Case and Research Letter
Oral Ivermectin to Treat Papulopustular Rosacea in an Immunocompetent Patient
Tratamiento con ivermectina oral en un paciente inmunocompetente con rosácea pápulo-pustulosa
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Hernández-Martín" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Á." "apellidos" => "Hernández-Martín" "email" => array:1 [ 0 => "ahernandez_hnj@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Beata María Ana de Jesús, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Infantil del Niño Jesús, Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento con ivermectina oral en un paciente inmunocompetente con rosácea pápulo-pustulosa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 656 "Ancho" => 1500 "Tamanyo" => 187285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Clinical appearance of the lesions before treatment with a single dose of oral ivermectin (250<span class="elsevierStyleHsp" style=""></span>μg/kg). B, Clinical appearance 6 months later.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Papulopustular rosacea is a chronic inflammatory disease characterized by erythematous, papular, and papulopustular lesions on the face with variable ocular involvement. Various antimicrobial treatments such as erythromycin, metronidazole, permethrin, and oral tetracyclines have proven effective, as well as topical immunomodulators and, in severe cases, oral isotretinoin.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> However, despite the varied therapeutic arsenal available, rosacea can be difficult to treat in some patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 44-year-old man who had had facial rosacea since age 30 years and no other past history of interest. Over the course of his illness, the patient had received treatment with retinoids and topical immunomodulators, oral cloxacillin, and repeated cycles of doxycycline, with only partial and/or transient improvement. Physical examination revealed diffuse erythema and a moderate number of papuloerythematous lesions on both cheeks and the dorsum of the nose (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). After obtaining informed consent from the patient, we recommended treatment with a single 250<span class="elsevierStyleHsp" style=""></span>μg/kg dose of oral ivermectin and specifically instructed the patient not to apply any topical treatment. After 2 weeks, significant improvement was observed and the disease has remained in complete remission for 6 months after treatment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of rosacea is not fully understood. It is thought to be caused by a combination of factors, including augmented immune response, neuroimmune dysregulation, and vasoregulatory alterations.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> There is growing evidence that <span class="elsevierStyleItalic">Demodex</span> mites play a role in the etiology and pathogenesis of rosacea. The density of <span class="elsevierStyleItalic">Demodex</span> organisms has been found to be greater in areas affected by rosacea than in healthy skin, and these mites have been found in a significant proportion of patients with rosacea.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Good response to acaricidal agents has been reported.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In addition, <span class="elsevierStyleItalic">Demodex</span> mites have started to gain recognition as one of the numerous factors that trigger the expression of Toll-like receptors 2 (TLR-2), giving rise to the exacerbated immune response observed in patients with papulopustular rosacea.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Ivermectin is an antiparasitic agent that has been widely used since 1988 for oral treatment of filariasis and other parasitic infections. Ivermectin not only has an antiparasitic effect but also has an immunomodulatory and anti-inflammatory effect by inhibiting the lipopolysaccharide-induced production of cytokines.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The use of topical ivermectin for the treatment of rosacea was approved by the US Food and Drug Administration in 2014 and by the European Medicines Agency in 2015. Oral ivermectin has also been successfully used, without formal indication, in the treatment of demodicosis, in both immunosuppressed<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> and immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Oral ivermectin has also been used, with satisfactory results, in 2 healthy patients with papulopustular rosacea; in 1 case, the patient received 3<span class="elsevierStyleHsp" style=""></span>mg/d for 8 days in association with 5% topical permethrin 3 times a week,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> and in the other case, a child with severe oculocutaneous rosacea received a single dose of 250<span class="elsevierStyleHsp" style=""></span>μg/kg.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Rosacea can be treated but not cured. Like all chronic diseases, rosacea requires safe, effective treatment that achieves long periods of remission. In patients who have received oral ivermectin for the treatment of systemic infections, adverse effects have been very rare (<<span class="elsevierStyleHsp" style=""></span>1%) over the past few decades and appear to be related to parasite load.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Similarly, no serious adverse effects have been reported when a single dose (200<span class="elsevierStyleHsp" style=""></span>μg/kg) has been given for the treatment of scabies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> However, only short-term safety studies have been carried out and it is not known whether repeated treatment is safe. Our patient had no adverse effects and prolonged remission was achieved with a single dose, but prospective studies with large groups of patients are needed in order to confirm our results.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández-Martín Á. Tratamiento con ivermectina oral en un paciente inmunocompetente con rosácea pápulo-pustulosa. Actas Dermosifiliogr. 2017;108:685–686.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 656 "Ancho" => 1500 "Tamanyo" => 187285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Clinical appearance of the lesions before treatment with a single dose of oral ivermectin (250<span class="elsevierStyleHsp" style=""></span>μg/kg). B, Clinical appearance 6 months later.</p>" ] ] ] "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" => "Interventions for rosacea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E.J. Van Zuuren" 1 => "Z. Fedorowicz" 2 => "B. Carter" 3 => "M.M.D. van der Linden" 4 => "L. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 124 | 12 | 136 |
| 2024 Octubre | 1026 | 69 | 1095 |
| 2024 Septiembre | 1234 | 68 | 1302 |
| 2024 Agosto | 1709 | 104 | 1813 |
| 2024 Julio | 1487 | 46 | 1533 |
| 2024 Junio | 1202 | 73 | 1275 |
| 2024 Mayo | 1375 | 57 | 1432 |
| 2024 Abril | 1149 | 40 | 1189 |
| 2024 Marzo | 1032 | 45 | 1077 |
| 2024 Febrero | 858 | 36 | 894 |
| 2024 Enero | 950 | 58 | 1008 |
| 2023 Diciembre | 787 | 32 | 819 |
| 2023 Noviembre | 1036 | 71 | 1107 |
| 2023 Octubre | 865 | 63 | 928 |
| 2023 Septiembre | 902 | 38 | 940 |
| 2023 Agosto | 824 | 46 | 870 |
| 2023 Julio | 749 | 51 | 800 |
| 2023 Junio | 840 | 40 | 880 |
| 2023 Mayo | 811 | 34 | 845 |
| 2023 Abril | 754 | 57 | 811 |
| 2023 Marzo | 736 | 35 | 771 |
| 2023 Febrero | 765 | 29 | 794 |
| 2023 Enero | 593 | 49 | 642 |
| 2022 Diciembre | 147 | 57 | 204 |
| 2022 Noviembre | 48 | 35 | 83 |
| 2022 Octubre | 56 | 30 | 86 |
| 2022 Septiembre | 46 | 52 | 98 |
| 2022 Agosto | 56 | 57 | 113 |
| 2022 Julio | 67 | 51 | 118 |
| 2022 Junio | 113 | 42 | 155 |
| 2022 Mayo | 817 | 62 | 879 |
| 2022 Abril | 1000 | 62 | 1062 |
| 2022 Marzo | 1093 | 60 | 1153 |
| 2022 Febrero | 1442 | 48 | 1490 |
| 2022 Enero | 1696 | 86 | 1782 |
| 2021 Diciembre | 1322 | 68 | 1390 |
| 2021 Noviembre | 1375 | 79 | 1454 |
| 2021 Octubre | 1728 | 98 | 1826 |
| 2021 Septiembre | 2608 | 120 | 2728 |
| 2021 Agosto | 2206 | 88 | 2294 |
| 2021 Julio | 1065 | 70 | 1135 |
| 2021 Junio | 855 | 82 | 937 |
| 2021 Mayo | 794 | 62 | 856 |
| 2021 Abril | 1441 | 116 | 1557 |
| 2021 Marzo | 614 | 46 | 660 |
| 2021 Febrero | 489 | 45 | 534 |
| 2021 Enero | 541 | 25 | 566 |
| 2020 Diciembre | 437 | 26 | 463 |
| 2020 Noviembre | 238 | 21 | 259 |
| 2020 Octubre | 211 | 19 | 230 |
| 2020 Septiembre | 324 | 23 | 347 |
| 2020 Agosto | 230 | 44 | 274 |
| 2020 Julio | 243 | 33 | 276 |
| 2020 Junio | 155 | 40 | 195 |
| 2020 Mayo | 128 | 24 | 152 |
| 2020 Abril | 102 | 18 | 120 |
| 2020 Marzo | 44 | 19 | 63 |
| 2020 Febrero | 7 | 0 | 7 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 9 | 0 | 9 |
| 2019 Agosto | 6 | 0 | 6 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 7 | 0 | 7 |
| 2019 Mayo | 6 | 0 | 6 |
| 2019 Abril | 18 | 0 | 18 |
| 2019 Marzo | 4 | 0 | 4 |
| 2019 Febrero | 5 | 0 | 5 |
| 2019 Enero | 8 | 0 | 8 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 7 | 0 | 7 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Julio | 1 | 1 | 2 |
| 2018 Junio | 4 | 0 | 4 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 1 | 1 | 2 |
| 2018 Febrero | 154 | 19 | 173 |
| 2018 Enero | 203 | 17 | 220 |
| 2017 Diciembre | 113 | 11 | 124 |
| 2017 Noviembre | 106 | 10 | 116 |
| 2017 Octubre | 134 | 21 | 155 |
| 2017 Septiembre | 317 | 28 | 345 |
| 2017 Agosto | 20 | 11 | 31 |
| 2017 Julio | 10 | 18 | 28 |
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