of contraceptives (>4 years) and MM.
Our ﬁndings may be
attributed to the substantially lower dose of EE currently
employed in contraceptives. Further, our results support a
majority of reports that do not specify, but likely include a pre-
ponderance of microdose EE products, where no association is
found for MM.
Strengths of this study include the large sam-
ple size, deﬁnition of study population to restrict ﬁndings to
microdose EE exposure, and multi-year follow-up. Limitations
of the study include the retrospective nature and limited sample
size for the outcome of interest, which did not allow for further
analyses. Findings from this study provide valuable supporting
evidence for the safety proﬁle of microdose EE contraceptives
and risk for MM.
A. E. Verzi,
D. P. West
Department of Dermatology, Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA,
Robert H. Lurie Comprehensive Cancer
Center, Northwestern University, Chicago, IL, USA
*Correspondence: D. P. West. E-mail: firstname.lastname@example.org
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Immune deﬁciency and rosacea
We thank Ciccarese et al.
for their interest in our report.
They wonder whether the patients that we reported deﬁnitely
had demodicidosis associated with rosacea, and above all, they
provide their own interesting ﬁndings in 60 patients with rosa-
cea, ﬁndings that we will not comment here.
We agree that skin scraping with a D. folliculorum count is
certainly the less unreliable way to support a diagnosis of
demodicidosis. We did not perform this test, as in our
experience, strong itching in papulopustular rosacea in individu-
als with immune deﬁciency is always associated with D. folliculo-
rum proliferation. Furthermore, the key message of our
publication was to report the factual occurrence of rosacea segre-
gating with GOF STAT1 mutations in a well-investigated family,
the infection with D. folliculorum being only one possible causa-
To respond to their questions, we treated the two individuals
(children) who complained about itch. A single dose of iver-
mectin 200 microgram/kg resulted in almost complete ameliora-
tion that lasted about 1–2 months, and treatment was repeated
J. Second, D. Lipsker*
Dermatology Department, H
opitaux Universitaires de Strasbourg,
*Correspondence: D. Lipsker. E-mail: email@example.com
1 Lipsker D, Second J, Korganow AN, Jannier S, Puel A. Rosacea and
demodicidosis associated with gain-of-function mutation in STAT1. J Eur
Acad Dermatol Venereol 2017. https://doi.org/10.1111/jdv.14413.
2 Ciccarese J, Parodi A, Rebora A, Drago AE. The usefulness of investigating
the possible underlying conditions in rosacea. J Eur Acad Dermatol Vener-
eol 2017. https://doi.org/10.1111/jdv.14547.
The usefulness of investigating
the possible underlying
conditions in rosacea
The paper entitled ‘Rosacea and demodicidosis with gain of
function mutation in STAT1’ by Second et al.
is of indubitable
interest and prompted us to make some observations. The
Authors described a patient with cutaneous and ocular rosacea
that they related to demodicidosis as oral ivermectin improved
the cutaneous lesions.
However, the Authors did not demon-
strate by skin scraping nor by standardized skin surface biopsy
(SSSB) an excessive number of Demodex folliculorum (DF) mites
in the pilosebaceous units to justify an oral antiparasitic treat-
ment as a drug of ﬁrst choice.
DF is usually found in the pilose-
baceous follicle with an average density <5 mites/cm
its density may increase in the skin affected by rosacea.
Authors used 200 lg/kg ivermectin without indicating the daily
dosage nor the treatment duration.
Furthermore, it is not clear
if the relatives of the proband, who shared the same STAT1
mutation and were diagnosed as having rosacea, have been trea-
ted with oral ivermectin and, in such case, if they improved as
Lastly, the Authors did not specify the disease-free time
© 2017 European Academy of Dermatology and Venereology
2018, 32, e86–e121
Letters to the Editor