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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:

Systemic steroids

Monomorphic pink papules on face and trunk

Topical steroids

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

EGF-R Inhibitors

   Pretty severe and widespread. Correlates with better response of cancer to the drug


Image: Sven Cipido

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