Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis caused by Demodex spp.: A randomized clinical trial

Efficacy of Treatments in Reducing Inflammatory Lesion Count in Rosacea: A Systematic Review

INTRODUCTION

Rosacea is a chronic inflammatory skin condition affecting approximately 5.5% of the global population. Patients present heterogeneously with a mix of features in the central facial region, of which papules and pustules are considered to be a major feature. The identification of effective treatments for reducing inflammatory lesions in rosacea can alleviate the psychosocial burden that many rosacea patients experience, including reduced self-esteem, anxiety, and social withdrawal. The objective of this systematic review is to determine the effectiveness of topical and systemic therapies in reducing lesion count in rosacea patients.

METHODS/RESULTS

Medline, Embase, and Cochrane CENTRAL databases were searched, resulting in the inclusion of 43 clinical trials reporting on a total of 18,347 rosacea patients. The most well-studied treatments include ivermectin, metronidazole, azelaic acid, minocycline, and doxycycline. Oral isotretinoin was the most effective treatment in reducing inflammatory lesions and may be recommended for severe recalcitrant cases of rosacea.

CONCLUSIONS

Several topical and systemic therapies have demonstrated efficacy in reducing inflammatory lesion count in rosacea patients, with mechanisms of action centred around suppressing inflammation and killing Demodex folliculorum mites. Additional research is required to determine effective combination therapies in rosacea.

Efficacy and Safety of Lotilaner Ophthalmic Solution (0.25%) for the Treatment of Demodex Blepharitis: A GRADE Assessed Systematic Review and Meta-Analysis of Observational & Experimental Studies

PURPOSE

Several treatments have been in use for Demodex blepharitis, before the discovery of lotilaner, like tea tree oil and antibiotics; however, they either have irritable effects or systemic adverse effects, respectively. Lotilaner, a novel ectoparasiticide, has been proposed as a treatment for patients grappling with Demodex blepharitis. This review aims to assess the safety and efficacy of lotilaner in the treatment of Demodex blepharitis.

DESIGN

Systematic review and meta-analysis.

METHODS

An extensive search was conducted on PubMed, Cochrane Library, Scopus, and Google Scholar to find relevant literature till July 31, 2023 following the PRISMA guidelines. A total of 143 articles were retrieved by database searching, out of which 6 studies met the inclusion criteria and were included in the review. Four randomized controlled trials were included in the meta-analysis of mite eradication incidence. The review is registered with PROSPERO: CRD42023459997.

RESULTS

Lotilaner is effective in eradicating Demodex mites in individuals suffering from Demodex blepharitis according to RR for the intervention versus the control group of 3.55 (95% confidence interval [CI]: 2.87-4.40, P < .00001, I2 = 0%). The meta-analysis of clinically meaningful collarette score revealed the summary RR for the intervention versus the control group was 3.15 (95% CI: 2.56-3.89, P < 0.00001, I2 = 27%). In conclusion, the results of the included studies were comparable and consistent.

CONCLUSIONS

Our results indicated that lotilaner is an effective, well-tolerated, and promising drug in treating patients with Demodex blepharitis. Lotilaner administration and cost-effectiveness should now be contemplated for the study population as these constituents have a vital impact on its treatment success.

The impact of Demodex blepharitis on patient symptoms and daily life

SIGNIFICANCE

Patients with Demodex blepharitis have a considerable symptomatic burden that negatively impacts their daily activities and well-being. Despite chronic manifestations of and problems associated with blepharitis that resulted in multiple visits to eye care providers, Demodex blepharitis remained underdiagnosed or misdiagnosed.

PURPOSE

This study aimed to evaluate the effect of Demodex blepharitis on patients' daily activities and well-being.

METHODS

This prospective, multicenter, observational study recruited 524 patients with Demodex blepharitis from 20 U.S. ophthalmology and optometry practices. Demodex blepharitis was diagnosed based on the presence of the following clinical manifestations in at least one eye: >10 collarettes on the upper lashes, at least mild lid margin erythema of the upper eyelid, and mite density of ≥1.0 mite/lash (upper and lower combined). Patients were asked to complete a questionnaire related to their symptoms, daily activities, and management approaches.

RESULTS

The proportion of patients who experienced blepharitis symptoms for ≥2 years was 67.8%, and for ≥4 years, it was 46.5%. The three most bothersome symptoms ranked were "itchy eyes," "dry eyes," and "foreign body sensation." Overall, 77.4% of patients reported that Demodex blepharitis negatively affected their daily life. One-third (32.3%) of patients had visited a doctor for blepharitis at least two times, including 19.6% who visited at least four times. Despite having clinical manifestations of Demodex blepharitis confirmed by an eye care provider, 58.7% had never been diagnosed with blepharitis. Commonly used management approaches were artificial tears, warm compresses, and lid wipes. Among those who discontinued their regimen, 45.9% had discontinued because of either tolerability issues or lack of effectiveness. Among contact lens wearers, 64.3% of the patients either were uncomfortable wearing contact lenses or experienced vision changes "sometimes" or "frequently."

CONCLUSION

Demodex blepharitis results in a significant negative impact on daily activities, creating a psychosocial and symptomatic burden on patients.

Topical ivermectin 1.0% cream in the treatment of ocular demodicosis

PURPOSE

Ocular demodicosis can cause debilitating ocular surface disease. As ivermectin is effective at reducing Demodex proliferation in rosacea, this study investigated the efficacy of topical ivermectin 1.0% cream in treating ocular demodicosis.

METHODS

This retrospective single-centre clinical practice chart analysis involved the off-label treatment of patients who had ocular demodicosis with topical ivermectin 1.0 % cream (Soolantra, Galderma Ltd, UK) applied nightly to the lid margins of both eyes for 3 months. Ocular surface health was assessed at baseline when the treatment was prescribed and followed up at 3 and 12 months after baseline. Slit lamp biomicroscopy was used to take digital images of the upper eyelid lashes. Manual image analysis with ImageJ was conducted by a masked assessor to quantify signs of ocular demodicosis including the number of lashes with collarettes, with visible Demodex tails and with follicle pouting.

RESULTS

Data from a total of 75 patients with ocular demodicosis were analysed for this study (mean age 66.6 ± 13.9 years, 44 female). The numbers of lashes with collarettes (Median [Interquartile range]: 8 [4-13] at baseline to 0 [0-2] at the final visit, p < 0.001) and lashes with follicle pouting (3 [1-5] at baseline to 0 [0-1.8] at the final visit, p < 0.001) decreased with treatment. Any sign of lashes with visible tails was eliminated by the final visit (p < 0.007). Fluorescein staining severity score also improved, particularly from baseline (1 [0-2]) to the second visit (0 [0-1], p < 0.001).

CONCLUSIONS

The findings of this study show evidence for the efficacy of a 3-month course of topical ivermectin 1.0% cream in treating ocular demodicosis as indicated by reduction in collarettes, follicle pouting and visible Demodex tails. More research is warranted to improve the diagnosis, management and monitoring of this condition which is often overlooked or misdiagnosed.

Treatment of ocular rosacea: a systematic review

Rosacea is a common chronic skin disease distributed primarily around the central face. Ocular manifestations of rosacea are poorly studied, and estimates of prevalence vary widely, ranging from 6% to 72% in the rosacea population. Treatment options for ocular rosacea include lid hygiene, topical and oral antibiotics, cyclosporine ophthalmic emulsion, oral vitamin A derivatives, and intense pulsed light; however, a direct comparison of treatment methods for ocular rosacea is lacking. This review aims to compare treatment efficacy and adverse events for different treatment modalities in ocular rosacea. We performed a systematic review by searching Cochrane, MEDLINE and Embase. Title, abstract, full text screening, and data extraction were done in duplicate. Sixty-six articles met the inclusion criteria, representing a total of 1,275 patients. The most effective treatment modalities were topical antimicrobials and oral antibiotics, which achieved complete or partial response in 91% (n = 82/90) and 89% (n = 525/580) of patients respectively, followed by intense pulsed light (89%, n = 97/109 partial response), cyclosporine ophthalmic emulsion (87% n = 40/46), and lid hygiene (65%, n = 67/105). Combination treatments achieved a complete or partial response in 90% (n = 69/77). Results suggest that topical antimicrobials, oral antibiotics, intense pulsed light. and cyclosporine were the most efficacious single modality treatments.

Therapie der okulären Rosazea: Eine systematische Literatur-Übersicht: Treatment of ocular rosacea: a systematic review

Die Rosazea ist eine häufige chronische Hauterkrankung, die sich hauptsächlich im mittleren Bereich des Gesichtes manifestiert. Die okulären Manifestationen der Rosazea wurden bisher nur unzureichend untersucht und bereits die Schätzungen der Prävalenz schwanken erheblich zwischen 6% und 72% der Gesamtpopulation aller Rosazea‐Patienten. Zu den Behandlungsmöglichkeiten der okuläre Rosazea gehören die Lidhygiene, topisch anwendbare antimikrobielle Substanzen, topisch oder oral verabreichte Antibiotika und Vitamin‐A‐Derivate, Cisclosporin‐haltige Emulsionen speziell für das Auge und IPL‐Behandlungen (intense pulsed light). Direkte Vergleiche zwischen den verschiedenen Therapieoptionen fehlen jedoch. Ziel dieser Literatur‐Übersicht ist es, die Wirksamkeit und Nebenwirkungen der verschiedenen Behandlungsmöglichkeiten der okulären Rosazea zu vergleichen. Dazu wurden systematische Datenbankrecherchen in Cochrane, MEDLINE und Embase durchgeführt. Titel, Abstrakt, Volltext und Daten wurden jeweils doppelt durchgesehen. Insgesamt erfüllten 66 Artikel mit einer kumulierten Patientenzahl von 1275 Patienten die Einschlusskriterien. Zu den wirksamsten Behandlungsoptionen zählten topisch anwendbare antimikrobielle Substanzen und die orale Gabe von Antibiotika. Damit konnte bei 91% (n  =  82/90) bzw. 89% (n  =  525/580) der Patienten ein vollständiges oder partielles Ansprechen erzielt werden. Es folgten die IPL‐Behandlung (89%, n  =  97/109 partielles Ansprechen), die Ciclosporin‐Augen‐Emulsion (87% n  =  40/46) und die Lidhygiene (65%, n  =  67/105). Kombinationsbehandlungen führten in 90% der Fälle (n  =  69/77) zu einem vollständigen bzw. partiellen Ansprechen. Diese Ergebnisse deuten darauf hin, dass eine topische Therapie mit antimikrobiellen Substanzen, Antibiotika per os, IPL und Ciclosporin‐haltige Emulsionen die effektivsten Einzelmaßnahmen zur Behandlung der okulären Rosazea darstellen.

A Systematic Review and Meta-Analysis of the Safety and Efficacy of 0.25% Lotilaner Ophthalmic Solution in the Treatment of Demodex Blepharitis

Demodex blepharitis is marked by an excessive presence of Demodex mites on the eyelids, particularly in the lash follicles. While these microscopic mites are a natural component of the skin microbiota, their overabundance can lead to ocular complications. Symptoms associated with Demodex blepharitis include eyelid itching, inflammation, and ocular irritation. Our objective is to investigate Lotilaner as a potential treatment for Demodex blepharitis, assessing both the safety and efficacy of the ophthalmic formula in managing this disease. We conducted research in Web of Science, PubMed, Cochrane Library, and Scopus up to November 2023. The quality of studies was evaluated using the Cochrane Risk of Bias tool, and it was employed to evaluate the quality of evidence. Our meta-analysis was executed using Review Manager 5.4. We evaluated the safety and efficacy of Lotilaner ophthalmic solution with a concentration of 0.25%. The following outcomes were assessed: clinically meaningful reduction in collarette, collarette cure, composite cure, drop comfort, erythema cure, mite density, and mite eradication. In the case of dichotomous data, we used the risk ratio (RR) with a 95% confidence interval (CI). In our analysis, all included studies, comprising a total of 891 participants, consistently reported clinically meaningful reductions in collarettes. The findings were statistically significant, with Lotilaner demonstrating a substantially higher reduction compared to the vehicle group (RR = 3.09, 95% CI [2.65-3.60]; P-value < 0.0001). Notably, results for Drop Comfort outcomes were nonsignificant, indicating no discernible differences compared to the group that used the vehicle (RR = 1.03, 95% CI [0.98-1.07]; P-value = 0.26). However, both mite density and mite eradication outcomes exhibited significant improvements with Lotilaner in comparison to the vehicle (RR = 2.58, 95% CI [2.25-2.95]; P-value < 0.0001) and (RR = 3.80, 95% CI [2.88-5.01]; P-value < 0.0001). The Lotilaner ophthalmic solution at 0.25% showed superior efficacy over the vehicle in reducing collarettes, achieving complete mite eradication within six weeks, and significantly decreasing erythema in Demodex blepharitis. It demonstrated safety with no reported side effects compared to the vehicle. Direct comparative studies with alternative treatments are recommended for a comprehensive assessment of efficacy and safety.

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.

The role of macrophages in rosacea: implications for targeted therapies

Introduction

Rosacea, a widespread chronic skin condition, may be influenced by macrophages, key immune cells in the skin, although their exact role is not yet fully understood. This review delves into the function of macrophages, their potential contribution to rosacea pathogenesis, current treatments, and promising macrophage-targeted therapies. It concludes by identifying knowledge gaps and potential areas for future rosacea research.

Method

Leveraging systematic and narrative literature review techniques, we conducted a comprehensive search of databases such as PubMed, Embase, and Web of Science. Utilizing keywords like "rosacea" and "macrophages", we targeted English articles from the last 5 years (2018-2023). We manually checked reference lists of relevant articles for additional studies. We included only articles emphasizing macrophages' role in rosacea and/or the development of related therapies and published within the specified timeframe.

Results

The systematic search of electronic databases yielded a total of 4,263 articles. After applying the inclusion and exclusion criteria, 156 articles were selected for inclusion in this review. These articles included original research studies, review articles, and clinical trials that focused on the role of macrophages in rosacea and/or the development of macrophage-targeted therapies for the disease. The selected articles provided a comprehensive and up-to-date overview of the current state of research on macrophages in rosacea, including their function in the skin, the potential mechanisms through which they may contribute to rosacea pathogenesis, and the current treatments and therapies available for the disease. Additionally, the articles identified gaps in knowledge regarding the role of macrophages in rosacea and suggested potential areas for future research.

Conclusion

This literature review emphasizes the important role that macrophages, vital immune cells in the skin, may play in the pathogenesis of rosacea, a common chronic inflammatory skin disorder. The selected studies suggest potential mechanisms by which these cells might contribute to rosacea progression, although these mechanisms are not yet fully understood. The studies also spotlight current rosacea treatments and illuminate the promising potential of new macrophage-focused therapies. Despite these insights, significant gaps persist in our understanding of the precise role of macrophages in rosacea. Future research in this area could provide further insights into the pathogenesis of rosacea and contribute to the development of more effective, targeted therapeutic strategies.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Demodex Blepharitis: An Analysis of Nine Patients

Inflammatory eyelid symptoms are common in primary care and there have been several reports on Demodex blepharitis. In the present study, we evaluate the 9 patients with Demodex blepharitis, who showed inflammation of the eyelids, dry eye, and cylindrical dandruff at the base of the eyelashes. The causative species from all patients was Demodex folliculorum of either the adult or nymph stage. Two patients had recurrent chalazion and 3 patients had keratitis. Weekly lid scrubs with 50% tee tree oil were performed for 6 weeks. After treatment, the symptoms of blepharitis and keratitis had improved in all patients. This case report provides clinical reference source for the proper treatment of ocular demodicosis.

Efficacy of Topical Ivermectin 1% in the Treatment of Demodex Blepharitis

The purpose of this study was to evaluate the efficacy of topical ivermectin 1% cream application on the eyelashes in combination with eyelid hygiene in the treatment of Demodex blepharitis.