might have mites in my areola. I found one when I tried to squeeze what I thought was a whitehead and saw a demodex mite come out. I went to my primary doctor, and he did not believe me. What can I do?

Dear Reader: Demodex mites are microscopic parasites that live and feed on mammals. More specifically, they are what are known as ectoparasites. Unlike parasites that can live and reproduce in tissues and organs throughout the body, ectoparasites typically occupy or infect only the topmost layers of their host’s skin. There are about 65 known species of demodex mites, each of which is specific to a particular animal. Of those 65, two make their homes on humans.

The thought of playing host to microscopic mites can be upsetting. However, they are quite common and are present in up to 90% of adults. The most numerous are Demodex folliculorum, which live primarily in hair follicles on the face, including the eyelashes, and to a lesser extent, on the neck and chest. They feed on dead skin cells. Not as widespread are Demodex brevis, a smaller mite that lives inside of the sebaceous glands that lubricate the hair follicles. They feed on sebum, which is the oily lubricant the glands produce. It is possible for them to be present in the oil glands around the areola.

These tiny arachnids are nocturnal. They spend their days tucked into the hair follicle or oil gland. At night, they emerge to the surface of the skin to consume dead skin cells and to mate. For most people, because the immune system keeps their numbers in check, demodex mites are not a problem. But when someone is immunocompromised, whether due to illness or medical treatment, the colonies of mites can grow out of control. This overgrowth is a condition known as demodicosis. Symptoms can include redness, itching or burning on the affected skin; patches of rough or scaly skin; and the sudden appearance of tiny white bumps.

An overgrowth of mites near the eyes can cause an inflammation of the eyelids known as blepharitis. It usually appears at the front edge of the eyelid, where the eyelashes emerge from the skin. Symptoms include dry or red eyes; eyelids that are swollen; sticky eyelashes; itching, burning or stinging; grittiness in the eyes; and crustiness around the outer edge of the eyelid.

Demodex mites are microscopic, which may be why your doctor was skeptical that you had seen one. And because they are so common, anything less than an overgrowth that is leading to symptoms would not be a cause for concern. If you are experiencing the symptoms associated with demodex overgrowth, you should let your doctor know. Diagnosis includes the use of a powerful magnifying lens to examine the skin, and perhaps a skin scraping or biopsy to identify the species of mites. Treatment often involves a routine of rigorous skin cleansing, along with medications to address the overgrowth.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: My 22-year-old son is severely bipolar, which impacts his life terribly. I have kept up with the studies that have shown success in treating bipolar with a fecal transplant. Do you know of any open studies right now that might take my son? We would travel anywhere to get it done.

Dear Reader: Bipolar disorder is a mental health condition that is marked by extreme swings in mood, energy, thoughts and behaviors. These repeated shifts from intense elation to crushing depression can disrupt sleep, impede judgment and interfere with the ability to think clearly. As with many conditions that affect mental health, bipolar disorder exists on a spectrum. That means each case is unique, and symptoms vary in severity, frequency and presentation. But even in its milder forms, bipolar disorder can significantly impair quality of life.

It is common for the first indications of bipolar disorder to emerge in late adolescence and early adulthood. Diagnosis includes a mental health assessment, medical history and physical exam. Once diagnosed, treatment typically combines medications, such as mood stabilizers and perhaps antidepressants, with individual, group or family-focused psychotherapy. Due to the unpleasant side effects of some of the medications, treatment can be challenging.

The cause of bipolar disorder is not yet clearly understood. Previous research has suggested links to a mix of heredity, mental health and environmental factors. More recently, though, growing awareness of a connection between the gut microbiome and the brain is leading researchers in an intriguing new direction. This connection, known as the gut-brain axis, is a bidirectional communication system between the trillions of microbes in the gut and the brain. An imbalance in the gut microbiome has been found to contribute to inflammation, immune system dysfunction and the production of harmful metabolites.

This imbalance, known as gut dysbiosis, has been linked to a range of neurodegenerative diseases. These include Alzheimer’s disease, multiple sclerosis, Parkinson's disease and amyotrophic lateral sclerosis, or ALS. As you have pointed out, there is evidence that gut dysbiosis may play a role in bipolar disorder as well. It is not suggested that gut dysbiosis is the sole cause of these diseases. However, some researchers believe modulating the gut microbiome may have therapeutic benefits. This may be done through diet, the use of specific prebiotics and probiotics, and fecal transplants. This is when a person’s colon is infused with a solution containing fecal matter from a healthy donor. A few small studies have reported success in lessening the symptoms of severe bipolar disorder through fecal transplants.

We searched at clinicaltrials.gov, the United States National Institutes of Health’s clinical trials database. At this time, there do not appear to be any new or ongoing investigations into the use of fecal transplants to manage bipolar disorder. However, several bipolar studies are exploring probiotics. You may find it useful to browse all of the studies listed on the site associated with bipolar disorder. Even if none are right for your son, they are an excellent way to keep abreast of new directions in research.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: I had a pain on the right side of my abdomen. A CT scan found a perforated appendix with an abscess. I was treated with IV antibiotics, and now I am feeling fine. Do I need to have my appendix taken out? My doctor says, in cases like mine, people have problems again 30% of the time.

Dear Reader: The appendix is a thin tubelike pouch that extends from the colon on the lower right side of the abdomen. It was previously thought to be a vestigial organ with no purpose. Newer research suggests a link to immune system function and the gut microbiome. If something blocks the opening to the appendix, it closes. This prevents the organ from draining and restricts blood flow. A blockage sets the stage for inflammation, infection and internal pressure that can cause the organ to get a small hole or rupture.

A ruptured appendix is a medical emergency. The large break in the appendix wall allows the build-up of infectious materials to spill into and contaminate the abdominal cavity. This can quickly escalate to a life-threatening infection known as peritonitis. Surgery is the primary treatment for a ruptured appendix. The appendix must be removed, and the abdominal cavity must be cleaned out. However, in cases that are less severe, new approaches are emerging.

Sometimes, as in your own case, a CT scan will show that, while the organ is inflamed, has an abscess or is perforated, it is not in danger of bursting. This is a condition known as uncomplicated appendicitis. In these cases, rather than immediate surgery to remove the organ, initial treatment with antibiotics can become an option. Patients who wish to avoid the risks associated with surgery, the cost of an appendectomy or the recovery sometimes choose this approach.

It sounds like you don’t have the fever, pain or nausea that signal infection. It appears your doctors consider you a candidate for ongoing nonsurgical management. Unlike an appendectomy, which removes the organ, this is not a cure. This is the first step of an approach known as watchful waiting. First, the condition is treated with antibiotics. Then your symptoms are actively monitored. The option of surgery is still available if necessary.

In 2021, a study on uncomplicated appendicitis was published in the New England Journal of Medicine. It analyzed health data from 1,552 adults in 25 United States medical centers with this condition. The researchers found that half of patients made it four years before needing surgery. One-third developed recurrent appendicitis and required surgery within three months. This study has influenced a shift to offering nonsurgical management to eligible patients.

The decision regarding surgery should be made with guidance from your own doctors. If you continue with nonsurgical treatment, it’s important to look out for symptoms of appendicitis. If you get any symptoms, let your doctor know immediately. Another round of antibiotics or surgery may be needed.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

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