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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I thank Ciccarese et al&#46; for their comments and welcome their thoughts about my article on the successful therapy of papulopustular rosacea in an immunocompetent patient&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Rosacea is a chronic inflammatory condition diagnosed clinically&#46; In the absence of clinical findings suggestive of any underlying comorbidity&#44; analytical assessment or histological study is largely unnecessary&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Skin surface biopsy technique and skin scrapings may help visualize mites from follicular canals&#44; but the relevance of this finding to the management of the condition is unclear and it is not routine&#46; Nevertheless&#44; we agree with Ciccarese et al&#46; that ivermectin might play a role not only as an acaricide drug but also as an immunodulatory agent in controlling rosacea flares&#46; In fact&#44; the mechanism of action of topical immunomodulators such as pimecrolimus and tacrolimus &#40;that proved non-efficacious in our patient&#41; is centered on diminution of inflammation rather than antimicrobial action&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several microorganisms have been hypothesized to play a role in the pathogenesis of rosacea&#44; but their exact role is unclear&#46; Ciccarese and colleagues have published two studies on the role of <span class="elsevierStyleItalic">Demodex folliculorum</span>&#44; <span class="elsevierStyleItalic">Helicobacter pylori</span> and small intestine bacterial overgrowth &#40;SIBO&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> in rosacea pathogenesis&#44; concluding that the eradication of such underlying triggers might be crucial in improving the disease and maintaining the long-term clinical remission&#46; However&#44; a recent systematic review and meta-analysis found weak non-statistical significance associations between rosacea and <span class="elsevierStyleItalic">H&#46; pylori</span> infection as well as the effect of <span class="elsevierStyleItalic">H&#46; pylori</span> eradication on rosacea symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Additionally&#44; the pathogenic role of SIBO in rosacea patients has been challenged&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">From a practical point of view&#44; evidence-based therapy of rosacea is still limited and therapeutic decisions are often based on personal experiences and patient preference&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Although there is still a lack of randomized controlled trials&#44; oral ivermectin has already proved useful and well tolerated in immunocompetent children with rosacea&#44; providing long-term remission after monotherapy with one single dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> I am aware that oral ivermectin has only been assessed for short-term safety&#44; but these preliminary studies provide promising data about oral ivermectin as an innovative and inexpensive therapeutic approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ciccarese&#39;s comments about a possible combined action of different trigger agents in rosacea are interesting and may contribute to elucidating the underlying pathogenesis of the condition&#46; They do not however allow any definite conclusions to be drawn about the relevance of SIBO in rosacea management&#46;</p></span>"
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Letter to the Editor
Reply To: The Possible Combined Action of Different Trigger Agents in Rosacea
Réplica a “Posible acción combinada de los diferentes agentes desencadenantes en la rosácea”
Á. Hernández-Martín
Servicio de Dermatología, Hospital Beata Maria Ana de Jesús y Hospital Infantil del Niño Jesús, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I thank Ciccarese et al&#46; for their comments and welcome their thoughts about my article on the successful therapy of papulopustular rosacea in an immunocompetent patient&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Rosacea is a chronic inflammatory condition diagnosed clinically&#46; In the absence of clinical findings suggestive of any underlying comorbidity&#44; analytical assessment or histological study is largely unnecessary&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Skin surface biopsy technique and skin scrapings may help visualize mites from follicular canals&#44; but the relevance of this finding to the management of the condition is unclear and it is not routine&#46; Nevertheless&#44; we agree with Ciccarese et al&#46; that ivermectin might play a role not only as an acaricide drug but also as an immunodulatory agent in controlling rosacea flares&#46; In fact&#44; the mechanism of action of topical immunomodulators such as pimecrolimus and tacrolimus &#40;that proved non-efficacious in our patient&#41; is centered on diminution of inflammation rather than antimicrobial action&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several microorganisms have been hypothesized to play a role in the pathogenesis of rosacea&#44; but their exact role is unclear&#46; Ciccarese and colleagues have published two studies on the role of <span class="elsevierStyleItalic">Demodex folliculorum</span>&#44; <span class="elsevierStyleItalic">Helicobacter pylori</span> and small intestine bacterial overgrowth &#40;SIBO&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> in rosacea pathogenesis&#44; concluding that the eradication of such underlying triggers might be crucial in improving the disease and maintaining the long-term clinical remission&#46; However&#44; a recent systematic review and meta-analysis found weak non-statistical significance associations between rosacea and <span class="elsevierStyleItalic">H&#46; pylori</span> infection as well as the effect of <span class="elsevierStyleItalic">H&#46; pylori</span> eradication on rosacea symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Additionally&#44; the pathogenic role of SIBO in rosacea patients has been challenged&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">From a practical point of view&#44; evidence-based therapy of rosacea is still limited and therapeutic decisions are often based on personal experiences and patient preference&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Although there is still a lack of randomized controlled trials&#44; oral ivermectin has already proved useful and well tolerated in immunocompetent children with rosacea&#44; providing long-term remission after monotherapy with one single dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> I am aware that oral ivermectin has only been assessed for short-term safety&#44; but these preliminary studies provide promising data about oral ivermectin as an innovative and inexpensive therapeutic approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ciccarese&#39;s comments about a possible combined action of different trigger agents in rosacea are interesting and may contribute to elucidating the underlying pathogenesis of the condition&#46; They do not however allow any definite conclusions to be drawn about the relevance of SIBO in rosacea management&#46;</p></span>"
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