Real-life experience on effectiveness and tolerability of topical ivermectin in papulopustular rosacea and antiparasitic effect on Demodex mites

Raising awareness of Demodex mites: a neglected cause of skin disease

BACKGROUND

Demodex mites are among the most prevalent human parasites. While commonly found on healthy individuals, an overpopulation of this arachnid resident of human skin triggers demodicosis, a neglected yet widely prevalent disease with considerable skin and eye morbidity. Despite its health impact, demodicosis remains overshadowed by other common skin diseases. This neglect has significant consequences for individual and public health, which require a paradigm shift in our understanding and management of this ubiquitous ectoparasite. We reviewed the literature to re-evaluate the pathogenicity of the Demodex mite, paying particular attention to the primary risk factors-immune dysregulation, altered microbiota, and concurrent infections-that may contribute to pathogenicity. We discuss the challenges in combating neglect of demodicosis and provide updates on various impediments in achieving this goal. We explore the issues and research gaps in various domains such as those related to parasite biology, pathogenesis, diagnosis, treatment, prevention and control. We present potential solutions and outline future prospects for tackling this important disease. Finally, we hope to catalyze greater attention and investment for this neglected public health issue.

CONCLUSION

Raising awareness of Demodex and demodicosis and its major contribution to human diseases requires a multidisciplinary approach. Efforts to prioritize its place on the global health agenda, invest in research, improve diagnostic tools, and develop new treatment strategies will lead to improved public health outcomes and a higher quality of life for those affected.

Microbe-Host Interaction in Rosacea and Its Modulation through Topical Ivermectin

Rosacea is characterized by inflammatory lesions, often accompanied by an increased density of the common skin mite Demodex folliculorum. Although rosacea shows a high prevalence and significantly affects the QOL of patients, the underlying mechanisms, especially the role of cutaneous dysbiosis, are largely unknown. Hence, we aimed to systematically characterize disease severity of patients with rosacea in the context of mite density, the cutaneous microbiome, and the host's transcriptome before and after 30 days of topical 1% ivermectin cream treatment. At day 30, a marked decrease in mite density was observed in 87.5% of patients. At day 0, distinct microbial community changes included the decrease in Cutibacterium acnes abundance, whereas Staphylococcus epidermidis colonization increased compared with that in healthy volunteers. Interestingly, the insect symbiont Snodgrassella alvi was recovered from a highly Demodex-colonized patient and eradicated by treatment on day 30. Although topical ivermectin did not affect bacterial dysbiosis, the host's transcriptome significantly normalized, and an "ivermectin transcriptomic signature" was defined. Findings of this study support that rosacea lesions are associated with dysbiosis. However, improvement of clinical signs during topical ivermectin is not associated with normalization of the bacterial microbiome but rather a decrease of transcriptomic dysregulation and mite density.

Presence of Demodex spp. on the face and scalp in patients affected by papulopustular rosacea of face

BACKGROUND

The increased proliferation of Demodex mites in the pilosebaceous unit can be the cause of rosacea flare-ups on the face. Signs and symptoms of the scalp (e.g., itching, dandruff) have sometimes been reported in patients with papulopustular rosacea of face; they may be due to a proliferation of Demodex mites on the scalp.

METHODS

To study the Demodex mites count, a standardized skin surface biopsy was performed on the cheek and on the scalp. Microscopic examination and molecular identification of Demodex were performed. Pearson's χ2 Test or Fisher's Exact Test were used to test for any association between categorical variables and outcome.

RESULTS

Patients affected by papulopustular rosacea had a greater frequency of Demodex-positive standardized skin surface biopsy than controls at the scalp (35.0% vs. 0%, P=0.033), at the face and/or at the scalp (50% vs. 10%, P=0.032). Demodex positive patients with a Demodex-positive face sample were more frequently found to have a Demodex-positive scalp sample (P=0.035). The predominant species was found to be Demodex folliculorum (92.6% of samples); the species Demodex brevis was identified only in 7.4% of samples.

CONCLUSIONS

Demodex folliculorum is more frequently found on the scalp and face of patients with rosacea than controls, even though it is not statistically associated with scalp symptoms. The scalp may be a reservoir area for Demodex mites which could migrate on the face again after an acaricidal treatment.

Detection of demodex mites in papulopustular rosacea using microscopic examination and polymerase chain reaction: a comparative case-control study

Demodex mite proliferation is frequently involved in the pathogenesis of rosacea. The gold standard for Demodex identification is microscopic examination on a standardized skin surface biopsy. However, this method of sampling can be distressing and painful, especially when performed on hairy sites. In this case-control study, we compared the sensitivity of PCR and microscopic examination in diagnosing a Demodex infestation. Moreover, we investigated the possible correlations between the presence of Demodex mites and clinical characteristics. In total, 20 patients affected by papulopustular rosacea and 10 controls were included. At both microscopic examination and PCR, patients with rosacea presented a greater prevalence of positive samples than controls at the scalp and at the face. Microscopy had sensitivity of 50% at the face and of 46.7% at the scalp. PCR had sensitivity of 93.75% at the face and of 86.7% at the scalp. The positivity of PCR was associated to a higher frequency of facial papules and pustules. Patients with positivity at the face had a more frequent positivity at the scalp. The scalp could represent a reservoir for the Demodex mites, and should be investigated by sensitive and painless methods. PCR performed on painlessly collected samples should be further investigated.

Follicular scales, scalp and ocular involvement in patients with papulopustular rosacea: prevalence and association with Demodex mite proliferation

Facial follicular scales, dandruff, scalp itching and ocular alterations are lesser-known signs of rosacea and demodicosis. The aim of this prospective original study was to investigate the presence of these signs and symptoms in patients with almost-clear, mild and moderate papulopustular rosacea (PPR) and to study the differences between Demodex-positive (D+) and Demodex-negative (D-) rosacea. Twenty-seven out of 60 patients (45%) presented follicular scales, 24 (40%) ocular involvement and 22 (36.67%) scalp involvement. Follicular scales were more frequently observed in mild and moderate than in almost-clear rosacea (P<0.001). Itching of the scalp was more frequently reported in patients with moderate rosacea than in those with mild disease (P=0.05). Follicular scales (P=0.002) and scalp itching (P=0.05) were more frequently reported in D+ than in D- patients. Among D+ patients, scalp itching was more frequently reported in mild than in almost clear rosacea (P=0.01) and ocular symptoms associated to scalp itching were more frequently reported in moderate than in almost-clear rosacea (P=0.05). We suggest looking for these signs and symptoms in all patients with PPR, because they can be a sign of a more severe form of rosacea or of demod-icosis.

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.

Case Series of Demodicosis in Acne Vulgaris Patients

An abnormal density of Demodex mites can trigger many skin disorders known as demodicosis. Clinical manifestations of demodicosis may resemble other skin diseases and can coexist with other skin disorders, resulting in underdiagnosis and a more challenging diagnosis. Here, we report three cases of demodicosis in acne vulgaris patients. These case series have discussed their clinical features along with optimal strategies for diagnosis and treatment.

Has the Use of the Mask Exacerbated Rosacea During the Pandemic?

INTRODUCTION

During the COVID-19 pandemic, personal protective equipment, particularly face masks, became an essential requirement to engage in various activities. Several articles reported an increase of recurrences of dermatologic facial diseases (ie, acne, rosacea) related to mask use.

OBJECTIVES

To evaluate the number of recurrences of rosacea related to face mask use.

METHODS

This prospective study was conducted on adult patients with a pre-pandemic diagnosis of mild and moderate papulopustular rosacea. All patients had previously achieved either partial or complete remission after a 4-month treatment with topical ivermectin in 2019. We collected data in two different phases characterized by different intensity of mask use during the pandemic and post-pandemic period. We collected data through clinical assessment of the disease, questionnaires on personal habits and standardized skin surface biopsy to study the Demodex mites count.

RESULTS

We enrolled a total of 30 patients. In the pandemic period, 5/30 patients had a relapse of mild papulopustular rosacea; the Demodex sample resulted positive in 4/5 relapsed patients. In the post-pandemic period, 4/30 patients reported a relapse of mild rosacea (3 patients) and moderate papulopustular rosacea (1 patient). At the Demodex exam, 1/4 relapsed patients resulted positive.

CONCLUSIONS

We did not find a significant increase in relapses of papulopustular rosacea during the pandemic. An appropriate anti-parasitic treatment may reduce the number of recurrences due to mask use.

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.

Development of an animal model for rosacea‑like skin lesions caused by Demodex

To develop an animal model of rosacea-like skin lesions caused by Demodex mites, a suspension of Demodex mites was injected into the skin of Japanese rabbits. The pathology of the skin lesion was assessed using H&E staining after 4 weeks of modeling. The skin lesions observed after 4 weeks were further treated with the recombinant bovine basic fibroblast growth factor (rbFGF) gel. Untreated lesions in the same rabbit were considered as the blank control. Erythema papules were observed in the model rabbit skin and could be observed most clearly in the 2nd week. Lumpy foreign bodies, telangiectasia and granuloma-like structure were observed in the model rabbit in the 1st, 2nd, and 3rd weeks, respectively. An organized granuloma-like structure was observed in the 4th week. The color of the skin lesions became lighter than that of the self-control after 4 weeks of rbFGF treatment. In conclusion, the model of Demodex-induced rosacea-like skin lesions can be developed through intradermal injection of suspension of Demodex mites into Japanese rabbits. The model can mimic the phenotype of skin lesions and histopathological manifestations in the Demodex mite-positive patient with rosacea.

Comparison of in vitro Killing Effect of N, N-Diethyl-Meta-Toluamide (DEET) versus Permethrin on Demodex folliculorum

Background

There is no single effective treatment for demodicosis; successful treatment requires a multimodal approach. Relapse or recurrence of demodicosis is relatively high, making the therapy challenging. Several reports have documented the successful treatment of demodicosis with acaricidal agents, which aimed at reducing the excessive number of Demodex mites and improving the patients' symptoms. Reports of irritation and resistance to topical acaricidal agents have led to the search for effective alternative treatments.

Materials and Methods

A total of 100 standardized skin surface biopsy (SSSB) biopsy slides from 100 patients with demodicosis were randomly divided into five groups, each with 20 slides exposed to immersion oil, N, N-diethyl-meta-toluamide (DEET) 5%, 10%, 20%, and permethrin 1%, respectively. The microscopic evaluation started immediately after the test agents exposed the mites. The survival time (ST) was defined as the interval between the first exposure of Demodex folliculorum to the test agents to the time the movements ceased.

Results

The differences between the median ST of DEET 5% (44 min), 10% (22 min), and 20% (14 min) were significant when compared to the negative control group (240 min) with p<0.001, <0.001, <0.001, respectively. While the median ST of permethrin 1% (42 min) was not significantly different from the median ST of DEET 5% (p=0.7395).

Conclusion

This study demonstrated the dose-related acaricidal effect of DEET on D. folliculorum. The survival times of DEET 5%, 10%, and 20% were significantly shorter than the negative control (immersion oil). DEET 5% had a comparable in vitro killing effect as permethrin 1%. Further in vivo studies are necessary to determine the clinical efficacy in patients with demodicosis.

Demodex: the worst enemies are the ones that used to be friends

Demodex mites are common ectoparasites of the human pilosebaceous units. Most adults are infested with Demodex mites without clinical symptoms. Demodex mite will only become a pathogenic organism when there is an abnormal increase in the number of Demodex mite density. This situation happens when the equilibrium between Demodex mites, skin microenvironment and human immunity system changes. Demodex infestation can cause multiple skin disorders, which are grouped under the term demodicosis or demodicidosis. Clinical manifestations of demodicosis can mimic other known skin diseases such as folliculitis, rosacea, perioral dermatitis, which is why it is often misdiagnosed. Diagnosis criteria consists of relevant correlation of suspected clinical skin lesions, confirmed by the presence of abnormal proliferation of Demodex mites and by clinical cure after acaricidal treatment together with normalization of Demodex mite density. Dermatologists should be aware that demodicosis is not an uncommon skin disease, and there are still many unknowns about it that should be researched further.

Dermoscopy of papulopustular rosacea and comparison of dermoscopic features in patients with or without concomitant Demodex folliculorum

BACKGROUND

The dermoscopic findings of papulopustular rosacea include tiny papules and pustules, follicular plugs and follicular dilatation. Demodex tails and Demodex follicular openings are dermoscopic indicators that are mainly found in primary demodicosis and, less frequently, in rosacea.

AIM

To describe the dermoscopic features of papulopustular rosacea and to investigate the differential dermoscopic features between patients with and without concomitant Demodex infestation.

METHODS

We conducted a prospective study of patients with almost-clear, mild or moderate papulopustular rosacea. For each patient, dermoscopic images were taken and a standardized skin surface biopsy was performed.

RESULTS

In this group of 60 patients, the most frequent dermoscopic findings were yellow dots, vascular polygons and follicular scales. Patients with moderate rosacea had more Demodex follicular openings compared with patients with mild rosacea (P = 0.02), while patients with mild rosacea had a higher frequency of follicular scales than did patients with almost-clear rosacea (P = 0.01). Patients with moderate rosacea had higher rates of Demodex follicular openings (P = 0.02), follicular scales (P < 0.001), follicular annular pigmentation (P = 0.001) and follicular pustules (P < 0.001) compared with patients with almost-clear rosacea. No significant dermoscopic differences were observed between patients with and without concomitant Demodex infestation.

CONCLUSIONS

Papulopustular rosacea has specific dermoscopic findings. In our opinion, dermoscopy is not sufficient by itself for the diagnosis of Demodex proliferation in rosacea.

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.

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.

Rosacea Treatment: Review and Update

Rosacea is a chronic and inflammatory skin disease characterized by flushing, nontransient erythema, papules/pustules, telangiectasia, and phymatous changes. Secondary manifestations, such as itching, burning, or stinging, are often observed in patients with rosacea. In 2017, a phenotype-based approach for diagnosis and classification was recommended. With the update of the diagnosis and classification of rosacea, treatment options for patients with rosacea have attracted the attention of dermatologists. Here, we summarize the latest advances in rosacea treatment, including skin care and cosmetic treatments, topical therapies, oral therapies, laser- and light-based therapies, injection therapies, treatments for specific types of rosacea, treatments for systemic comorbidities, and combination therapies. The impact of the phenotype-based approach on rosacea treatment and future directions are also discussed.

The Pathogenic Role of Demodex Mites in Rosacea: A Potential Therapeutic Target Already in Erythematotelangiectatic Rosacea?

Rosacea is a common facial dermatosis but its definition and classification are still unclear, especially in terms of its links with demodicosis. Triggers of rosacea (ultraviolet light, heat, spicy foods, alcohol, stress, microbes) are currently considered to induce a cascading innate and then adaptive immune response that gets out of control. Recent histological and biochemical studies support the concept that this inflammatory response is a continuum, already present from the onset of the disease, even when no clinical signs of inflammation are visible. The Demodex mite is beginning to be accepted as one of the triggers of this inflammatory cascade, and its proliferation as a marker of rosacea; moreover, the papulopustules of rosacea can be effectively treated with topical acaricidal agents. Demodex proliferation appears to be a continuum process in rosacea, and may not be clinically visible at the onset of the disease. Molecular studies suggest that Demodex may induce tolerogenic dendritic cells and collaborate with vascular endothelial growth factor (VEGF) to induce T cell exhaustion and favor its own proliferation. These interactions among VEGF, Demodex, and immunity need to be explored further and the nosology of rosacea adapted accordingly. However, treating early rosacea, with only clinically visible vascular symptoms, with an acaricide may decrease early inflammation, limit potential flare-ups following laser treatment, and prevent the ultimate development of the papulopustules of rosacea. The effectiveness of this approach needs to be confirmed by prospective controlled clinical trials with long-term follow-up. Currently, the evidence suggests that patients with only vascular symptoms of rosacea should be carefully examined for the presence of follicular scales as signs of Demodex overgrowth or pityriasis folliculorum so that these patients, at least, can be treated early with an acaricidal cream.

Effectiveness of benzyl benzoate treatment on clinical symptoms and Demodex density over time in patients with rosacea and demodicosis: a real life retrospective follow-up study comparing low- and high-dose regimens

Background: Patients with rosacea and demodicosis have high facial skin Demodex densities (Dds), which decrease with benzyl benzoate (BB) treatment.Objectives: To evaluate the impact of topical BB (+crotamiton) treatment on Dds and clinical symptoms during prolonged follow-up and to compare low (12% once daily) and high (12% twice daily or 20-24% once daily) BB dose regimens.Methods: This retrospective study included 344 patients (103 rosacea, 241 demodicosis) observed for 7.1 ± 0.5 months. Dds were measured on two consecutive standardized skin surface biopsies and symptoms evaluated using investigator global assessment. Compliance was considered good if patients correctly followed treatment instructions.Results: At final follow-up, in the 248 patients with good compliance, Dd had normalized in 217 (88%) and symptoms cleared in 204 (82%). The high dose was associated with better compliance and faster results than the low-dose. The higher the initial Dd, the longer it took to normalize. In the 96 poorly compliant patients, treatment was less effective and slower.Conclusions: These findings indirectly support a key role of the mite in rosacea and suggest that topical treatment with BB (+crotamiton), especially the higher dose, may be a useful alternative treatment for rosacea as well as for demodicosis.[Formula: see text].

Demodex: a skin resident in man and his best friend

Demodex mites are microscopic arachnids found in the normal skin of many mammals. In humans, it is well established that Demodex mite density is higher in patients with the skin condition rosacea, and treatment with acaricidal agents is effective in resolving symptoms. However, pathophysiology of rosacea is complex and multifactorial. In dogs, demodicosis is a significant veterinary issue, particularly the generalized form of the disease which can be fatal if untreated. In each species, clinical and molecular studies have shown that the host's immunological interactions with Demodex mites are an important, but not fully understood, aspect of how Demodex can live in the skin either as a harmless commensal organism or as a pathogenic agent. This review outlines the role of Demodex mites in humans and dogs, considering morphology, prevalence, symptoms, diagnosis, histology treatment and pathogenesis.

Efficacy of topical ivermectin and impact on quality of life in patients with papulopustular rosacea: A systematic review and meta-analysis

Rosacea is a chronic dermatosis which affects negatively patients' quality of life (QoL). There is shortage of high-quality evidence comparing the efficacy of ivermectin cream (IVM) 1% with other available topical choices. Besides, the well-documented impaired of self-esteem and stigmatization of rosacea patients make essential to address which treatment provides the greatest psychological and social benefit. Our objective is to critically review and appraise the efficacy of IVM 1% in PPR and the impact in patients' QoL against other options. We carried out a literature search from PubMed, MEDLINE, EMBASE, Cochrane, and clinicaltrials.gov using the following descriptors: "rosacea" AND "ivermectin." Efficacy was assessed with the Investigator Global Assessment (IGA), and the impact on QoL was based on the DLQI score. Six studies from four published articles were included. The meta-analysis estimated that more participants achieved "success" (IGA ≤ 1) and "complete clearance" (IGA = 0) with IVM1%. The overall effect estimate for IGA ≤ 1 was: 1.56 [1.23-1.97], whereas for IGA = 0, it was: 1.72 [1.40-2.11]. The rate of participants achieving lower DLQI score, and thus, better QoL was with IVM 1%. The overall effect estimate was: 1.71 [1.34-2.18] at week 16# and 1.64 [1.38-1.94] at week 52#. This meta-analysis confirms IVM 1% cream as the most effective topical treatment and it satisfies the impairment of social life with sustained better QoL. Further studies extending this period of remission are warranted, as well as researches about the potential application of this agent combined with other agents. KEY POINTS: Question: What is the current efficacy of ivermectin versus other choices in papulopustular rosacea and its impact on patients' quality of life? Findings: In this meta-analysis, ivermectin showed higher efficacy than metronidazol, azelaic acid, and placebo measured by Investigator Global Assessment. Parallely, the DLQI score highlighted that this agent was more beneficious in both short and long-term. Meaning: This meta-analysis gives strong evidence that ivermectin is the most effective topical treatment. Besides, this agent provides the greatest psychological benefit as it satisfies the stigmatization of rosacea patients as well as the impairment of social and working life with a sustained better QoL above other alternatives.