Rosacea and Dry Eyes Part 10: more on treatments (& Demodex)…
Helm CJ. Treatment of ocular Demodex infestation with topical ivermectin cream. Am J Ophthalmol Case Rep. 2022 Apr 21;26:101551. doi: 10.1016/j.ajoc.2022.101551. PMID: 35509284; PMCID: PMC9058595.
The following consists of a report on the off-label use of a common treatment for rosacea that can be applied to the lids and lash area as described from the article below. It was the basis for much of my treatment before Xdemvy became commercially available (just one year ago this month) and can be found in my earlier post, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease
Treatment of ocular Demodex infestation with topical ivermectin cream
“Ivermectin 1% cream was approved by the FDA in 2014 for the treatment of rosacea, a Demodex-associated condition.32 The cream was found to be well tolerated in FDA studies, leading to skin irritation and a burning sensation in less than 1% of patients when used during a 12-week study period.33, 34 Topical ivermectin 1% cream has been reported to be effective in treating ocular rosacea,35,36 and was recently found by Choi et al. to be effective in treating Demodex blepharitis.37 In their study, ivermectin 1% cream was applied weekly. However, the findings of this case series suggests that even a single application of ivermectin 1% cream has a very potent and prolonged effect that lasts for several months, making weekly application unnecessary.
The patients in this series reported that the cream caused temporary ocular stinging and burning, which was mitigated by instillation of a topical anesthetic. The symptoms did not recur after the anesthetic wore off. Temporary blurred vision was also reported, but no one felt unsafe to drive after 30 minutes. An increase in dry eye symptoms commonly occurred a few days after treatment.
In summary, this case series presents compelling anecdotal evidence of the effectiveness of a single or double application of topical ivermectin 1% cream in producing a prolonged, months-long reduction in the clinical signs of Demodex infestation. Further investigation of the off-label use of topical ivermectin 1% cream for ocular demodicosis is warranted to confirm its efficacy and to develop protocols that extend the duration of treatment effect.
The treatment consisted of instilling a drop of proparacaine into each eye. The exam chair was reclined. A dry cotton-tipped applicator was used to evert the lashes. Another cotton-tipped applicator with ivermectin 1% cream (Soolantra, Galderma, Ft. Worth, Texas, USA) was used to apply the cream to the base of the eyelashes, taking care to keep the cream off of the ocular surface (Fig. 1). After ensuring that the eyelash bases of both the upper and lower eyelids were saturated with the cream, it was applied to the surrounding upper and lower eyelid skin. The cream was left in place for 10 min, after which a sterile saline-soaked eye pad was used to remove the excess cream from the eyelids. Dry cotton-tipped applicators were used at the slit lamp to remove excess cream, and the remainder of the cream around the lashes was left in place. Artificial tears were instilled if the patient was experiencing ocular burning or irritation.”
My “take home” message about Demodex and Rosacea, from my personal experiences and this post, is that Demodex is a common irritant that will aggravate rosacea and its related inflammation - both on the face and on the lids (which can spill over as inflammation onto the eyes). Ivermectin 1% cream and the newer eye drop, Xdemvy, have proven of value in reducing the load of Demodex and the related inflammation. Since inflammation is a foundational aspect of dry eye and related ocular surface diseases, it is often important to address this common mite. Protocols continue to evolve around “best practices” and may require customization according to the degree of its effect on the individual patient.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463