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Contact Lens and Anterior Eye

journal homepage: www.elsevier.com/locate/clae

Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis

caused by Demodex spp.: A randomized clinical trial
Marcel Y. Ávila*, Dayron F. Martínez-Pulgarín, Carolina Rizo Madrid
Department of Ophthalmology, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia

A R T I C LE I N FO A B S T R A C T

Keywords: Purpose: To evaluate the efficacy of topical ivermectin-metronidazole combined therapy in the management of
Blepharitis Demodex-associatedblepharitis.
Demodex Methods: Sixty patients with a diagnosis of Demodex-associatedblepharitis were recruited in a randomized
Eyelash clinical trial. Thirty receiving topical ivermectin (0.1%)-metronidazole (1%) gel treatment on days 0, 15 and 30.
Inflammation
Thirty additional patients were used as a control group receiving vehicle on days 0, 15 and 30. The primary
Rosacea
efficacy measure was the number of Demodex spp. mitesin the eyelashes of patients. The secondary outcomes
Treatment
included clinical improvement of signs and adverse events.
Results: Complete eradication of Demodex spp. was found in 96.6% of patients in the treatment group.
Furthermore, a significant reduction of inflammation signs were found in all treated patients versus controls.
None of the patients experienced any adverse effects associated with the treatment.
Conclusion: Demodex infection was controlled satisfactorily with the ivermectin (0.1%)-metronidazole (1%) gel,
and no adverse effects were observed. Application of this gel for the treatment of different parasitic infections of
the eyelids could be feasible, and this requires further exploration.

1. Introduction
Demodex folliculorum is a microscopic, elongated mite which is
considered to be the most prevalent ectoparasite in humans [1]. It has
been implicated in several skin diseases including rosacea [2], acne
vulgaris [3] and basal cell carcinoma [4]. The eyelid can also be in-
fected, leading to blepharitis. Association with Bacillus oleronius colo-
nisation can induce aberrant wound healing, as well a severe in-
flammatory response [5]. Around 41.6%–81.25% of blepharitis patients
have concomitant infestation with Demodexspp[6], reaching up to 100%
in patients older than 70 years. In Colombia, according Galvis-Ramírez
et al., the prevalence for Demodex infestation is 42.1%, and in patients
with documented blepharitis is 63.2%, [7]. In the clinic were this study
was performed prevalence is 72% of the patients with blepharitis.
Numerous compounds have been described for the treatment of
these infections, including tea tree oil, systemic ivermectin [8], sys-
temic metronidazole [9] and a metronidazole gel [10]. Development of
a novel therapeutic approach to eradicate this mite with minimal ad-
verse events and maximum tolerability is required. In this study, iver-
mectin, an establish acaricidal with an acceptable safety profile which
is widely used for the control of mites in humans [11] and in veterinary
medicine combined with metronidazole, a drug with antibacterial
activity against Bacillus oleronius and with antiparasitary action was
evaluated in vitro and in vivo.
Ivermectin is an effective systemic and topical antiparasitic drug. It
is selective against parasites due to its affinity for the glutamate-gated
chloride ion channels present in the peripheral nervous system of in-
vertebrates, causing increased chloride ion channel permeability [12]
and subsequent paralysis and eventual death of parasites and mites. It
can be delivered orally or topically with a good safety profile and tol-
erability. Ivermectin is used in children for the management of pedi-
culosis, and in adults for the management of rosacea, requiring minimal
dosage [13]. Metronidazole is an antibiotic drug with an additional
anti-inflammatory effect, and has been proposed as a possible treatment
for blepharitis and rosacea. The acaricidal effect of a combination of
ivermectin and metronidazole has been demonstrated to provide better
eradication of Demodex than ivermectin or metronidazole single
therapy according to clinical studies using the systemic drugs [9]. Based
on this, the possible synergistic acaricidal effect of this therapeutic
combination using a novel topical preparation was considered for the
treatment of Demodex.
The aim of this study was to evaluate the efficacy of a topical
ivermectin (0.1%)-metronidazole (1%) gel in the treatment of ble-
pharitis caused by Demodex infestation.

⁎
Corresponding author at: Department of Ophthalmology, Facultad de Medicina, Universidad Nacional de Colombia, Carrera 30 Calle 45, Bogota DC,Colombia.
E-mail address: myavilac@unal.edu.co (M.Y. Ávila).

https://doi.org/10.1016/j.clae.2020.04.011
Received 7 March 2020; Received in revised form 20 April 2020; Accepted 21 April 2020
1367-0484/ © 2020 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Marcel Y. Ávila, Dayron F. Martínez-Pulgarín and Carolina Rizo Madrid, Contact Lens and Anterior Eye,
https://doi.org/10.1016/j.clae.2020.04.011
M.Y. Ávila, et al.
2. Materials and methods
2.1. Ivermectin-metronidazol preparation
A gel containing ivermectin and metronidazol was prepared by
Solution´s Pharmacy under the regulation 1403–2007 of the Ministry of
Health and in accordance with local regulation. A gel base was pre-
pared with ivermectin 0.1% and metronidazol 1%, with a stability of 9
months from the date of preparation.
Briefly 100 mL of water USP is stabilized at 7.2 pH with trietano-
lamine, then carbomer 940 USP (0.4 gm) was added and mixed ob-
taining a gel base, then metronidazole USP at 1% and ivermectin USP at
0.1% were prepared in this gel base. The preparation of placebo consist
in carbomer 940 (0.4 gm) dissolved in 100 mL of water and stabilized at
7.2 pH with trietanolamine.
2.2. Participants
This study followed the tenets of the Helsinki Declaration. It was
conducted at the Hospital Engativa following approval by the
Institutional Review Board of the Universidad Nacional de Colombia
(Facultad de Medicina).The clinical trial was registered on
ClinicalTrials.gov under the code NCT02236403. The trial design was
executed according to CONSORT guidelines (Fig. 1) [14]. All patients
signed an informed consent form following an explanation of the ob-
jectives of the study.
Sample size was calculated based in previous pre-clinical results
with an type I/II error data with alpha of 0.05 and power of 95% and
Fig. 1. Flow diagram of the progress through the phases of the study.
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estimated mean difference between pre and post treatment of 70% and
enrolment ratio of 1:1 determining a sample size of 30 patients per
group (treatment group vs control group).
Sixty patients with cylindrical dandruff of the eyelashes were in-
cluded in the study with a total of 120 eyes. All patients underwent a
routine complete eye examination and were found to have demodex
blepharitis. All patients reported the use of several medications in-
cluding antibiotics, steroids and antiallergics such as olopatadine and
sodium cromoglycate, as well as eyelash solutions for cleaning. For at
least 1 week prior to the study, participants were instructed to avoid
using any medications.
Inclusion Criteria were patients with symptomatic Demodex ble-
pharitis for duration of at least 3 months, 18 years and older, both
genders and all ethnic groups comparable with the local community,
able to understand and willing to sign a written informed consent, able
and willing to cooperate with the investigational plan, able and willing
to complete all mandatory follow-up visits.
Exclusion Criteria were patients who are currently engaged in an-
other clinical trial, unwilling or unable to give consent, or to return for
scheduled visits, children under 18, pregnant women or expecting to be
pregnant during the study, systemic immune deficient conditions such
as human immunodeficiency virus infection or under systemic im-
munosuppressant, concomitant use of ophthalmic topical medications
(excluding non-preserved tear substitutes), concomitant use of systemic
antibiotics or steroids, contact lens wear, active ocular infection or al-
lergy, unable to close eyes or uncontrolled blinking, or previous allergic
reaction to metronidazole and / or ivermectin.
M.Y. Ávila, et al.
Fig. 2. Percentage of patients with remaining viable parasites through visits.
2.3. Clinical Demodex evaluation and sample preparation
Clinical infestation by Demodex was determined through the rota-
tion of the eyelash with cylindrical dandruff. It was possible to observe
Demodex mites moving out and leaving the base of the eyelashes, and
the eyelash was depilated. A total of four eyelashes were depilated from
each patient under a slit lamp microscope in order to determine the
presence of Demodex as well as the species (Demodexbrevis or
Demodexfolliculorum). A positive evaluation was confirmed if one or
more Demodex mites were observed in the sampling. Both eyes were
considered for the analysis.
2.4. Demodex quantification and evaluation
For the detection of Demodex, a drop of glycerol carbonate (TCI
America, Portland, USA) with fluorescein 0.25% (Lab Bioglo, Bogota
DC, Colombia) was used. The eyelashes were mounted with a cover slip.
Demodex mites were examined between 2–4 h after sampling to
assess their morphology. Demodex were counted according to the de-
scribed method, performed by an independent observer.
2.5. Randomization
Patients were randomly assigned to either treatment or placebo
group at a ratio 1:1 (thirty patients for each group) using a computer-
generated randomization schedule. The assignment was done in a
single-blinded manner, in which the subjects were blinded to the
treatment assignment.
2.6. Intervention
Once a diagnosis was established, the patients randomized to
treatment group received an application of the gel containing iver-
mectin 0.1% plus metronidazole 1% on the lid margins of both eyes.
Lid margin redness and bulbar conjunctival hyperaemia were ca-
tegorised from 0 (none) to 3 (severe) according to the following scoring
system: none (0), mild (1, slight localised infection), moderate (2, pink
coloration), and severe (3, dark redness).The score was done by a
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physician different from the one who applied the medication.
Patients were instructed to immediately report any changes and
signs of discomfort. They returned at day 15 for a second clinical eva-
luation, at which time an additional eyelash sample was obtained. They
received the second application of the ivermectin 0.1% plus me-
tronidazole 1% gel, and were scheduled for a third visit. Patients ran-
domized to control group received placebo gel with an identical scheme
as treatment group. These patients after third visit, received the treat-
ment proposed.
Criteria for discontinuing was any adverse effect to medication as
inflammation, redness, and intolerance to the topical gel.
2.7. Statistical analysis
Mann–Whitney tests were performed for between-group compar-
isons. Wilcoxon signed rank test was executed for changes from the
baseline in each group SPSS Statistics (IBM, USA) was used for all
analyses. Data are presented as the mean and standard deviation (SD).
3. Results
3.1. Patient characteristics
The 30 patients assigned to treatment group had an average age of
55.4 ± 19.1 years (range 21–85 years), and the 30 controls were aged
57.6 ± 19.3 years (range 24–85 years).
3.2. Demodex evaluation
The clinical method of rotating eyelashes and evaluating the
movement of the Demodex was easy to perform and allowed for a sa-
tisfactory sample to be obtained for microscopic visualization.
The use of glycerol medium allowed the identification of immature
forms of Demodex, as well as eggs and preserved the structures of the
mites.
M.Y. Ávila, et al.
Fig. 3. Demodex counts per eyelash according to the day of application of ivermectin (0.1%)-metronidazole (1%) gel.
3.3. Efficacy
All patients included tested positive for Demodex spp. before the
treatment, and the counts per eyelash showed a clear correlation with
patient’s signs. A second application of the gel was performed in all
patients on day 15, at which point 86% of patients in the treatment
group tested positive for mites (≥1 mite/lash). Of these patients,
counts were reduced from 8.1 ± 3.5 to 3.0 ± 2.1 mites. A third appli-
cation was conducted on day 30, with only one patient presenting with
mites in the treatment group (Fig. 2). Patients randomized to control
group tested positive for Demodex Spp. in the three visits and, the
counts did not changed. The differences between basal Demodex count
and demodex count at day 15 and 30 (Fig. 3) were statistically sig-
nificant (p < 0.001) in the treatment group, a representative photo of
treated patient pre and post treatment with ivermectin-metronidazol
gel (Fig. 5).
The average value for redness and bulbar conjunctival hyperaemia
score was for the treatment group 2.30 ± 0.75 prior to the treatment
and 0.30 ± 0.5 after the treatment which represented a statistically
significant (p < 0.001) improvement in symptoms and reduction in
redness. In the control group, basal redness and bulbar conjunctival
hyperaemia score was 2.0 ± 0.8 and 2.2 ± 0.8 at the end of the treat-
ment (p = 0.28) (Fig. 4, ).
4. Discussion
Several topical medications have been proposed for the treatment of
blepharitis, including lindane, tea tree oil, permethrin, hexaclor-
ocyclohexane and camphor oil, although all these have several draw-
backs and some toxicity to the ocular surface [15–17]. The mechanism
of action of these drugs is based on topical application allowing direct
contact to the Demodex invading the eyelash folliculum, creating an
acaricidal effect. Novel compounds have been described for the re-
duction and control of Demodex infection as specific terpinoids, how-
ever the maximal acaeridal effect is observed from 20−160 min post
application in the in vitro analysis [18]. A higher dose of ivermectin can
be applied when used topically, and its access to the deeper stratum of
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the skin may have a better effect on the eradication of Demodex inside
the folliculum, this effect has been demonstrated with the topical ap-
plication of ivermectin in the management of rosacea showing an
average reduction from 99 mites/cm2 to 0.8 mites/cm2 [19].
Some studies have demonstrated an effect of ivermectin by itself in
reducing the Demodex mite count; however, the combination of me-
tronidazole and ivermectin produces better results in the management
of blepharitis and rosacea [9].
The use of topical preparations is desirable due to the minimal
systemic effects of both medicaments, and is also better accomplish-
ment by the patients. Topical ivermectin has an excellent profile in the
treatment of Demodex infestation, and also has associated anti-in-
flammatory, antiparasitic and antibacterial actions, reducing the in-
flammatory processes of the skin in rosacea patients [20].
In this study, it was found an excellent response in patients with
blepharitis caused by Demodex spp. infestation, with complete remis-
sion observed in 96% of patients. This result may be attributed to the
release of several antigens by Demodex, including the antigens asso-
ciated with Bacillus oleroneus, which generates an immune response
with several inflammatory changes in the cornea including a reduction
in the proliferation of corneal epithelial cells [21]. Metronidazole is
effective against the inflammatory component of the disease, and also
has antibacterial activity through inhibition of the formation of reactive
oxygen species and have some acaricidal effect per se [22,23].
Systemic ivermectin leads to a reduction in Demodex mites when
used alone, but does not achieve complete remission. This can be ex-
plained by two factors: a high concentration is required, which can only
be achieved by topical application; and its combination with me-
tronidazole could induces a synergistic effect leading to complete era-
dication of the mites, although this hypothesis was not proven in this
study.
In this paper, it was proposed a novel treatment for blepharitis
management, demonstrated to reduce the Demodex spp. count in 96.6%
of patients. This is a better result than studies using systemic treat-
ments, which have reported a reduction in the Demodex count in up to
85% of patients. Therefore, this topical approach seems to be superior
to systemic treatment, also having a better safety profile and posing less
M.Y. Ávila, et al.
Fig. 4. Change in redness score over time of patients included in the study.
Fig. 5. Representative images of lids and eyelashes of patients with Demodex
blepharitis (A) prior to treatment and (B) 15 days after the first application of
the ivermectin (0.1%)-metronidazole (1%) gel.
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risk to patients.
The study had some limitations, the absence of comparison between
single ivermectin or metronidazole therapy and the combined therapy,
and the lack of an objective assessment and registration of symptoms
referred by the patients.
This results are promising and more studies incluiding larger ran-
domized clinical trials comparing with actual management will give us
more information for the management of this entity and this approach
might also be suitable for the management of several parasitic infec-
tions in the eyelids.
Funding
Universidad Nacional de Colombia, Facultad de Medicina,
Convocatoria Trabajos de grado, 2017.
Declaration of Competing Interest
None.
Acknowledgements
The authors gratefully acknowledge the support and permanent
accompaniment provided by E.S.E Hospital Engativa during the im-
plementation of the study.
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