Facial Findings in Clinical Practice
This live blog covers information provided by Dr. Matthew Zirwas on treating Demodex and Folliculitis. The lecture was given at the SDPA 2014 Fall Conference in San Diego.
Dr. Matthew Zirwas discussed the treatment regimens for demodex and folliculitis with the participants of the SDPA 2014 Fall Conference in San Diego. This blog covers a brief outline of his talk.
When to think “Demodex”
With Rosacea that only responds partially or not at all to therapy
With Rosacea with more scaling than usual
Demodex can be treated like Rosacea. If that treatment doesn’t work, then change your plan and treat Demodex.
Demodex prep: The mites look like little “carrots with legs” sticking out of the follicle.
It doesn’t always respond to topical therapy because a lot of the heads are down in the follicle where the topical doesn’t reach
Dr. Zirwas recommends an initial 2 week combination therapy:?
Ivermectin 1 mg/10 lbs x 2 doses, 1 wk apart
(same way we treat scabies)
Metronidazole 250 mg tid, for 14 days
(Start on the same day as the Ivermectin)
?Permethrin 5% Cream every other day
Metronidazole gel qd
How to spot Pityrosporum Folliculitus
Common on chest, shoulders, upper back. Can involve face, lower back, abdomen, lower arms.
Monomorphic pink papules ?– Less red and less deep than acne lesions
May or may not itch
Itraconazole 100 mg bid x 1 week to 1 month
Depends on severity?
Start there and then once weekly x 3 months to prevent relapse
Fluconazole 150 mg bid x 1 week to 1 month
Then once weekly x 3 months to prevent relapse
With either systemic, also implement 2% ketoconazole shampoo as a daily bodywash
What to know about Eosinophilic Folliculitis
Itchy papules that look almost urticarial or like arthropod
Can be trunk, face, extremities, or all over
Several known possible etiologies, although usually none identified. ?
Difficult to treat?
Consider trial of therapy for pityrosporum or demodex
Check for HIV?
Cetirizine at high dose (up to 40 mg/day)?
Topical steroids, pimecrolimus, tacrolimus
This burns because of a substance P is released from the nerve endings. It will stop burning when substance P runs out. Same thing happens with spicy peppers on the tongue.
? Start at 25 mg/day, taper upward as tolerated and necessary
Drug Induced or Exacerbated Acne
Clues that should cause suspicion:?
New onset acne in an odd demographic?
Sudden worsening of acne that has been stable
?Monomorphic, rather than several different types of lesions
Distribution that is not entirely typical
Main Drugs and morphologies:
Monomorphic pink papules on face and trunk
Rosaceaform or Perioral Dermatitis like
Typical acne, but pretty severe
Doxycyline or Minocycline?
Gram negative folliculitis – often trunk predominant, deeper
Happens after chronic therapy
Pretty typical acne in cases I’ve seen
Pretty severe and widespread. Correlates with better response of cancer to the drug
Image: Sven Cipido