Please note that I have absolutely no conflict of interest regarding Soolantra (Galderma).
In my experience, Soolantra (1% ivermectin) has been a good treatment for papulopustular rosacea. Studies suggest that it may be even more effective than topical metronidazole, both in terms of having an extended remission (1) and in quality of life. Presumably, topical ivermectin is effective both by being anti-inflammatory and by decreasing the population of Demodex mites (2).
Recently, I treated a patient with long-standing papulopustular rosacea with Soolantra, who previously had a modest response to metronidazole and azelaic acid. She was delighted with her initial response to Soolantra. After using it for a few months, however, it completely lost its efficacy.
I am not one to reach conclusions based on one patient’s experience. We all have had patients with rosacea who flare, regardless of treatment.
I could not help but wonder, however, if perhaps her Demodex mites were becoming resistant to ivermectin. There is very little literature that I can find about ivermectin resistance and mites (3, 4), the first dealing with goats in the UK and the second addressing Demodex in blepharitis (I did not have access to the latter article).
The following is from the article by Cornall and Wall (3):
The treatments used by some farmers for both preventative and therapeutic management of ectoparasites were of concern as there was an apparent reliance on macrocyclic lactones, particularly ivermectin. The widespread use of macrocyclic lactones for ectoparasite control is likely to hasten coincidental selection for resistance in endoparasites (Domke et al., 2011) jeopardising the future viability of these drugs.
Have you had any patients with a similar clinical course with Soolantra – initial improvement lasting for months, with a subsequent loss of efficacy? Are we inducing ivermectin resistance?
- Taieb A, et al. Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-week extension of the ATTRACT randomized study. J Eur Acad Dermatol Venereol 2016; 30: 829-36.
- Cardwell LA, et al. New developments in the treatment of rosacea – role of once-daily ivermectin cream. Clin Cosmet Investig Dermatol 2016; 9: 1-7.
- Cornall K, Wall R. Ectoparasites of goats in the UK. Vet Parasitol 2015; 207 (1-2): 176-9.
- Hervás Ontiveros A, et al. Ethyl ether: an old ally against oral ivermectin-resistant Demodex blepharitis. Arch Soc Esp Oftamol 2014; 89: 85-6.