Letter to the Editor
The Possible Combined Action of Different Trigger Agents in Rosacea
Posible acción combinada de los diferentes agentes desencadenantes en la rosácea
G. Ciccarese
, A. Parodi, A. Rebora, F. Drago
Corresponding author
DISSAL, Department of Dermatology, IRCCS San Martino IST, Genoa, Italy
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Ciccarese, A. Parodi, A. Rebora, F. Drago" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Ciccarese" "email" => array:1 [ 0 => "giuliaciccarese@libero.it" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Parodi" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Rebora" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Drago" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "DISSAL, Department of Dermatology, IRCCS San Martino IST, Genoa, Italy" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Posible acción combinada de los diferentes agentes desencadenantes en la rosácea" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the paper entitled “Oral ivermectin to treat papulopustular rosacea in a immunocompetent patient.” by Hernández-Martín<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> that prompted us to make some observations and to report our experience. The Author described a patient with papulopustular rosacea that has been considered immunocompetent but it was not specified whether laboratory examinations have been performed to investigate the immune status of the patient (as complete blood count, human immunodeficiency virus test). Moreover, the Author stated that the past medical history of the patient included topical immunomodulators, but without defining the specific drug.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Due to the only partial and/or transient rosacea improvement after several topical and systemic treatments, Hernández-Martín recommended a single 250<span class="elsevierStyleHsp" style=""></span>μg/kg dose of oral ivermectin leading to complete remission of the rosacea lesions.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> However, the Author did not demonstrate by skin scraping or standardized skin surface biopsy neither the presence nor an excessive number of <span class="elsevierStyleItalic">Demodex folliculorum</span> (DF) mites in the pilosebaceous units to justify the oral antiparasitic therapy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> It is known that patients with papulopustular rosacea may have a higher density of DF mites on their faces than controls. However, in the absence of any qualitative and quantitative information on DF, it could be hypothesized that ivermectin may have operated through immunomodulating mechanism rather than through a true acaricidal action. The immunomodulatory effect of ivermectin has been reported long ago in mice,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> and very recently confirmed by Schaller et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> who found, in 20 Caucasian patients with moderate to severe rosacea treated with topical ivermectin for ≥12 weeks, that the gene expression levels LL-37, HBD3 and TNF-α was significantly reduced after and during treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Regrettably, Hernández-Martín<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> neglected that also a DF-related bacterium, <span class="elsevierStyleItalic">Bacillus oleronius</span>, may express antigens that stimulates an inflammatory immune response<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> and that other different triggers may contribute in the pathogenesis of rosacea, more specifically gastrointestinal disorders like <span class="elsevierStyleItalic">Helicobacter pylori</span> (HP) infection and small intestine bacterial overgrowth (SIBO).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> In two previous studies, we reported our experience on 60 rosacea patients that were followed up for 3 years, in which we have investigated the prevalence of three possible trigger agents: DF (through SSSB on rosacea lesions [test was considered positive for density >5 mites/cm<span class="elsevierStyleSup">2</span>]), HP infections (through urea breath test) and SIBO (through lactulose breath test).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> Recently, we completed the study with a 5-year follow up. Shortly after enrolment, DF was the agent most frequently found (75%) followed by SIBO (67%) and HP infection (13%). HP infection prevailed in patients with erythrosis, SIBO in patients with papulo-pustular rosacea whereas DF was not associated with specific rosacea types. DF was found as the only trigger in 16 patients whereas 29 patients were positive for more than one trigger agent (23 patients had DF<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SIBO, 4 patients DF<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>HP and 2 patients DF<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>HP<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>SIBO). Patients that proved positive for more than one triggering agent were treated in the following order: DF acaricidal treatment (crotamiton cream once/daily associated with azelaic acid gel once/daily for 3 weeks); antibiotic therapy for SIBO (rifaximin 1200<span class="elsevierStyleHsp" style=""></span>mg/daily for 10 days), antibiotic therapy for HP (rabeprazole 10<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>amoxicillin 1000<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>metronidazole 250<span class="elsevierStyleHsp" style=""></span>mg twice/daily for 2 weeks). The topical therapy for DF was effective in reducing its population and in improving the cutaneous lesions but only 26% of the patients remitted. The 23 patients positive for both DF and SIBO underwent acaricidal treatment but the majority of them (74%) remitted only after rifaximin treatment. Among the 40 exclusively SIBO positive patients treated with rifaximin, 31 remitted, 8 improved and 1 did not. Overall, most of our patients (61%), treated in accordance with the specific causal agent, cleared and had no relapsed in the following 5 years, confirming our previous studies.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> In conclusion, we emphasize that the eradication of the underlying trigger agents in rosacea may be crucial in improving the disease and in maintaining the clinical remission over time. However, the search for the presence of SIBO should be done in rosacea patients since its treatment seems to be relevant in improving the disease and maintaining the clinical remission, also when more than one microorganisms are still present.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento con ivermectina oral en un paciente inmunocompetente con rosacea pápulo-pustulosa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Á. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 10 | 13 |
| 2024 October | 71 | 49 | 120 |
| 2024 September | 77 | 50 | 127 |
| 2024 August | 82 | 63 | 145 |
| 2024 July | 61 | 47 | 108 |
| 2024 June | 77 | 35 | 112 |
| 2024 May | 48 | 44 | 92 |
| 2024 April | 79 | 23 | 102 |
| 2024 March | 70 | 43 | 113 |
| 2024 February | 63 | 35 | 98 |
| 2024 January | 54 | 37 | 91 |
| 2023 December | 55 | 18 | 73 |
| 2023 November | 66 | 25 | 91 |
| 2023 October | 76 | 28 | 104 |
| 2023 September | 38 | 39 | 77 |
| 2023 August | 46 | 9 | 55 |
| 2023 July | 50 | 32 | 82 |
| 2023 June | 48 | 22 | 70 |
| 2023 May | 57 | 27 | 84 |
| 2023 April | 57 | 24 | 81 |
| 2023 March | 56 | 23 | 79 |
| 2023 February | 42 | 27 | 69 |
| 2023 January | 49 | 30 | 79 |
| 2022 December | 46 | 33 | 79 |
| 2022 November | 24 | 29 | 53 |
| 2022 October | 29 | 20 | 49 |
| 2022 September | 21 | 34 | 55 |
| 2022 August | 23 | 38 | 61 |
| 2022 July | 26 | 34 | 60 |
| 2022 June | 26 | 16 | 42 |
| 2022 May | 91 | 35 | 126 |
| 2022 April | 79 | 30 | 109 |
| 2022 March | 113 | 38 | 151 |
| 2022 February | 117 | 15 | 132 |
| 2022 January | 129 | 34 | 163 |
| 2021 December | 107 | 37 | 144 |
| 2021 November | 143 | 43 | 186 |
| 2021 October | 83 | 38 | 121 |
| 2021 September | 102 | 40 | 142 |
| 2021 August | 112 | 32 | 144 |
| 2021 July | 72 | 31 | 103 |
| 2021 June | 79 | 33 | 112 |
| 2021 May | 55 | 43 | 98 |
| 2021 April | 147 | 63 | 210 |
| 2021 March | 94 | 31 | 125 |
| 2021 February | 88 | 30 | 118 |
| 2021 January | 50 | 22 | 72 |
| 2020 December | 40 | 13 | 53 |
| 2020 November | 30 | 28 | 58 |
| 2020 October | 19 | 10 | 29 |
| 2020 September | 28 | 18 | 46 |
| 2020 August | 31 | 17 | 48 |
| 2020 July | 23 | 19 | 42 |
| 2020 June | 23 | 32 | 55 |
| 2020 May | 49 | 11 | 60 |
| 2020 April | 43 | 16 | 59 |
| 2020 March | 27 | 17 | 44 |
| 2020 February | 9 | 0 | 9 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 8 | 0 | 8 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 1 | 7 |
| 2019 April | 4 | 0 | 4 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 5 | 0 | 5 |
| 2018 June | 0 | 1 | 1 |
| 2018 February | 82 | 22 | 104 |
| 2018 January | 84 | 35 | 119 |
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