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Can oral ivermectin cure pediatric periorificial dermatitis? It mite!

DII small banner By Warren R. Heymann, MD
March 5, 2017

Pediatric Periorificial Dermatitis
A 13-year-old boy with severe rosacea before (A) and 1 month (B) and 4 months (C) after receiving oral therapy with a single dose of 250 μg/kg ivermectin (case 3). Note the facial desquamation after the first weeks of therapy, not attributable to any concurrent topical therapy. A 5-year-old boy with periorificial dermatitis before (D) and 1 month (E) and 4 months (F) after starting topical ivermectin therapy.
Credit: JAAD
Ask any child when how long it is until their next birthday and they can usually give you a precise answer. If I’m treating a child with periorificial dermatitis (POD, also granulomatous POD or perioral dermatitis), I can’t wait until they turn 8, so I can prescribe doxycycline. Somehow the other options, such as oral erythromycin, or topical agents including metronidazole, azelaic acid, and sulfacetamide just don’t seem quite as effective in my experience.

Although the role of Demodex mites in the pathogenesis of rosacea (and variants of rosacea, such as POD) awaits elucidation, techniques such as reflectance confocal microscopy have demonstrated that decomposing D. folliculorum mites correlates with improvement following the application of topical ivermectin (Soolantra) (1).
Single-dose ivermectin has been reported successfully in treating demodicosis in immunosuppressed patients, although it has also proven effective in immunocompetent patients. Brown et al reported the case of a 12-year-old girl who presented with severe ocular and cutaneous rosacea unresponsive to oral doxycycline, oral isotretinoin, and topical tacrolimus. A biopsy specimen showed numerous mites within the folliculosebaceous unit. Treatment with a single dose of oral ivermectin achieved resolution of her symptoms (2).

Noguera-Morel et al studied therapeutic value of using either oral or topical ivermectin in 15 children diagnosed with either papulopustular rosacea (PPR) or POD. Eight patients PPR and 7 with POD (mean age 9.8 ± 2.2 years) were treated with either a single dose of 200 to 250 μg/kg of oral ivermectin or a compound of 1% ivermectin in an oil-in-water base cream applied once a day for 3 months. Oral ivermectin was prescribed for 6 children with PPR and 3 with POD. Oral or topical therapy was chosen depending on the severity of the condition. No other medications were allowed. Complete or almost complete clearance was achieved in 8 patients treated orally and in 6 children treated with topical ivermectin. One patient did not improve after oral therapy. The overall response to topical or oral ivermectin was excellent: 14 of 15 (93%) patients achieved complete or almost complete clearance of lesions; 3 of 14 patients experienced relapses (21%) and 11 of 14 remained disease-free for a prolonged period. Mean follow-up was 11.9 ± 7.1 (range 2-42) months. The only adverse event observed was mild, transient desquamation of the affected skin in 3 patients receiving oral ivermectin and in 2 patients using topical ivermectin.
If you extrapolate the data from this study, looking exclusively at children < 8 years old for whom doxycycline would be contraindicated, 5 children were studied — 3 with POD and 2 with PPR. One in each group was treated successfully with oral ivermectin; A 3 year-old boy with POD who relapsed after 12 months, and a 4 year-old girl with PPR relapsing 2 months after her dose of ivermectin (3).

This data, while preliminary, is encouraging. I’m not immediately jumping on the ivermectin bandwagon for all cases of pediatric POD or PPR; I can say confidently however that in recalcitrant cases, especially for children < 8 years old, it is not a question if I “mite” prescribe ivermectin — I will!

1. Ruine C. Monitoring structural changes in Demodex mites under topical ivermectin in rosacea by means of reflectance confocal microscopy: A case series. J Eur Acad Dermatol Venereol 2016; Dec 15 [Epub ahead of print].
2. Brown M, et al. Severe demodexfolliculorum-associated oculocutaneous rosacea in a girl successfully treated with ivermectin. JAMA Dermatol 2014; 150: 61-3.
3. Noguera-Morel L, et al. Ivermectin therapy for papulopustular rosacea and periorificial dermatitis in children. J Am Acad Dermatol 2017; 76: 567-70.

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