On the other hand, a review by Aylesworth and Vance11 found that 117 (10%) of 1124 skin biopsies and 198 (12%) of 1692 follicles incidentally revealed that follicular mites were found in patients with various unrelated skin disorders, thereby suggesting that Demodex is a normal inhabitant of the hair follicle and is not pathogenic.11 Other histologic evidence that failed to show a correlation between Demodex presence and skin disease was an examination of the results of 108 biopsy specimens of rosacea, of which only 20 (19%) contained Demodex.12 There was no correlation between Demodex mites and skin disease in a study of 29 biopsy samples of the head and neck by Nutting and Green.13 We must note that the reported prevalence of Demodex presence is partially determined by the preciseness of the detection method used.
There are several treatment options available for demodicosis. In our case, the patient cleared with a combination of sulfacetamide 10% plus sulfur 5% cream, in addition to selenium sulfide 2.5% shampoo. Other commonly used treatment options include ivermectin,10 topical antibiotics, and topical retinoids.
The persistence of the patient's folliculitis despite treatment with clindamycin 1% gel; rapid clearance after therapy with sulfacetamide 10% plus sulfur 5% cream twice daily and selenium sulfide 2.5% shampoo once daily is initiated; and positive results of the ectoparasite wet mount suggest a pathogenic role of Demodex in causing the patient's symptoms. Although the link between folliculitis and Demodex infection remains controversial, this case demonstrates the importance of considering the possible role of Demodex in the differential diagnosis of rosacea and papulopustular eruptions of the head and neck.