Pimecrolimus for treatment of acne rosacea

BACKGROUND

Rosacea is a common disease, which is often resistant to treatment. Topical calcineurin inhibitors have been efficacious in the treatment of other inflammatory disorders of the skin, and tacrolimus has been reported as an effective treatment option for erythrotelangiectatic rosacea.

OBJECTIVE

Because of the benefits seen with tacrolimus in previous publications, we investigated the efficacy of a closely related compound, pimecrolimus, in patients with erythrotelangiectatic, papulopustular, and edematous rosacea.

METHODS

Twelve patients with erthryotelangiectatic or papulopustular rosacea who had failed conventional therapy were treated with topical pimecrolimus cream twice daily for 12-18 weeks. No patients had used any other treatment for rosacea within 30 days of the start of therapy. During the course of the study, no other topical or systemic treatment of rosacea was allowed.

RESULTS

Ten of 12 patients showed substantial improvement of erythema, while five of six patients with a papulopustular component noted at least an 80% decrease in the number of lesions.

CONCLUSIONS

It appears pimecrolimus may be efficacious in the treatment of erythrotelangiectatic and papulopustular rosacea and may be considered in patients with recalcitrant disease.

Rosacea and its management: an overview

BACKGROUND

Rosacea is a chronic inflammatory disorder that affects 10% of the population. The prevalence of rosacea is highest among fair-skinned individuals, particularly those of Celtic and northern European descent. Since a cure for rosacea does not yet exist, management and treatment regimens are designed to suppress the inflammatory lesions, erythema, and to a lesser extent, the telangiectasia involved with rosacea.

OBJECTIVES

This review outlines the treatment options that are available to patients with rosacea.

METHODS

Published literature involving the treatment or management of rosacea was examined and summarized.

RESULTS

Patients who find that they blush and flush frequently, or have a family history of rosacea are advised to avoid the physiological and environmental stimuli that can cause increased facial redness. Topical agents such as metronidazole, azelaic acid cream or sulfur preparations are effective in managing rosacea. Patients who have progressed to erythematotelangiectatic and papulopustular rosacea may benefit from the use of an oral antibiotic, such as tetracycline, and in severe or recalcitrant cases, isotretinoin to bring the rosacea flare-up under control. Treatment with a topical agent, such as metronidazole, may help maintain remission. Patients with ocular involvement may benefit from a long-term course of an antibiotic and the use of metronidazole gel. A surgical alternative, laser therapy, is recommended for the treatment of telangiectasias and rhinophyma. Patients with distraught feelings due to their rosacea may consider cosmetic camouflage to cover the signs of rosacea.

CONCLUSIONS

With the wide variety of oral and topical agents available for the effective management of rosacea, patients no longer need to feel self-conscious because of their disorder.

Acneiform facial eruptions: a problem for young women

OBJECTIVE

To summarize clinical recognition and current management strategies for four types of acneiform facial eruptions common in young women: acne vulgaris, rosacea, folliculitis, and perioral dermatitis.

QUALITY OF EVIDENCE

Many randomized controlled trials (level I evidence) have studied treatments for acne vulgaris over the years. Treatment recommendations for rosacea, folliculitis, and perioral dermatitis are based predominantly on comparison and open-label studies (level II evidence) as well as expert opinion and consensus statements (level III evidence).

MAIN MESSAGE

Young women with acneiform facial eruptions often present in primary care. Differentiating between morphologically similar conditions is often difficult. Accurate diagnosis is important because treatment approaches are different for each disease.

CONCLUSION

Careful visual assessment with an appreciation for subtle morphologic differences and associated clinical factors will help with diagnosis of these common acneiform facial eruptions and lead to appropriate management.

Diagnosing and managing the patient with rosacea

Rosacea is a common, chronic facial dermatosis that may present in varying manners. Subtypes of rosacea include erythematotelangiectatic, papulopustular, phymatous, and ocular. In this article, we discuss the diagnosis of these rosacea subtypes and focus on the therapeutics specific to each. Treatments include topical agents, oral antibiotics, laser therapies, surgical treatments, and the role of cosmetics and skin care.

Subantimicrobial dose doxycycline: a unique treatment for rosacea

Rosacea affects many individuals and is commonly treated with long-term antibiotics, which are associated with the emergence of antibiotic-resistant organisms. Recently, subantimicrobial dose doxycycline 20 mg twice a day (SDD) has been used to treat rosacea because of its anti-inflammatory properties. Results of clinical studies support the benefits of SDD, its efficacy in rosacea and acne vulgaris, and even its potential use to prevent atherosclerosis.

Medical treatment of rosacea with emphasis on topical therapies

Due to the development and release of newer topical formulations, the diagnosis and treatment of rosacea has received renewed attention over the past 3-5 years both in the literature and at medical symposia. Rosacea is a very common facial dermatosis. In the US, rosacea is estimated to affect > 14 million people, predominantly adults with approximately 60% of cases diagnosed before the age of 50. A frustrating aspect of the disease is its inherent chronicity punctuated with periods of exacerbation and relative remission. A variety of subtypes have been identified which correlate with clinical presentation. Although the pathogenesis of rosacea is poorly understood, multiple topical agents are available. The efficacy of topical therapy for rosacea relates primarily to reduction in inflammatory lesions (papules, pustules), decreased intensity of erythema, a reduction in the number and intensity of flares and amelioration of symptoms, which may include stinging, pruritus and burning. The list of main topical agents utilised for the treatment of rosacea include metronidazole, sulfacetamide-sulfur, azelaic acid and topical antibiotics (clindamycin, erythromycin). Depending on the severity at initial presentation, topical therapy may be combined with systemic antibiotic therapy (e.g., oral tetracycline derivative). Newer therapeutic choices primarily involve improved vehicle formulations, which demonstrate favourable skin tolerability and cosmetic elegance.

The pharmacologic therapy of rosacea: a paradigm shift in progress

A number of topical and systemic pharmacologic therapies, some of which remain investigational, have been used to treat rosacea. The pathophysiology of rosacea appears to be inflammatory, and most of the interventions modulate the inflammatory process in some way. Topical agents include various formulations of sodium sulfacetamide and sulfur, metronidazole, azelaic acid, and benzoyl peroxide/clindamycin. Oral agents include antibiotics in conventional and subantimicrobial doses. A paradigm shift in progress in the management of rosacea encompasses the use of these and other agents either alone or, increasingly, in different combinations, based on the subtype of rosacea.

Adapalene vs. metronidazole gel for the treatment of rosacea

BACKGROUND

Rosacea is a common, chronic dermatosis that requires long-term therapy. Oral isotretinoin and topical and/or oral antibiotics are effective, but their usage may be limited due to side-effects.

OBJECTIVE

The goal of the study was to compare the efficacy of topical adapalene gel (0.1%) and topical metronidazole gel (0.75%) in the treatment of patients with papulopustular rosacea.

METHODS

This study included 55 patients with papulopustular rosacea. Diagnostic efforts were focused on clinical and histological features. Patients were randomly assigned to the adapalene (n = 30) and metronidazole (n = 25) groups. Sunlight protection factor 20 cream was used to protect all patients from sunlight. The characteristics and numbers of inflammatory papules, pustules, erythema and telangiectasia were scored at baseline and after 2, 4, 8 and 12 weeks. Side-effects were recorded at each visit.

RESULTS

Fifty patients, 27 in the adapalene group and 25 in the metronidzaole group, completed the study. Significant reductions in the total number of inflammatory lesions were found in the adapalene group compared with the metronidazole group. There was no significant difference in the scores of erythema and telangiectasia in the adapalene group. However, a significant reduction in erythema was seen in the metronidazole group.

CONCLUSIONS

Adapalene gel is well tolerated and can be used as an alternative for topical treatment of papulopustular rosacea.

Evidence-based dermatology

Evidence-based dermatology (EBD) is the application of the principles of evidence-based medicine to the diagnosis and treatment of skin disorders. EBD does not discount the individual dermatologist's clinical judgment. In fact, EBD is based on the interaction of external evidence, the physician's clinical experience, and the patient's experience. Randomized controlled trials constitute one of the highest levels of evidence and are the gold standard for validating a therapeutic intervention. For the treatment of rosacea, oral tetracycline, topical metronidazole, topical azelaic acid, and topical sulfur/sodium sulfacetamide have been validated by more than one randomized controlled trial.

Present and future rosacea therapy

Despite its prevalence, rosacea has not received the same attention of researchers as other dermatologic disorders. Nevertheless, new pharmacologic and nonpharmacologic therapies for the condition continue to be developed. The future of rosacea treatment will probably involve a combination of drugs and devices. Certain core therapies (i.e., topical metronidazole, topical azelaic acid, oral tetracyclines, and topical sulfur/sodium sulfacetamide) are validated by the greatest amount of high-order clinical evidence and will undoubtedly remain first-line therapeutic choices. However, more research is necessary to validate the efficacy and safety of newer pharmacologic agents and light-based therapy. Because rosacea is a chronic condition, pharmacologic maintenance therapy is necessary to maintain remission.

[Perolen cream for therapy of rosacea]

Acne rosacea belongs to the most common inflammatory dermatoses of the face. Current treatments for this disease remain unsatisfactory, that's why searching for new methods and remedy are very important. For the topical therapy we have used a new cream perolen ("New Pharma", Georgia). The main component of the creme is the water extract of gastric mucous membrane of cow, which is the source of proteolytic ferments. Another main component is a Perilla oil which contains unsaturated fatty acids--linolenic and linol, presented in the highest amounts. The cream is characterized by bactericidal, bacteriostatical, anti-inflammatory and anti-oxidant effects, it also assists to tissue regeneration, make blood vessels more elastic and decreases penetration. We have observed 40 patients with papulo-pustular subtype of rosacea (25 females and 15 males). Patients were divided into two groups. For oral therapy in both groups we used Tetracycline and Trichopol. For topical treatment in the first group of patients was used rosamet cream and in the second group--perolen cream. Both of these creams were applied once daily during 2 months. Reduction of comedones, inflammations, papules, pustules and small nodules occurred after one month. Erythema, oedema, desquamation improved significantly during the treatment, but the positive effects were more prominent in the second group of patients. In conclusion, the study shows that topically used cream perelon represents a new approach in the management of acne rosacea.

The rigor of trials evaluating Rosacea treatments

The Cochrane Collaboration is an international nonprofit organization that conducts systematic reviews of healthcare interventions. The organization has recently reviewed all studies meeting designated criteria on interventions for rosacea. To be included in the review, trials had to be randomized controlled trials (RCTs) that met the methodological criteria of the reviewers and that were conducted in an adult patient population with moderate to severe rosacea. The electronic databases searched included The Cochrane Skin Group Specialised Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, BIOSIS, and Science Citation Index. The reviewers tried to obtain details of unpublished and ongoing RCTs through correspondence with authors and pharmaceutical companies. After evaluating the included studies, the reviewers concluded there is evidence that topical metronidazole in 1% cream and 0.75% gel formulations and azelaic acid in 20% cream formulation are effective and safe. Furthermore, there is some evidence that oral metronidazole and tetracycline are effective. The reviewers also made suggestions about future rosacea research.

A review of clinical experience and recommendations for improving patient care

This article reviews the history of retinoids from the 1960s to the present, clinical experiences, and recommendations for improving care for patients with acne. How a retinoid is chosen by the clinician based on irritation potential, treatment outcome, patient profile, type of acne, and the patient's clinical experience is discussed, as well as the use of retinoids in the treatment of photoaging and other approved and off-label uses.

[Demodicidosis in humans as a current problem in dermatology]

Demodex mites are common parasites in the hair follicles and in the pilosebaceous glands. Demodex folliculorum and D. brevis have been identified in humans and play a role in three facial conditions: Pityriasis folliculorum, rosacea-like demodicidosis and Demodicidosis gravis. The highly infected sites by this mites are: forehead, area around the orbit, area around the nose, chin and area around the mouth. Infection of the skin by D. folliculorum is more frequent among females and in the elderly people. The presence of mites can be determined by microscopic inspection of secretion from sebum glands and skin surface biopsy. The aim of our study was to report a 25-year-old woman suffering from skin diseases with high D. folliculorum density.

Use of Macrolides and Tetracyclines for Chronic Inflammatory Diseases

OBJECTIVE:

To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions.

DATA SOURCES:

Searches of MEDLINE (1966–March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis.

STUDY SELECTION AND DATA EXTRACTION:

Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based.

DATA SYNTHESIS:

Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea.

CONCLUSIONS:

The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

Non-acne dermatologic indications for systemic isotretinoin

Systemic isotretinoin has been used to treat severe acne vulgaris for 20 years. However, isotretinoin also represents a potentially useful choice of drugs in many dermatologic diseases other than acne vulgaris. Diseases such as psoriasis, pityriasis rubra pilaris, condylomata acuminata, skin cancers, rosacea, hidradenitis suppurativa, granuloma annulare, lupus erythematosus and lichen planus have been shown to respond to the immunomodulatory, anti-inflammatory and antitumor activities of the drug. Isotretinoin also helps prevent skin cancers such as basal cell carcinoma or squamous cell carcinoma. A combination of systemic isotretinoin and interferon-alpha-2a may provide a more potent effect than isotretinoin alone in the prevention and treatment of skin cancers.Systemic isotretinoin may be considered as an alternative drug in some dermatologic diseases unresponsive to conventional treatment modalities. However, randomized clinical trials aimed at determining the role of systemic isotretinoin therapy in dermatologic diseases other than acne vulgaris are required.

Ocular rosacea: an update on pathogenesis and therapy

PURPOSE OF REVIEW

Ocular rosacea is a common and potentially blinding eye disorder with an uncertain etiology. Therapies currently in vogue for ocular rosacea have not been rigorously studied with regards to specific indications, optimal dosing regimens, or treatment efficacy. This review will summarize the recent literature with regards to etiology and therapy of ocular rosacea, and will also examine current thinking about the parent disorder, acne rosacea.

RECENT FINDINGS

Comparatively few papers on ocular rosacea were published in the past year. Recent articles on the prevalence of ocular rosacea in patients with acne rosacea suggested that between 6 and 18% of acne rosacea patients have signs or symptoms of ocular rosacea, but few cases were confirmed by an ophthalmologist. Recent articles on the pathogenesis of ocular rosacea have focused on the role of bacterial lipases, and interleukin-1alpha and matrix metalloproteinases in the blepharitis and corneal epitheliopathy, respectively. Other reports highlighted the presence of the disorder in children, and the lack of masked, placebo-controlled studies for those therapies currently in common use.

SUMMARY

The epidemiology, etiology, and optimal therapy of ocular rosacea remain to be determined, and will require a more concerted effort to delineate.

Rosacea lymphoedema of the eyelid

PURPOSE

To present a patient with rosacea lymphoedema of one upper eyelid resulting in unilateral complete ptosis.

METHODS

A 51-year-old white man presented with a 12-month history of progressive painless swelling of the left upper eyelid. An incisional biopsy of the upper eyelid was performed.

RESULTS

The biopsy showed dermal oedema with lymphangiectasia and telangiectasia, accompanied by a mild to moderate mixed chronic inflammatory infiltrate of lymphocytes, histiocytes, plasma cells and rare eosinophils. Stains for fungi and mycobacteria were negative. The lack of lichenoid reaction, dermal mucin or lip swelling indicated a lymphoedematous manifestation of rosacea. The patient was treated with minocycline and prednisolone with no effect.

CONCLUSION

Rosacea lymphoedema involving the eyelid, as in our case, is a rare complication and can present diagnostic and therapeutic challenges to the ophthalmologist.