Is Ivermectin (antiparasitic medication) cream safe for treating rosacea during pregnancy?

Ivermectin Cream Safety for Rosacea During Pregnancy

Ivermectin cream should not be used during pregnancy for treating rosacea as its safety in pregnancy has not been established. 1

Safety Profile of Ivermectin in Pregnancy

Topical ivermectin 1% cream, while effective for treating papulopustular rosacea, carries significant concerns for use during pregnancy:

• The FDA drug label explicitly states: "Ivermectin should not be used during pregnancy since safety in pregnancy has not been established." 1
• Animal studies have shown teratogenic effects (cleft palate and clubbed forepaws) at higher doses, although these occurred at doses that were also toxic to the mother 1
• While no adequate well-controlled studies exist in pregnant women, the potential risk to the fetus cannot be ruled out 1

Alternative Treatments for Rosacea During Pregnancy

For pregnant women with rosacea, safer alternatives should be considered:

• Topical metronidazole (0.75% or 1%) is the preferred first-line treatment for rosacea during pregnancy 2
• Azelaic acid is another topical option with a better safety profile during pregnancy compared to ivermectin 3
• Azithromycin is the only oral therapy considered safe for pregnant patients with rosacea, particularly for more severe cases 2

Management Algorithm for Rosacea in Pregnancy

1. First-line treatment:

   • Topical metronidazole 0.75% or 1% once or twice daily 3, 2
   • Gentle skincare routine with sun protection (SPF 30+)
   • Avoidance of identified triggers (alcohol, spicy foods, extreme temperatures)

2. For inadequate response:

   • Add topical azelaic acid 15% gel/foam 3
   • Consider oral azithromycin for moderate-to-severe cases 2

3. For ocular rosacea during pregnancy:

   • Lid hygiene (daily cleansing of eyelid margins, warm compresses)
   • Preservative-free artificial tears for mild symptoms
   • Ophthalmological referral for symptoms beyond mild 3

Important Considerations

• Despite ivermectin's superior efficacy compared to metronidazole in non-pregnant patients (38.4-40.1% success rates vs. 30% for metronidazole) 4, 5, the unknown pregnancy risks outweigh potential benefits
• Treatment of rosacea during pregnancy is challenging as many effective treatments are contraindicated 2
• Resume more effective treatments like topical ivermectin after pregnancy and breastfeeding are complete 1

Breastfeeding Considerations

• Ivermectin is excreted in human milk in low concentrations 1
• Treatment of mothers who intend to breastfeed should only be undertaken when the risk of delayed treatment outweighs possible risk to the newborn 1
• The CDC guidelines note that ivermectin is "probably compatible with breastfeeding" 4

The safety of the mother and developing fetus must take priority when treating rosacea during pregnancy, making topical metronidazole the safest and most appropriate first-line treatment option, despite ivermectin's potentially superior efficacy in non-pregnant patients.