Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-week extension of the ATTRACT randomized study

Treatment of Common Dermatologic Conditions

Dermatologic concerns are discussed in about a third of all primary care visits. This review discusses treatments for common dermatologic diagnoses addressed in primary care settings, with an emphasis on new and emerging treatments. Topical, oral, and injectable treatment of common forms of alopecia, facial rashes, atopic dermatitis, psoriasis, seborrheic dermatitis, and stasis dermatitis will be discussed to help increase comfort in prescribing and alert providers to common side effects or complications of more intensive treatments used by dermatologists.

Microencapsulated Benzoyl Peroxide for Rosacea in Context: A Review of the Current Treatment Landscape

Rosacea, a chronic skin condition affecting millions of people in the USA, leads to significant social and professional stigmatization. Effective management strategies are crucial to alleviate symptoms and improve patients' quality of life. Encapsulated benzoyl peroxide 5% (E-BPO 5%) is a newly FDA-approved topical treatment for rosacea that shows promise in enhancing therapeutic response and minimizing skin irritation. This review aims to assess the role of recently FDA approved E-BPO 5% in the current treatment landscape for rosacea management, as it is not yet included in clinical guidelines that predominantly rely on older approved therapies. The review focuses on randomized controlled trials conducted in English-speaking adults. It evaluates the efficacy, safety, and tolerability of various US Food and Drug Administration (FDA)-approved agents used for rosacea treatment, including E-BPO cream, metronidazole gel, azelaic acid gel and foam, ivermectin cream, minocycline foam, oral doxycycline, brimonidine gel, and oxymetazoline HCl cream. Existing therapies have been effective in reducing papulopustular lesions and erythema associated with rosacea for many years. E-BPO 5% offers a promising addition to the treatment options due to its microencapsulation technology, which prolongs drug delivery time and aims to improve therapeutic response while minimizing skin irritation. Further research is necessary to determine the exact role of E-BPO 5% in the therapeutic landscape for rosacea. However, based on available evidence, E-BPO 5% shows potential as a valuable treatment option for managing inflammatory lesions of rosacea, and it may offer benefits to patients including: rapid onset of action, demonstrated efficacy by Week 2, excellent tolerability, and sustained long-term results for up to 52 weeks of treatment.

Comorbidity of Ocular and Facial Demodicosis

PURPOSE

To determine the association between ocular and facial demodicosis, and the effect of facial treatment on ocular demodicosis.

DESIGN

Prospective clinical cohort study.

METHODS

Ocular demodicosis outpatients from a tertiary medical center were enrolled from April to December 2020. The diagnosis was based on epilation of 4 eyelashes from each upper eyelid. High ocular Demodex load (ODL) was defined as ≥8 mites per eye. Facial infestation was assessed by direct microscopic examination, with facial Demodex overgrowth (FDO) defined as a density >5 mites/cm2. All patients were prescribed 3 months of ocular treatment, and FDO patients received dermatologic treatment.

RESULTS

Eighty-nine patients were enrolled. Among those that completed the treatment course, 39 presented high ODL. Lower cylindrical sleeve counts were found in low ODL patients (low ODL vs high ODL: 8 vs 14, P = .009). FDO was less prevalent in this group (49% vs 77%, P = .012). The Ocular Surface Disease Index score decreased in patients without FDO (20.0 ± 17.1 to 14.0 ± 16.6, P = .027) after 3 months of topical tea tree oil treatment. Topical ivermectin treatment on the facial skin provided a higher ocular Demodex eradication rate in FDO patients (76% vs 16%, P < .001).

CONCLUSION

Concurrence of ocular and facial demodicosis is common, especially in cases of severe ocular demodicosis. Although ocular treatment alone is effective for patients with ocular demodicosis only, cotreatment with topical ivermectin on the facial skin enhances ocular Demodex eradication in patients with comorbid facial Demodex overgrowth.

Long-term maintenance treatment of rosacea: experts' opinion

BACKGROUND

Rosacea is a chronic inflammatory dermatosis characterized by remissions and flares. Although the rosacea active treatment phase is well established, the long-term maintenance phase is still challenging.

OBJECTIVE

To discuss and make recommendations on how to treat patients during the long-term maintenance phase for the main rosacea phenotypes.

METHODS

A panel of six board-certified Brazilian dermatologists and one American dermatologist gathered to compose a consensus based upon an initial statement on how to treat rosacea during the long-term maintenance phase based on the methodology Nominal Group Technique. The experts discussed each factor based upon an initial statement on how to treat rosacea patients in the long-term maintenance phase. A sequence of comprehensive narrative reviews was performed; a questionnaire preparation about the definition of the maintenance phase and its management was presented; an interpersonal discussion and ranking of the ideas were conducted. Recommendations were made if the specialists had 75% agreement.

RESULTS

The maintenance treatment phase, which starts by achieving IGA 0 or 1 grades at the active phase, should be considered at least during the 9-month period after remission. The recommendations of all treatments target this period. Daily skincare regimen and sunscreen are crucial. Active treatment phase should be recommended if signs or symptoms reappear or worsen.

CONCLUSION

Maintenance phase success depends on patient's adherence to daily skin care, appropriate treatments, continued follow-up with dermatologist, and self-assessment to identify new signs and symptoms indicating disease relapse.

Mediation roles of neutrophils and high-density lipoprotein (HDL) on the relationship between HLA-DQB1 and rosacea

BACKGROUND

Though the previous genome-wide association studies found the association between HLA alleles and rosacea in the European populations, the data is lacking among the Asians. Moreover, neutrophils are important in the immune-related mechanism of rosacea, and dyslipidemia is closely related to rosacea. We aimed to explore the association between HLA genes and rosacea in Chinese rosacea patients, as well as the mediation effect of neutrophils, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) on the relationship between HLA genes and rosacea.

METHODS

A total of 249 rosacea and 150 controls were ranked by the international investigator global rosacea severity scores. HLA genes, neutrophils, HDL, and LDL were detected. And their mediation effects on the relationship between HLA and rosacea risk or severity were analysed.

RESULTS

HLA-DQB1*03:03 allele (OR = 41.89, 95% CI: 9.80 ∼ 179.09, p = 4.7*10^-7), HLA-DQB1*04:02 allele (OR = 0.16, 95% CI: 0.03 ∼ 0.81, p = 0.026) and HLA-DQB1*03:03/05:02 genotype (OR = 5.57, 95% CI: 1.13 ∼ 27.52, p = 0.0351) were significantly associated with rosacea. Moreover, HLA-DQB1*03:03 allele (b = 1.434, SE = 0.217, p = 2.0*10^-10), HLA-DQB1*05:01 allele (b = 0.894, SE = 0.33520, p = 0.008) and HLA-DQB1*03:03/06:01 genotype (b = 0.998, SE = 0.472, p = 0.040) were positively associated with rosacea severity. Furthermore, we found both neutrophils and HDL, instead of LDL, have mediation effects on the relationship between HLA-DQB1*03:03 and risk or severity of rosacea.

CONCLUSIONS

We discovered novel susceptible HLA alleles for rosacea in the Chinese population, and disclosed the mediation effect of neutrophils and HDL on the relationship between HLA-DQB1 and rosacea, implying a possible correlation between rosacea and inflammatory or metabolic factors, providing hints for future studies in the mechanism of rosacea. Key messagesHLA-DQB1*03:03 allele, HLA-DQB1*04:02 allele and HLA-DQB1*03:03/05:02 genotype were significantly associated with rosacea.HLA-DQB1*03:03 allele, HLA-DQB1*05:01 allele and HLA-DQB1*03:03/06:01 genotype were positively associated with rosacea severity.Neutrophils and HDL have mediation effects on the relationship between HLA-DQB1*03:03 and risk or severity of rosacea.

Papulopustular Rosacea Treated With Ivermectin 1% Cream: Remission of the Demodex Mite Infestation Over Time and Evaluation of Clinical Relapses

INTRODUCTION

Topical ivermectin is an anti-inflammatory and anti-Demodex drug for papulopustular rosacea. Rosacea is a relapsing disease and the time between recurrences should be considered alongside efficacy.

OBJECTIVES

The aims of this study were to assess the time of first relapse and relapse rates of Demodex mite infestation and papulopustular rosacea.

METHODS

We conducted a prospective study of subjects affected by different degrees of papulopustular rosacea. Patients that achieved a complete response after treatment were monitored every 4 weeks and up to 32 additional weeks. For each patient, we evaluated recording the time to first relapse and relapse rate of Demodex mite infestation and rosacea.

RESULTS

The overall success rate on Demodex infestation was 87.5% only 12.5% relapse. Ivermectin leads to complete response in 70% of patients. Median time to relapse was 140 days, the mean time was 152 days. The global success rate was 54.76%.

CONCLUSIONS

Topical ivermectin keeps a remission of Demodex infestation and clinical remission for long time. We proposed a twice weekly ivermectin maintenance therapy to reduce recurrences.

The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review

Rosacea, a chronic condition usually recognized by its visible presentation, can be accompanied by invisible symptoms, such as burning and stinging. The aim of this review is to gather the most recent evidence on burning and stinging, in order to further emphasize the need to address these symptoms. Inflammatory pathways can explain both the signs and symptoms of rosacea, but available treatments are still evaluated primarily on their ability to treat visible signs. Recent evidence also highlights the adverse impact of symptoms, particularly burning and stinging, on quality of life. Despite an increasing understanding of symptoms and their impact, the management of burning and stinging as part of rosacea treatment has not been widely investigated. Clinicians often underestimate the impact of these symptoms and do not routinely include them as part of management. Available therapies for rosacea have the potential to treat beyond signs, and improve burning and stinging symptoms in parallel. Further investigation is needed to better understand these benefits and to optimize the management of rosacea.

Long-Term Inflammatory Rosacea Management with Subantibiotic Dose Oral Doxycycline 40 mg Modified-release Capsules Once Daily

BACKGROUND

An important goal of effective rosacea treatment is to maximize the duration of remission.

METHODS

This was a 2-part study. Part 1 was a multicenter, open-label, 12-week study in which adults with moderate or severe inflammatory lesions (papules and pustules) of rosacea received subantibiotic dose oral doxycycline 40mg modified release (SDD₄₀ ) and topical metronidazole gel 1%. Part 2 was a multicenter, randomized, double-blind, placebo-controlled, 40-week study in which successfully treated subjects received once-daily SDD₄₀ or placebo capsules. The primary objective was to assess relapse and efficacy during long-term use of SDD₄₀ versus placebo. Relapse was defined as a return to baseline Investigator Global Assessment (IGA) or lesion count, or any other necessary change in treatment.

RESULTS

Part 1 enrolled 235 subjects. Sixty-five subjects in the SDD₄₀ treatment group and 65 subjects in the placebo group met the definition of treatment success at week 12, and were included in the part 2 analysis. At the end of part 2, half as many subjects in the SDD₄₀ group had relapsed compared to the placebo group (13.8% [n = 9] vs. 27.7% [n = 18], P < .05). Significant differences in the median change in inflammatory lesion counts were also observed (P < .05). Adverse events (AEs) were generally mild-moderate in severity, and most were not treatment-related. Stinging/burning responded with more improvement in subjects treated with SDD₄₀ .

CONCLUSION

After 52 weeks of once-daily treatment, subantibiotic dose doxycycline significantly reduced the relapse rate and inflammatory lesion counts in subjects with moderate-to-severe inflammatory rosacea. This article is protected by copyright. All rights reserved.

Rosacea with persistent facial erythema and high Demodex density effectively treated with topical ivermectin alone or combined with oral carvedilol

Topical ivermectin is effective in treating papulopustular rosacea, but its effect on persistent facial erythema of rosacea with high Demodex densities has not been well documented. We retrospectively reviewed 39 rosacea patients with persistent facial erythema and high Demodex densities. Clinician's erythema assessment (CEA) and Demodex density were evaluated before and after topical ivermectin alone or combined with oral carvedilol. Three patients (all with papulopustular rosacea, in ivermectin group) dropped out due to early ivermectin-induced local flare of rosacea. In the remaining patients (ivermectin group n = 14; ivermectin-carvedilol group n = 22), the CEA grade and Demodex density were significantly reduced, both P < .01. There was no statistically significant difference between the two groups in CEA before and after treatment (P = .07 and P = .23, respectively), and in Demodex density (P = .82 and .10, respectively). Both regimens markedly improved the persistent facial erythema with response being excellent in 26 of 36 patients (72%), good in 2, fair in 4 and none in 4. There was a correlation between the reduction of CEA and Demodex density after treatment (rho = 0.50, P = .002). The results showed that topical ivermectin was effective in reducing persistent facial erythema of rosacea with Demodex overgrowth.

Content in YouTube Videos for Rosacea: Cross-sectional Study

BACKGROUND

Rosacea is an inflammatory skin disease that is chronic in nature. In addition to the physical symptoms, there are substantial quality of life issues that patients with rosacea experience, largely due to the visible nature in which rosacea manifests.

OBJECTIVE

The purpose of this study was to describe the content related to rosacea in highly viewed English- and Spanish-language videos on YouTube.

METHODS

We coded identifying information for each video and categories including characteristics of rosacea, clinical solutions, and alternative solutions. The 100 YouTube videos examined were viewed 18.5 million times between 2006 and 2020, and 57.3% (10,652,665/18,592,742) of these views were of consumer videos.

RESULTS

Videos posted by consumers more often promoted or were trying to sell a product or procedure (32/55, 58% of consumers vs 10/31, 32% of medical professionals and 4/14, 29% of television, internet, news, or entertainment sources; P=.03) and more frequently mentioned the use of makeup or other ways to cover up rosacea (30/55, 55% of consumers vs 6/31, 19% of medical professionals and 2/14, 14% of television, internet, news, or entertainment sources; P<.001). Videos sourced from medical professionals more often mentioned medication (17/31, 55%) than videos uploaded by consumers (14/55, 25%) or TV, internet, news, or entertainment sources (3/14, 21%) (P=.01).

CONCLUSIONS

Given that rosacea is experienced differently for each person, consumer advice that works for one individual may not work for another. There is a need for reliable videos on rosacea to emphasize this and clarify misconceptions.

Comparison of the efficacy of tea tree (Melaleuca alternifolia) oil with other current pharmacological management in human demodicosis: A Systematic Review

Various treatments are found to be moderately effective in managing Demodex-related diseases except tea tree oil (TTO) and terpinen-4-ol (T4O), which showed superior miticidal and anti-inflammatory effects in numerous clinical studies. Their possible effects include lowering mite counts, relieving Demodex-related symptoms, and modulating the immune system. This review summarizes the current clinical topical and oral treatments in human demodicosis, their possible mechanisms of action, side-effects and resistance in treating this condition. TTO (especially T4O) is found to be the most effective followed by metronidazole, ivermectin and permethrin in managing the disease. This is because TTO has anti-parasitic, anti-bacterial, anti-fungal, anti-inflammatory and wound-healing effects. Furthermore, nanoTTO can even release its contents into fungus and Pseudomonas biofilms. Combinations of different treatments are occasionally needed for refractory cases, especially for individuals with underlying genetic predisposal or are immuno-compromised. Although the current treatments show efficacy in controlling the Demodex mite population and the related symptoms, further research needs to be focused on the efficacy and drug delivery technology in order to develop alternative treatments with better side-effects profiles, less toxicity, lower risk of resistance and are more cost-effective.

Update on the pathogenesis and management of ocular rosacea: an interdisciplinary review

PURPOSE

Rosacea is one of the most common conditions affecting the ocular surface. The purpose of this review is to provide an update on the pathogenesis and treatment of rosacea based on the dermatology and ophthalmology literatures.

METHODS

Literature searches were conducted for rosacea and ocular rosacea. Preference was given to systematic reviews, meta-analysis, case-controlled studies, and documented case reports while excluding poorly documented case studies and commentaries. The data were examined and independently analyzed by more than two of the authors.

RESULTS

Rosacea is a complex inflammatory condition involving the pilosebaceous unit. Its underlying mechanism involves an interplay of the microbiome, innate immunity, adaptive immunity, environmental triggers, and neurovascular sensitivity. The latest classification of rosacea includes three dermatologic subgroups and a fourth subgroup, ocular rosacea. Ocular rosacea clinically displays many features that are analogous to the cutaneous disease, such as lid margin telangiectasia and phlyctenulosis. The role of environmental triggers in the exacerbation of ocular rosacea appears to be understudied. While lid hygiene and systemic treatment with tetracycline drugs remain the mainstay of treatment for ocular rosacea, newer dermatologic targets and therapies may have potential application for the eye disease.

CONCLUSIONS

Ocular rosacea appears to embody many of the manifestation of the dermatologic disease. Hence, the basic pathophysiologic mechanisms of the ocular and cutaneous disease are likely to be shared. Better understanding of the ocular surface microbiome and the immunologic mechanisms, may lead to novel approaches in the management of ocular rosacea.

Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee

In 2017, a National Rosacea Society Expert Committee developed and published an updated classification of rosacea to reflect current insights into rosacea pathogenesis, pathophysiology, and management. These developments suggest that a multivariate disease process underlies the various clinical manifestations of the disorder. The new system is consequently based on phenotypes that link to this process, providing clear parameters for research and diagnosis as well as encouraging clinicians to assess and treat the disorder as it may occur in each individual. Meanwhile, a range of therapies has become available for rosacea, and their roles have been increasingly defined in clinical practice as the disorder has become more widely recognized. This update is intended to provide a comprehensive summary of management options, including expert evaluations, to serve as a guide for tailoring treatment and care on an individual basis to achieve optimal patient outcomes.

A randomized phase 3b/4 study to evaluate concomitant use of topical ivermectin 1% cream and doxycycline 40-mg modified-release capsules, versus topical ivermectin 1% cream and placebo in the treatment of severe rosacea

BACKGROUND

Randomized controlled studies of combination therapies in rosacea are limited.

OBJECTIVE

Evaluate the efficacy and safety of combining ivermectin 1% cream (IVM) and doxycycline 40-mg modified-release capsules (ie, 30-mg immediate-release and 10-mg delayed-release beads) (DMR) versus IVM and placebo for treatment of severe rosacea.

METHODS

This 12-week, multicenter, randomized, investigator-blinded, parallel-group comparative study randomized adult subjects with severe rosacea (Investigator's Global Assessment [IGA] score, 4) to receive either IVM and DMR (combination arm) or IVM and placebo (monotherapy).

RESULTS

A total of 273 subjects participated. IVM and DMR displayed superior efficacy in reduction of inflammatory lesions (-80.3% vs -73.6% for monotherapy [P = .032]) and IGA score (P = .032). Combination therapy had a faster onset of action as of week 4; it significantly increased the number of subjects achieving an IGA score of 0 (11.9% vs 5.1% [P = .043]) and 100% lesion reduction (17.8% vs 7.2% [P = .006]) at week 12. Both treatments reduced the Clinician's Erythema Assessment score, stinging/burning, flushing episodes, Dermatology Life Quality Index score, and ocular signs/symptoms and were well tolerated.

LIMITATIONS

The duration of the study prevented evaluation of potential recurrences or further improvements.

CONCLUSION

Combining IVM and DMR can produce faster responses, improve response rates, and increase patient satisfaction in cases of severe rosacea.

New indications for topical ivermectin 1% cream: a case series study

Introduction

Topical ivermectin is an effective treatment for inflammatory papulopustular rosacea in adults. Positive therapeutic effects of ivermectin due to its potential anti-inflammatory properties could be achieved in the other facial dermatoses.

Aim

To assess the efficacy of topical ivermectin 1% cream therapy in mild and moderate perioral dermatitis (PD), seborrheic dermatitis (SD) and acne vulgaris (AV).

Material and methods

The study comprising 20 patients diagnosed with PD (8), SD (8) and AV (4) was conducted between November 2016 and July 2017. Two scales were applied to establish efficacy of the treatment: Investigator Global Assessment score (IGA) and Patient Global Assessment of Treatment (PGA).

Results

All patients responded to the treatment with topical ivermectin very well with a gradual reduction in inflammatory skin lesions. Complete or almost complete clearance (IGA score 0-1) was achieved in 20 cases. Four patients with PD achieved IGA 0-1 after 4 weeks of treatment, 1 patient after 5 weeks, 2 patients after 6 weeks and 1 patient after 12 weeks. In the total group of 8 patients with SD, 4 presented IGA 0 after 4 weeks of therapy, while 4 patients demonstrated IGA 1 after 6 weeks. Patients with AV required 8 and 10 weeks to obtain IGA 1. Nineteen patients of the studied group reported "very good" or "excellent" response to the therapy, only one patient with AV assessed therapy with topical ivermectin as "good". The adverse events were transient and manifested as mild-moderate desquamation, stinging and burning in 2 patients with PD.

Conclusions

Topical ivermectin was well tolerated and beneficial for treatment of mild and moderate PD, SD and AV.

Clinical and erythema-directed imaging evaluation of papulo-pustular rosacea with topical ivermectin: a 32 weeks duration study

Background: Ivermectin (IVM) 1% cream represents an emerging therapy for papulo-pustular rosacea (PPR) and erythema-directed photography is a useful tool for evaluation of patient's erythema. Objective: The aim of our study was to assess the efficacy of IVM in PPR in achieving clear status at 8 weeks or at 20 weeks followed by respectively 24 and 12 weeks follow-up, using clinical/instrumental evaluation. Methods: Twenty patients with PPR were instructed to apply IVM for 8 weeks. At week 8, in case of complete response the therapy was stopped and a follow-up period up to 24 weeks was carried out, whereas in case of improvement the treatment was extended for additional 12 weeks followed by a 12 weeks follow-up. Instrumental evaluation was performed by erythema-directed digital photography (VISIA-CR^TM- RBX^TM). Results: At week 8, complete response was observed in 31.6% of cases along with a significant decrease of erythema degree. During treatment extension, additional improvement in terms of complete response, respectively at 12 (42%), 16 (47%) and 20 (58%) weeks, and reduction of erythema degree was observed. Conclusions: IVM is a valuable therapeutic option in mild/moderate PPR. Erythema-directed digital photography enhances erythema changes visualization compared to clinical observation alone.

Clinical effectiveness of novel rosacea therapies

Rosacea is a common inflammatory skin disease that is difficult to manage because of the unknown etiology and due to its variable manifestations. These facts and the few new available treatment options make it difficult to select a really effective treatment. This review aims to assess the efficacy and safety of novel treatment options for rosacea. The topical alpha adrenergic agonist oxymetazoline reduces rosacea-related erythema. Topical ivermectin improves lesion count, inflammation, and maintenance of remission of rosacea compared to topical metronidazole. Procedural therapies including pulsed dye laser, radiofrequency, and dual frequency ultrasound are promising as both monotherapies or in combination. Although there are several effective treatment modalities for rosacea management, treatments options should be tailored for the specific clinical scenario.

Topical Ivermectin in the Treatment of Papulopustular Rosacea: A Systematic Review of Evidence and Clinical Guideline Recommendations

Introduction

Rosacea is a chronic inflammatory skin disease with different phenotypes. There is accumulating evidence that the commensal Demodex mite is linked to papulopustular rosacea. Established treatment options, including topical metronidazole, azelaic acid, and tetracyclines, are thought to work through their anti-inflammatory effects. However, none of these therapies have been shown to be curative and are associated with frequent relapses. Therefore, new and improved treatment options are needed. Topical ivermectin 1.0% cream is a new option having both anti-inflammatory and acaricidal activity against Demodex mites which might pave the way to a more etiologic approach. Its use has now been widely adopted by clinical guidelines. The objective was to review the evidence and clinical guideline recommendations concerning ivermectin 1.0% cream in the treatment of papulopustular rosacea.

Methods

A systematic review of both medical literature and clinical guideline recommendations was conducted. Numbers needed to treat (NNT) were calculated for relevant dichotomous outcomes (e.g., relapse rate and achieving full lesion clearance) to compare ivermectin with other established treatment options for rosacea.

Results

The search identified three randomized trials, three extension studies, and two meta-analyses. Ivermectin has only been tested in moderate-to-severe papulopustular rosacea. Ivermectin is an effective treatment option for papulopustular rosacea and seems to be more effective than metronidazole (NNT = 10.5) at 12 weeks of treatment. Although ivermectin was numerically more effective than metronidazole at week 36 in preventing relapse (NNT = 17.5), relapse after discontinuation of treatment in both groups was common with 62.7% and 68.4% of patients relapsing. Based on limited generalizability of available evidence, clinical guidelines have yielded different treatment algorithms and, in some areas, conflicting recommendations.

Conclusion

Topical ivermectin is an effective option in the treatment of papulopustular rosacea. Although ivermectin seems to be more effective than topical metronidazole, with both treatment options about two-thirds of patient relapsed within 36 weeks after discontinuation of treatment. More research is needed to establish the clinical benefit of ivermectin’s acaricidal action in preventing relapse compared to other non-etiologic treatment approaches.

Ivermectin 1% (CD5024) for the treatment of rosacea

INTRODUCTION

Rosacea is a chronic and recurrent disease with a variety of cutaneous manifestations. The disorder is a centrofacial inflammatory dermatosis with significant financial, physical and psychological impacts. There are a number of topical, oral and systemic treatments available. Yet, treatment for rosacea remains difficult. The multifactorial nature of the disease combined with an incomplete understanding of the pathophysiology is challenging for providers and patients. Areas covered: This article provides an in-depth review of rosacea treatment and emerging use of ivermectin 1% cream for papulopustular rosacea based on multiple clinical trials. The PubMed database was searched using the combination of keywords "ivermectin, rosacea, and papulopustular." Expert opinion: Topical ivermectin 1% cream has emerged as a novel agent for treatment of papulopustular rosacea. The drug targets the Demodex mite which is increased in patients with rosacea. Though ivermectin 1% is a clinically efficacious medication, poor adherence continues to remain an issue due to topical application. Ultimately, the agent has the potential to be an effective drug when used as a single or combination agent. With the move to limit chronic antibiotic use, topical agents such as ivermectin 1% will continue to thrive as a specialized niche in the rosacea market.

Rosacea Management: Update on general measures and topical treatment options

Although there is presently no cure for rosacea, there are several recommended treatment options available to control many of the symptoms and to prevent them from getting worse. In addition to self-help measures like avoidance of trigger factors and proper skin care, rosacea management should include topical medications as one of the first-line choices for patients with erythematous and mild to severe papulopustular rosacea. Since mixed forms of characteristic rosacea symptoms are more common, medical treatment must be symptom-tailored for each individual case and will often involve a combination therapy. Approved topical agents for the major symptoms of rosacea encompass brimonidine for erythema and ivermectin, metronidazole or azelaic acid for inflammatory lesions, all of which have shown their efficacy in numerous valid, well-controlled trials. In addition, there are several other, not approved topical treatments which are possible options that require further validation in larger well-controlled studies.

Topical Treatment of Rosacea with Ivermectin Inhibits Gene Expression of Cathelicidin Innate Immune Mediators, LL-37 and KLK5, in Reconstructed and Ex Vivo Skin Models

Introduction

Numerous intrinsic and extrinsic factors have been associated with the pathophysiology of rosacea, including dysregulation of innate immunity. A high level of cathelicidin antimicrobial peptides (e.g., LL-37) has been shown in the facial skin of patients with rosacea. Excessive production of both LL-37 and KLK5, the serine protease responsible for its cleavage, has been suggested to play a role in the pathophysiology of rosacea. Ivermectin 10 mg/g cream, indicated for the treatment of inflammatory lesions of rosacea, is reported to have dual anti-parasitic and anti-inflammatory properties. However, the exact mechanism of action of ivermectin cream in the treatment of rosacea is unknown.

Methods

This study aimed to evaluate the effect of ivermectin on the expression of KLK5 and the subsequent effect on the maturation process of cathelicidins. Experimental studies were performed either on normal human epidermal keratinocytes (NHEK), reconstructed human epidermis (RHE) or on human skin ex vivo stimulated with calcitriol (1α,25-dihydroxyvitamin D3), which is known to induce KLK5 and LL-37 expression.

Results

The results show that ivermectin is able to inhibit KLK5 and CAMP gene expression and protein secretion in NHEK cells stimulated with calcitriol. Those results were confirmed in 3D models of the skin (RHE and skin ex vivo). The anti-inflammatory effects of ivermectin were associated with an inhibition of IL-8, IL-6 and MCP-1 (CCL2) secretion from NHEK cells.

Conclusions

These results suggest that ivermectin can prevent the inflammatory effects of rosacea triggered by abnormal LL-37 processing, through the inhibition of KLK5 gene expression in the epidermis.

Funding: Nestlé Skin Health R&D.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0176-3) contains supplementary material, which is available to authorized users.

Rosazea-Management: Update über allgemeine Maßnahmen und topische Therapieoptionen

Obwohl bislang für die Rosazea keine kurative Therapie besteht, können verschiedene Optionen zur Behandlung der Symptome und zur Vorbeugung von Exazerbationen empfohlen werden. Neben Selbsthilfemaßnahme wie der Vermeidung von Triggerfaktoren und einer geeigneten Hautpflege sollte das Rosazea-Management bei Patienten mit erythematöser und leichter bis schwerer papulopustulöser Rosazea die Anwendung topischer Präparate als First-Line-Therapie umfassen. Da Überlappungen der charakteristischen Rosazea-Symptome im klinischen Alltag die Regel sind, sollte die medikamentöse Therapie auf die individuellen Symptome zugeschnitten werden; auch eine Kombinationstherapie kann erforderlich sein. Zu den für die Behandlung der Hauptsymptome der Rosazea zugelassenen Wirkstoffen gehören Brimonidin gegen das Erythem sowie Ivermectin, Metronidazol oder Azelainsäure gegen entzündliche Läsionen. Ihre Wirksamkeit wurde in zahlreichen validen, gut kontrollierten Studien belegt. Darüber hinaus existieren verschiedene nicht zugelassene topische Behandlungsmöglichkeiten, deren Wirksamkeit und Sicherheit noch in größeren, kontrollierten Studien zu untersuchen ist.

Topical Ivermectin 10 mg/g and Oral Doxycycline 40 mg Modified-Release: Current Evidence on the Complementary Use of Anti-Inflammatory Rosacea Treatments

Rosacea is a common, chronic inflammatory skin disease that can present with a variety of signs and symptoms. The potentially simultaneous occurrence of different signs and symptoms is due to different underlying inflammatory pathways, emphasizing the need for complementary treatment approaches. Topical ivermectin cream (10 mg/g) and systemic, oral anti-inflammatory doxycycline (40 mg modified-release) are both approved for the treatment of papulopustular rosacea (PPR). Whether or not a combined therapeutic approach may be more beneficial than monotherapy for patients with PPR remains to be tested. Here, we summarize underlying inflammatory pathways implicated in rosacea and clarify the impact of these two agents on selective pathways during inflammation, due to specific characteristics of their individual mechanisms of action (MoA). Based on the complementary MoA of doxycycline modified-release and ivermectin, a scientific rationale for a combined therapy targeting inflammatory lesions in rosacea is given. We propose that topical ivermectin cream is a promising new candidate as first-line treatment to target the inflammatory lesions of rosacea, which can be used in combination with systemic doxycycline modified-release to provide an optimal treatment approach considering all inflammatory pathways involved in PPR.

Funding Galderma.

Superior Efficacy with Ivermectin 1% Cream Compared to Metronidazole 0.75% Cream Contributes to a Better Quality of Life in Patients with Severe Papulopustular Rosacea: A Subanalysis of the Randomized, Investigator-Blinded ATTRACT Study

Introduction

Ivermectin 1% cream (IVM 1%) is indicated for the treatment of inflammatory lesions of rosacea. The objective of this subanalysis was to compare IVM 1% vs. metronidazole 0.75% cream (MTZ 0.75%) in the treatment of severe inflammatory lesions of rosacea.

Methods

A subanalysis of the investigator-assessed severe subjects from a Phase 3, investigator-blinded, randomized study comparing IVM 1% once daily (QD) with MTZ 0.75% twice daily (BID) over 16 weeks followed by a 36-week extension period was performed. Efficacy assessments were Dermatology Life Quality Index (DLQI) and EuroQol-5 Dimension (EQ-5D) questionnaires, investigator’s global assessment (IGA), subject assessment of rosacea improvement, and inflammatory lesion counts. Adverse events (AEs) were monitored throughout the study.

Results

A total of 161 subjects (16.7% of overall study population; 80 IVM 1% and 81 MTZ 0.75%) had an IGA score of 4 at baseline representing severe papulopustular rosacea. Significantly more IVM 1% subjects had a minimal clinically important difference (MCID, defined as a decrease from baseline of ≥4 points) in DLQI score than MTZ 0.75% subjects at week 16 (65.4% vs. 39.2%; P = 0.001) and week 52 (68.8% vs. 40.4%; P = 0.003). At week 16, the mean EQ-5D score for the IVM 1% subjects was higher (better quality of life) than for MTZ 0.75% subjects (0.941 vs. 0.896). Significantly more IVM 1% subjects were IGA “clear” or “almost clear” at week 16 compared to MTZ 0.75% (82.5% vs. 63.0%; P = 0.005). Incidence of AEs was comparable between groups.

Conclusion

Better efficacy with IVM 1% cream (QD) compared to MTZ 0.75% cream (BID) contributes to an improved quality of life with significantly more patients achieving an MCID in DLQI score at week 16 and higher mean EQ-5D score. IVM 1% cream is thus a better alternative than MTZ 0.75% cream for severe papulopustular rosacea patients.

Trial registration

EUDRACT number: 2011-004791-11.

Funding

Galderma R&D.

Canadian Clinical Practice Guidelines for Rosacea

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.