Applying the phenotype approach for rosacea to practice and research

BACKGROUND

Rosacea diagnosis and classification have evolved since the 2002 National Rosacea Society expert panel subtype approach. Several working groups are now aligned to a more patient-centric phenotype approach, based on an individual's presenting signs and symptoms. However, subtyping is still commonplace across the field and an integrated strategy is required to ensure widespread progression to the phenotype approach.

OBJECTIVES

To provide practical recommendations that facilitate adoption of a phenotype approach across the rosacea field.

METHODS

A review of the literature and consolidation of rosacea expert experience.

RESULTS

We identify challenges to implementing a phenotype approach in rosacea and offer practical recommendations to overcome them across clinical practice, interventional research, epidemiological research and basic science.

CONCLUSIONS

These practical recommendations are intended to indicate the next steps in the progression from subtyping to a phenotype approach in rosacea, with the goals of improving our understanding of the disease, facilitating treatment developments and ultimately improving care for patients with rosacea.

Development of Patient Decision Aids for Plaque Psoriasis and Acne

INTRODUCTION

Despite proven benefits in other medical specialties, there is a paucity of patient decision aids (PDAs) in dermatology. The present study developed online PDAs for acne and psoriasis, incorporating iterative patient and physician feedback, in accordance with International Patient Decision Aid Standards (IPDAS).

DESIGN AND METHOD

Content was adapted from clinical practice guidelines and primary research and formatted for an 8th grade reading level. Feedback on content and format was obtained through focus groups with 15 psoriasis patients and survey with 34 acne patients. Feedback on presentation and clinical utility of the PDAs was gathered by survey from 51 physicians in Canada and the United States. Each data collection stage informed further development.

RESULTS

Demand for decision support, and satisfaction with the PDAs was high among patients. Physicians were approving of content and expressed a strong interest in PDA use.

CONCLUSION

Patients and physicians approve of the PDAs' content, format, and intended use. Online PDAs allow accessibility for patients and may reduce barriers to use for physicians.

Oral health and dental morbidity in long-term allogeneic blood and marrow transplant survivors in Australia

BACKGROUND

Oral and dental disease is a major cause of long-term morbidity following allogeneic blood and marrow transplantation (Allo-BMT). This study aimed to describe the extent and range of oral and dental complications in BMT recipients and to identify gaps in service provision provided to this high-risk group.

METHODS

Participants were Allo-BMT recipients, aged >18 years, and received transplants between 2000 and 2012 in NSW. They completed seven surveys, the purpose-designed Sydney Post-BMT Study survey and six other validated instruments.

RESULTS

Of 441 respondents, many reported dry mouth (45.1%), dental caries (36.7%), mouth ulcers (35.3%), oral GVHD (35.1%), gingivitis (16.2%), tooth abscess (6.1%) and oral cancer (1.5%). Regular dental visits were reported by 66.2% of survivors. Middle-high income, older age and geographic location showed a positive association with regular dental visits. Of those who did not visit the dentist regularly, 37% stated they did not feel it necessary, 36% reported cost and 20% stated it was not advised by the treating team.

CONCLUSION

Despite oral complications commonly occurring after Allo-BMT, many survivors receive inadequate dental care. These results emphasize the need for improved oral health education, the importance of regular dental checks and improvement in the delivery of dental health services for BMT survivors.

[Three-year clinical effects of a modified semi-fixed bridge on restoring a missing posterior tooth]

OBJECTIVE

To observe the effects of a modified semi-fixed bridge to restore a missing posterior tooth for three years.

METHODS

In the study, 38 cases with a posterior tooth missed were chosen as experiment group. The inclusion criteria for these cases required that one abutment tooth be defected, and another abutment intact. The missed posterior tooth was restored with a modified semi-fixed bridge in which a metal wing retainer was applied to the intact abutment tooth and a full crown retainer was applied to the defected abutment tooth, and the non-rigid connector linked to the metal wing retainer and the pontic, while the rigid connector linked to the full crown retainer and the pontic. And 42 cases with same abutment conditions were chosen as control group. These control patients were treated with classical rigidly-fixed partial dentures. The clinical effects regarding the bridge survival, abutment conditions, and etc. were observed by examination.

RESULTS

The average observation time for experiment group was 40.3 months (from 9 to 60 months). One case failed with loose crown retainer after 7 months' usage. Another failed case was the same performance after 20 months' wearing. The restorations were rebounded after the inner face of crowns was treated, and they were used normally. No loose abutment and retainer, no decayed abutment teeth were found, and the marginal adaptations between retainers and abutment teeth were good. The average observation time of control group was 44.7 months(from 22 to 50 months). No secondary decays and loose abutment teeth were detected and the marginal adaptation of the retainers was good.

CONCLUSION

This modified semi-fixed bridge has similar survival rate and clinical effects to restore a missing posterior tooth when compared with the traditional rigidly-fixed partial dentures. But the long-term observation is required.

Thromboembolism Induced by Umbilical Cord Mesenchymal Stem Cell Infusion: A Report of Two Cases and Literature Review

OBJECTIVE

To investigate the thromboembolism induced by blood-mediated inflammatory reactions against infused cells during the clinical application of stem cells.

METHODS

Two patients with renal transplantation and chronic kidney disease, respectively, experienced thromboembolism after umbilical cord mesenchymal stem cell (UCMSC) infusion. The clinical manifestations and the laboratory test results were collected and analyzed.

RESULTS

The patients received stem cell infusion through the peripheral veins and presented with a swollen and painful forearm postinfusion. Doppler ultrasound showed venous clots at the proximal end of the puncture site. Urokinase and warfarin were used for thrombolytic therapy. The swelling and pain were relieved and cured.

CONCLUSION

Safety concerns are still a primary hurdle for stem cell therapy, and thromboembolism as a critical complication should be prevented appropriately.

Oncogenic activation of JAK3-STAT signaling confers clinical sensitivity to PRN371, a novel selective and potent JAK3 inhibitor, in natural killer/T-cell lymphoma

Aberrant activation of the JAK3-STAT signaling pathway is a characteristic feature of many hematological malignancies. In particular, hyperactivity of this cascade has been observed in natural killer/T-cell lymphoma (NKTL) cases. Although the first-in-class JAK3 inhibitor tofacitinib blocks JAK3 activity in NKTL both in vitro and in vivo, its clinical utilization in cancer therapy has been limited by the pan-JAK inhibition activity. To improve the therapeutic efficacy of JAK3 inhibition in NKTL, we have developed a highly selective and durable JAK3 inhibitor PRN371 that potently inhibits JAK3 activity over the other JAK family members JAK1, JAK2, and TYK2. PRN371 effectively suppresses NKTL cell proliferation and induces apoptosis through abrogation of the JAK3-STAT signaling. Moreover, the activity of PRN371 has a more durable inhibition on JAK3 compared to tofacitinib in vitro, leading to significant tumor growth inhibition in a NKTL xenograft model harboring JAK3 activating mutation. These findings provide a novel therapeutic approach for the treatment of NKTL.

Hemodynamic force triggers rapid NETosis within sterile thrombotic occlusions

Essentials Neutrophil extracellular traps (NETs) are generated during thrombosis and sepsis. The effect of hemodynamics on NETosis during sterile thrombosis was studied using microfluidics. Pressure gradients > 70 mmHg per mm-clot across sterile occlusions drive shear-induced NETosis. High interstitial hemodynamic forces trigger rapid NET release.

SUMMARY

Background Neutrophil extracellular traps (NETs) are released when neutrophils encounter infectious pathogens, especially during sepsis. Additionally, NETosis occurs during venous and arterial thrombosis, disseminated intravascular coagulation, and trauma. Objective To determine whether hemodynamic forces trigger NETosis during sterile thrombosis. Methods NETs were imaged with Sytox Green during microfluidic perfusion of activated factor XII-inhibited or thrombin-inhibited human whole blood over fibrillar collagen (with or without tissue factor). Results For perfusions at initial inlet venous or arterial wall shear rates (100 s-1 or 1000 s-1 ), platelets rapidly accumulated and occluded microchannels with subsequent neutrophil infiltration under either flow condition; however, NETosis was detected only in the arterial condition. The level of shear-induced NETs (SINs) at 30 min was > 150-fold higher in the arterial condition in the absence of thrombin and > 80-fold greater in the presence of thrombin than the level in the venous condition. With or without thrombin, venous perfusion for 15 min generated no NETs, but an abrupt shift-up to arterial perfusion triggered NETosis within 2 min, NETs eventually reaching levels 15 min later that were 60-fold greater than that in microchannels without perfusion shift-up. SINs contained citrullinated histone H3 and myeloperoxidase, and were DNase-sensitive, but were not blocked by inhibitors of platelet-neutrophil adhesion, high-mobility group protein box 1-receptor for advanced glycation end products interaction, cyclooxygenase, ATP/ADP, or peptidylarginine deiminase 4. For measured pressure gradients exceeding 70 mmHg per millimeter of clot across NET-generating occlusions to drive interstitial flow, the calculated fluid shear stress on neutrophils exceeded the known lytic value of 150 dyne cm-2 . Conclusions High interstitial hemodynamic forces can drive physically entrapped neutrophils to rapidly release NETs during sterile occlusive thrombosis.

The role of the endometrial receptivity array (ERA) in patients who have failed euploid embryo transfers

PURPOSE

Endometrial receptivity issues represent a potential source of implantation failure. The aim of this study was to document our experience with the endometrial receptivity array (ERA) among patients with a history of euploid blastocyst implantation failure. We investigated whether the contribution of the endometrial factor could be identified with the ERA test and if actionable results can lead to improved outcomes.

METHODS

A retrospective review was performed for 88 patients who underwent ERA testing between 2014 and 2017. Reproductive outcomes were compared for patients undergoing frozen embryo transfer (FET) using a standard progesterone protocol versus those with non-receptive results by ERA and subsequent FET according to a personalized embryo transfer (pET) protocol.

RESULTS

Of patients with at least one previously failed euploid FET, 22.5% had a displaced WOI diagnosed by ERA and qualified for pET. After pET, we found that implantation and ongoing pregnancy rates were higher (73.7 vs. 54.2% and 63.2 vs. 41.7%, respectively) compared to patients without pET, although differences were not statistically significant.

CONCLUSIONS

Our experience demonstrates that a significant proportion of patients with a history of implantation failure of a euploid embryo have a displaced WOI as detected by the ERA. For these patients, pET using a modified progesterone protocol may improve the outcomes of subsequent euploid FET. Larger randomized studies are required to validate these results.

Fluoroquinolones and BK Virus Nephropathy: A Myth or a Reality

BK polyomavirus (BKV) is a challenging problem for the transplant nephrologist. Various strategies have been used to prevent or treat BK virus nephropathy (BKVN). These include reduction in immunosuppression, intravenous immune globulin, cidofovir, leflunomide, and the fluoroquinolone antibiotics. All these agents have their own toxicities. Great interest was shown to use fluoroquinolones to prevent BKVN after its useful experience was reported in bone marrow transplant. Fluoroquinolones being cheap and easily available, attracted nephrologists to use it, for prevention of BKVN. These agents have been shown in vitro studies to be effective. However, there are mixed results about their effectiveness in prevention of BKVN in clinical setting. This review will focus the evidence available for using fluoroquinolones in prevention of BKVN and its usefulness. Furthermore, a way forward to use these agents or not for prevention of BKVN will also be discussed.

Shared decision making and patient decision aids in dermatology

Shared decision making combines individual patient interests and values with clinical best evidence under the guiding principle of patient autonomy. Patient decision aids can support shared decision making and facilitate decisions that have multiple options with varying outcomes for which patients may attribute different values. Given the variable psychosocial impact of skin disease on individuals and relative uncertainty regarding best treatments and their adherence in many dermatological conditions, informed shared decision making, supported by patient decision aids, should constitute a central component of dermatological care.

Metastatic melanoma: prognostic factors and survival in patients with brain metastases

Brain metastases from malignant melanoma carry a poor prognosis. Novel systemic agents have improved overall survival (OS), but the value of whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) remains uncertain. The melanoma-specific graded prognostic assessment (msGPA) provides useful prognostic information, but the relevance to the modern-day population has not been validated. Since 2011, 53 patients received treatment for brain metastases from malignant melanoma at the Rosemere Cancer Centre medical oncology clinic. Data were collated on demographic factors and survival. Survival analyses were performed using Kaplan–Meier methods. Cox regression was used to identify prognostic factors on univariate and multivariate analysis. OS from the date of diagnosis of brain metastases was 4.83 months (range 0.27–30.4 months). On univariate analysis, BRAF, performance status and msGPA were significant prognostic indicators for OS (p = 0.0056, p = 0.0039 and p = 0.0001 respectively). msGPA remained significant on multivariate analysis (p = 0.0006). OS for BRAF-positive patients receiving targeted treatment (n = 22) was significantly better than for BRAF-negative patients (n = 26), with median survival times of 8.2 and 3.7 months respectively (p = 0.0039, HR 2.36). SRS combined with systemic agents (n = 16) produced an OS of 13.5 months. Patients receiving WBRT alone (n = 21) had a poor prognosis (2.2 months). The msGPA remains a valid prognostic indicator in the era of novel systemic treatments for melanoma. BRAF-positive patients receiving targeted agents during their treatment had favorable survival outcomes. WBRT alone should be use with caution in the active management of melanoma brain metastases.

Risk of persistent or recurrent cervical neoplasia in patients with 'pure' adenocarcinoma-in-situ (AIS) or mixed AIS and high-grade cervical squamous neoplasia (cervical intra-epithelial neoplasia grades 2 and 3 (CIN 2/3)): a population-based study

OBJECTIVE

To compare outcomes of patients with pure adenocarcinoma-in-situ (AIS) and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma.

DESIGN

Retrospective cohort study.

SETTING

Statewide population in Western Australia.

POPULATION

Women diagnosed with AIS between 2001 and 2012.

METHODS

We conducted a retrospective, population-based cohort study.

MAIN OUTCOME MEASURES

De-identified linked data were utilised to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post-treatment), and adenocarcinoma.

RESULTS

636 patients were eligible for analysis. The mean age was 32.3 years and median follow-up interval was 2.5 years. Within the study cohort, 266 patients (41.8%) had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 patients (7.4%) had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (hazard ratio (HR) 2.3; 95%CI 1.28-3.94; P = 0.005), age >30 years (HR 2.1; 95%CI 1.16-3.81; P = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05-10.92; P = <0.001) and AIS lesions >8 mm (HR 2.5; 95%CI 1.00-6.20; P = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence.

CONCLUSION

In this study, pure AIS was associated with greater risk of persistence/recurrence than was mixed AIS/CIN 2/3. AIS lesions >8 mm and positive endocervical margins were significant predictors for persistent or recurrent disease.

TWEETABLE ABSTRACT

Pure cervical adenocarcinoma-in-situ (AIS) may have greater risk of recurrence than AIS co-existing with CIN 2/3.

Subunit Vaccines Consisting of Antigens from Dormant and Replicating Bacteria Show Promising Therapeutic Effect against Mycobacterium Bovis BCG Latent Infection

To screen effective antigens as therapeutic subunit vaccines against Mycobacterium latent infection, we did bioinformatics analysis and literature review to identify effective antigens and evaluated the immunogenicity of five antigens highly expressed in dormant bacteria, which included Rv2031c (HspX), Rv2626c (Hrp1), Rv2007c (FdxA), Rv1738 and Rv3130c. Then, several fusion proteins such as Rv2007c-Rv2626c (F6), Rv2031c-Rv1738-Rv1733c (H83), ESAT6-Rv1738-Rv2626c (LT40), ESAT6-Ag85B-MPT64_<190-198> -Mtb8.4 (EAMM), and EAMM-Rv2626c (LT70) were constructed and their therapeutic effects were evaluated in pulmonary Mycobacterium bovis Bacilli Calmette-Guérin (BCG) - latently infected rabbit or mouse models. The results showed that EAMM and F6 plus H83 had therapeutic effect against BCG latent infection in the rabbit model, respectively, and that the combination of EAMM with F6 plus H83 significantly reduced the bacterial load. In addition, the fusion proteins LT40 and LT70 consisting of multistage antigens showed promising therapeutic effects in the mouse model. We conclude that subunit vaccines consisting of both latency and replicating-associated antigens show promising therapeutic effects in BCG latent infection animal models.

Diphenylcyclopropenone for the treatment of cutaneous in-transit melanoma metastases - results of a prospective, non-randomized, single-centre study

BACKGROUND

Current treatments for in-transit melanoma (ITM) metastases are frequently invasive and do not improve overall survival. Recently, there has been increasing investigation into the use of topical agents. Diphenylcyclopropenone or diphencyprone (DPCP) is a novel, topical therapy that has been reported to have immune-sensitizing properties useful in the treatment of ITM.

OBJECTIVE

To assess the clinical outcomes of patients treated within a prospective, non-randomized, non-comparative study using DPCP for cutaneous ITM metastases.

METHODS

A review was conducted assessing the outcomes of 58 patients prospectively treated using DPCP. Patients had satellite or in-transit disease (stage IIIB+), with all lesion morphology types included. The patients were treated through a single, specialized clinic with regular outpatient follow-up. DPCP was topically applied as an aqueous cream in 0.005-1% concentrations once to twice per week for up to 24-48 h of duration. To assess variables associated with response, a per-protocol statistical analysis was performed.

RESULTS

Fifty-four patients were treated who satisfied eligibility criteria for analysis. The overall response rates were as follows: complete response 22%, partial response 39%, stable disease 24% and progressive disease 15%. The mean time to complete response was 10.5 months, mean duration (disease-free interval) 12.3 months and recurrence rate in complete responders 41%. Lesion morphology was predictive of clinical benefit with a higher response in epidermotropic disease (P < 0.05).

CONCLUSIONS

DPCP provided a well-tolerated, convenient and efficacious treatment for cutaneous ITM metastases. Identifying patterns of response may assist treatment selection and improve patient-rated outcomes.

Next Generation Driver for Attosecond and Laser-plasma Physics

The observation and manipulation of electron dynamics in matter call for attosecond light pulses, routinely available from high-order harmonic generation driven by few-femtosecond lasers. However, the energy limitation of these lasers supports only weak sources and correspondingly linear attosecond studies. Here we report on an optical parametric synthesizer designed for nonlinear attosecond optics and relativistic laser-plasma physics. This synthesizer uniquely combines ultra-relativistic focused intensities of about 10²⁰ W/cm² with a pulse duration of sub-two carrier-wave cycles. The coherent combination of two sequentially amplified and complementary spectral ranges yields sub-5-fs pulses with multi-TW peak power. The application of this source allows the generation of a broad spectral continuum at 100-eV photon energy in gases as well as high-order harmonics in relativistic plasmas. Unprecedented spatio-temporal confinement of light now permits the investigation of electric-field-driven electron phenomena in the relativistic regime and ultimately the rise of next-generation intense isolated attosecond sources.

Regenerate bone fracture rate following femoral lengthening in paediatric patients

PURPOSE

Femoral lengthening using a circular or mono-lateral frame is a commonly used technique. Fracture at the site of the regenerate bone is a major concern especially following removal of the external fixator. This aim of this study was to assess the rate of fracture of the regenerate bone in this single surgeon series of paediatric patients and determine potential risk factors.

METHODS

Retrospective review of all the femoral lengthening performed by the senior author was performed. The medical and physiotherapy notes were reviewed. The gender, age at time of surgery, disease aetiology, total days in the external fixator and length of the new regenerate bone were recorded. Patients who sustained a regenerate fracture were identified.

RESULTS

A total of 176 femoral lengthening procedures were performed on 108 patients. Eight regenerate fractures occurred in seven patients (4.5%). The mechanism of injury was a fall in five cases and during physiotherapy in three cases. The regenerate fracture occurred a median number of nine days following removal of frame. There was no significant difference between gender, age at time of surgery, total time in external fixator between those who sustained a regenerate fracture and those patients who did not. A significant difference was noted between the amount of lengthening between the 'regenerate fracture group' and the 'no fracture group' (50 mm vs 38 mm, respectively; p = 0.029). There was no association between disease aetiology and risk of regenerate fracture.

CONCLUSIONS

Femoral lengthening of more than 50 mm increases the risk of a fracture at the regenerate site regardless of the disease aetiology. We recommend avoidance of aggressive physiotherapy for the initial four weeks following external fixator removal.

Head-shaft angle changes during internal and external shoulder rotations: 2-D angulation in 3-D space

INTRODUCTION

Restoration of native head-shaft angle (HSA) is critical for treatment of proximal humerus fracture. However, HSA has not been properly investigated according to the humeral rotation. This study was designed to analyze the relationship between the humeral rotation and the HSA at 1° increments, and clarify its serial changing pattern according to the humeral rotation.

HYPOTHESIS

The angulation of HSA would be undervalued when the humerus is being rotated externally and it would be overvalued when it is being rotated internally.

MATERIALS AND METHODS

Eight dried cadaveric normal humeri were CT scanned. They were analyzed using computer-aided design with a standardized neutral position. HSA was the angle between the humeral shaft axis (SA) and the humeral head axis (HA). SA and HA were the best-fit lines through center of all the best-fitting circles in every cross section along the humeral shaft and within the humeral head, respectively. Each 3D model was rotated 30° internally and 45° externally relatives to the SA at 1° increments with the camera was fixed at antero-posterior view of neutral position. Angulation of HSA in every rotational degree was documented as ratio relatives to the angulation of HSA in neutral position.

RESULTS

The average HSA at neutral position was 133±1.93°. HSA was underestimated by 8±1.9% and it was overestimated by 20±5.1% at the maximum external rotation (ER) and internal rotation (IR), respectively. HSA was underestimated by 1% in every 5.8° of ER and overestimated by 1% in every 1.5° of IR. Rotational misalignments within 10° of IR and 18° of ER could be tolerated (P>.05).

CONCLUSIONS

HSA was underestimated at ER and was overestimated at IR. This information could be useful for surgeons in restoring the native HSA for treatment of proximal humerus fracture.

TYPE OF STUDY

Basic research study.

The α-β circular scanning with large range and low noise

A circular-route scanning method called α-β circular scanning is proposed and realized using sinusoidal signals with a constant phase difference of π/2. Experiments show that the circular scanning range of α-β circular scanning is 57% greater than the rectangular scanning range of raster scanning within an effective optical field of view. Moreover, the scanning speed is improved by 7.8% over raster scanning because the whole sine signal is utilized in α-β circular scanning whereas the flyback area of the saw-tooth signal needs to be discarded in raster scanning. The maximum scanning acceleration decreases by a factor of 44, drastically decreasing the high noise, which should considerably elongate the lifetime of the galvanometers while inhibiting internal vibration. The proposed α-β circular scanning technique could be used in scanning imaging, optical tweezers and laser-beam fabrication.

Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel

BACKGROUND

Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient management. The ROSacea COnsensus panel was established to address this issue.

OBJECTIVES

To incorporate current best treatment evidence with clinical experience from an international expert panel and establish consensus to improve outcomes for patients with rosacea.

METHODS

Seventeen dermatologists and three ophthalmologists reached consensus on critical aspects of rosacea treatment and management using a modified Delphi approach. The panel voted on statements using the responses 'strongly disagree', 'disagree', 'agree' or 'strongly agree'. Consensus was defined as ≥ 75% 'agree' or 'strongly agree'. All voting was electronic and blinded.

RESULTS

The panel agreed on phenotype-based treatments for signs and symptoms presenting in individuals with rosacea. First-line treatments were identified for individual major features of transient and persistent erythema, inflammatory papules/pustules, telangiectasia and phyma, underpinned by general skincare measures. Multiple features in an individual patient can be simultaneously treated with multiple agents. If treatment is inadequate given appropriate duration, another first-line option or the addition of another first-line agent should be considered. Maintenance treatment depends on treatment modality and patient preferences. Ophthalmological referral for all but the mildest ocular features should be considered. Lid hygiene and artificial tears in addition to medications are used to treat ocular rosacea.

CONCLUSIONS

Rosacea diagnosis and treatment should be based on clinical presentation. Consensus was achieved to support this approach for rosacea treatment strategies.