Paeoniflorin inhibits the macrophage-related rosacea-like inflammatory reaction through the suppressor of cytokine signaling 3-apoptosis signal-regulating kinase 1-p38 pathway

ABSTRACT

Rosacea is a facial chronic inflammatory skin disease with immune and vascular system dysfunction. Paeoniflorin (PF) is a traditional Chinese medicine with anti-inflammatory properties. However, its effects on rosacea remain unknown. Here, we investigated the mechanisms through which PF inhibits the macrophage-related rosacea-like inflammatory response. Immunohistochemical methods were used to detect differences in the inflammatory response and degree of macrophage infiltration in granulomatous rosacea lesions and their peripheral areas. Cell Counting Kit-8 was used to determine the cytotoxicity of PF towards RAW 264.7 cells. Reverse transcription-quantitative polymerase chain reaction and western blotting were used to measure the influence of PF on mRNA and protein expression levels of suppressor of cytokine signaling 3 (SOCS3), apoptosis signal-regulating kinase 1 (ASK1)-p38, Toll-like receptor 2, and cathelicidin antimicrobial peptide ( or LL37) in the lipopolysaccharide (LPS)-induced macrophage-related rosacea-like inflammatory response of RAW 264.7 cells. Inflammatory cell infiltration was more pronounced in granulomatous rosacea lesions than in peripheral areas. LL37 expression increased significantly, and the infiltration of a large number of CD68+ macrophages was observed in the lesions. PF promoted SOCS3 expression in RAW 264.7 cells and inhibited the LPS-induced increase in toll-like receptor 2 and LL37 expression through the ASK1-p38 cascade, thereby alleviating the macrophage-related rosacea-like inflammatory response. These changes could be abrogated by SOCS3 siRNA in vitro.In conclusion, the pathogenesis of rosacea involves abnormal macrophage infiltration within the lesions. PF inhibits the macrophage-related rosacea-like inflammatory response through the SOCS3-ASK1-p38 pathway, demonstrating its potential application as a novel drug for rosacea therapy.

Inhibition of Hippo Signaling Improves Skin Lesions in a Rosacea-Like Mouse Model

The Hippo signaling pathway plays a key role in regulating organ size and tissue homeostasis. Hippo and two of its main effectors, yes-associated protein (YAP) and WWTR1 (WW domain-containing transcription regulator 1, commonly listed as TAZ), play critical roles in angiogenesis. This study investigated the role of the Hippo signaling pathway in the pathogenesis of rosacea. We performed immunohistochemical analyses to compare the expression levels of YAP and TAZ between rosacea skin and normal skin in humans. Furthermore, we used a rosacea-like BALB/c mouse model induced by LL-37 injections to determine the roles of YAP and TAZ in rosacea in vivo. We found that the expression levels of YAP and TAZ were upregulated in patients with rosacea. In the rosacea-like mouse model, we observed that the clinical features of rosacea, including telangiectasia and erythema, improved after the injection of a YAP/TAZ inhibitor. Additionally, treatment with a YAP/TAZ inhibitor reduced the expression levels of YAP and TAZ and diminished vascular endothelial growth factor (VEGF) immunoreactivity in the rosacea-like mouse model. Our findings suggest that YAP/TAZ inhibitors can attenuate angiogenesis associated with the pathogenesis of rosacea and that both YAP and TAZ are potential therapeutic targets for patients with rosacea.

Lupus miliaris disseminatus faciei with complete response to isotretinoin

Lupus miliaris disseminatus faciei is an uncommon type of granulomatous rosacea characterized by a papular eruption in the central regions of the face. A 43-year-old woman presented with an asymptomatic papular eruption on the face that had developed over a period of five months. Physical examination revealed multiple, small, reddish-brown papules, distributed symmetrically on the central area of the face. A biopsy was taken, showing dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells. No foreign bodies were found in granulomas and no mycobacterial or fungal components were detected. On the basis of these findings, the diagnosis of lupus miliaris disseminatus faciei was made. The patient was given oral isotretinoin 20mg/day with initial slow response. After 6 months' treatment the lesions completely disappeared. Many authors consider this entity to be a variant of granulomatous rosacea. It is a chronic condition that primarily affects young adults. Treatment is usually unsatisfactory. Therapies with corticosterois, tetracyclines, retinoids, clofazimine or topical tacrolimus have been described but there is a lack of controlled studies and convincing results. Our success with a 6-month course of low dose isotretinoin suggests consideration of a longer trial prior to abandoning this as treatment.

Clinical Evaluation of a Nature-Based Bakuchiol Anti-Aging Moisturizer for Sensitive Skin

BACKGROUND

Patients with sensitive skin find topical retinoid use for anti-aging purposes challenging due to irritation. Bakuchiol, a meroterpene from the Psoralea corylifolia seed, has retinol functionality through retinol-like regulation of gene expression.

OBJECTIVE

This research examined the tolerability, efficacy, and barrier effects of a nature-based bakuchiol-containing cleanser and moisturizer in subjects with sensitive skin.

METHODS

60 female subjects Fitzpatrick skin types I–V age 40–65 years with sensitive mild to moderate photodamaged skin were enrolled in this 4 week study. A sensitive skin panel was constructed: 1/3 eczema/atopic dermatitis, 1/3 rosacea, 1/3 cosmetic intolerance syndrome. Subjects used a nature-based cleanser and moisturizer twice daily and underwent transepidermal water loss (TEWL), corneometry, tolerability assessments, and efficacy assessments at baseline, 5–10 minutes post-application, and week 4.

RESULTS

The skin care products were well tolerated and efficacious (P<0.001) in terms of investigator assessed improvement in visual smoothness, tactile smoothness, clarity, radiance, overall appearance, and global anti-aging. Cheek corneometry measurements demonstrated a statistically significant 16% increase in skin moisture content (P<0.001).

CONCLUSION

A bakuchiol nature-based anti-aging moisturizer is well tolerated and effective in individuals with sensitive skin.J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5522.

Consensus on the therapeutic management of rosacea - Brazilian Society of Dermatology

BACKGROUND

Rosacea is a chronic inflammatory disease of the skin, relatively more frequent in women over 30 with a low phototype and proven genetic predisposition. Although its etiology is unknown and possibly multifactorial, the immunological abnormality, associated with neurovascular dysregulation and triggering factors, are important elements in its pathophysiology, which lead to the main changes of inflammation, vasodilation, and angiogenesis that are responsible for the clinical manifestations. Despite the lack of cure, numerous therapeutic options are available for the different clinical presentations of the disease, with satisfactory responses.

OBJECTIVE

To reach a consensus, with recommendations from experts, on the therapeutic management of rosacea suitable to the Brazilian setting.

METHODS

The study was conducted by five specialized dermatologists from university centers, representatives of the different Brazilian regions, with experience in rosacea, who were appointed by the Brazilian Society of Dermatology. Based on the adapted DELPHI methodology, the experts contributed through an updated bibliographic review of the scientific evidence, combined with personal experiences.

RESULTS

The group of experts reached a consensus on the relevant aspects in the therapeutic management of rosacea, providing information on epidemiology, pathophysiology, triggering factors, clinical condition, classification, quality of life, and comorbidities. Consensus was defined as approval by at least 90% of the panel.

CONCLUSION

Despite the impossibility of cure, there are several therapeutic alternatives specific to each patient that provide excellent results, with chances of total improvement and long periods of remission, promoting a positive impact on quality of life. This consensus provides detailed guidance for clinical practice and therapeutic decisions in rosacea.

Updates on treatment guidelines for psoriasis, atopic dermatitis (eczema), hidradenitis suppurativa, and acne/rosacea during the COVID-19 pandemic

Owing to the evolving COVID-19 pandemic and emerging data regarding immunosuppressant therapies for inflammatory cutaneous diseases, dermatologists are being encouraged to reevaluate their patients' treatment regimens to minimize any potential risk of SARS-CoV-2 infection. This article includes an overview of the up-to-date international and U.S. treatment guidelines for psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne/rosacea; it provides tables summarizing these resources to assist providers and patients in remaining updated regarding recommended treatment modifications during the pandemic (See Tables 1-4).

Demodex-induced Lupus miliaris disseminatus faciei: A case report

RATIONALE

Lupus miliaris disseminatus faciei (LMDF) is an inflammatory granulomatous skin disease without a clear etiology that frequently involves the middle area of the face and the upper eyelids. Pathological features of the disease include caseation necrosis and epithelioid granuloma. Consensus treatment for LMDF is currently unavailable.

PATIENT CONCERNS

A 47-year-old Chinese female patient who presented with facial pruritic, erythematous papules 8 months before this study. She was diagnosed with skin tuberculosis at another hospital and given antituberculosis medication. However, the treatment was not efficacious.

DIAGNOSES

In this study, the diagnosis of Demodex-induced LMDF was made by a dermatologist according to physical examination, skin biopsy pathology, and microscopic examination.

INTERVENTIONS

The patient was given ornidazole tablets (500 mg twice a day) and recombinant bovine basic fibroblast growth factor gel (0.2 g/cm twice a day) for an 8-week period.

OUTCOMES

Eight weeks after the treatment, the facial erythematous papules were improved, and no new skin lesions were observed. The patient showed no signs of recurrence during the 6-month follow-up.

LESSONS SUBSECTIONS

This case showed that ornidazole combined with recombinant bovine basic fibroblast growth factor gel might be useful in treatment of Demodex-induced LMDF. In addition, the results suggested that pathological caseation necrosis was caused by a series of inflammatory and immune responses to Demodex infection.

Treating Inflammation in Rosacea: Current Options and Unmet Needs

Rosacea is a disease resulting from dysregulation of innate, adaptive, and neurovascular immune systems. Inflammatory pathways activated in rosacea can explain many of its signs and symptoms. Current treatments address some of these inflammatory processes, alleviating erythema and decreasing papules and pustules. However, for the majority of patients, complete clearance of these features is not currently achievable even with combination therapy. There is a need to address the spectrum of inflammatory processes involved in rosacea and for more efficacious agents with the goal of providing complete clearance for patients. J Drugs Dermatol. 2020;19(6): doi:10.36849/JDD.2020.5187.

Rosacea Treatment Satisfaction: Matching Adjusted Indirect Treatment Comparison Analysis of Metronidazole Gel or Cream vs Azelaic Acid Foam

OBJECTIVE

To assess differences in patient-reported treatment side effects and concerns associated with azelaic acid 15% foam (AAF) vs metronidazole cream (MC) and metronidazole gel (MG).

METHODS

This study used matching-adjusted indirect comparison (MAIC) to compare patient-reported outcomes from survey data evaluating rosacea treatments. Outcomes of interest included percentages of patients reporting concerns and side effects and measures of importance of the concerns and tolerability of the side effects. Patients in each analysis (MG vs AAF and MC vs AAF) were matched using stabilized inverse propensity scores.

RESULTS

When compared to AAF, MG-treated patients more frequently reported concerns with treatment efficacy (54% vs 4%), application (7% vs 3%), and treatment side effects. MC-treated patients more frequently reported concerns with treatment efficacy (61% vs 5%) and dryness (8% vs 5%). AAF-treated patients more frequently reported concerns with cost of treatment compared with MG (7% vs 1%) and MC (9% vs 4%). Among patients reporting concerns, level of importance associated with these concerns was similar for AAF-treated patients compared with MG- and MC-treated patients. When compared to AAF-treated patients, MG-treated patients more frequently reported side effects of dryness (26% vs 15%) and uneven skin tone (3% vs 0%), and MC-treated patients more frequently reported side effects of burning (7% vs 3%), itching (7% vs 5%), and redness (7% vs 5%). MG- and MC-treated patients indicated greater intolerance for reported side effects than AAF-treated patients.

CONCLUSIONS

MG- and MC-treated patients more frequently reported treatment concerns and side effects than AAF-treated patients, and tolerability of those side effects was higher for patients treated with AAF. While treatment cost is a more frequent concern in patients treated with AAF, these patients less frequently reported concerns with treatment efficacy and reported similar or greater tolerance to side effects than patients treated with either MC or MG. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.3679.

The role of hypothalamus-pituitary-adrenal (HPA)-like axis in inflammatory pilosebaceous disorders

Skin is the largest peripheral endocrine organ and functions as a hormone target and endocrine gland. A cutaneous hypothalamus-pituitary-adrenal (HPA)-like axis enables the skin to respond to stress and regulates its steroidogenic activity. The pilosebaceous unit is a site for production and metabolism of a number of steroid hormones, including stress and sex hormones. This is an overview of the important role that the cutaneous HPA-like-axis plays in the pathogenesis and treatment of inflammatory pilosebaceous disorders, including acne, rosacea, seborrheic dermatitis, and hidradenitis suppurativa.

Minocycline 1.5% foam for the topical treatment of moderate to severe papulopustular rosacea: Results of 2 phase 3, randomized, clinical trials

BACKGROUND

Efficacious topical medications for rosacea are needed. FMX103 1.5% is a novel topical minocycline foam that may have therapeutic benefits in treating rosacea while minimizing systemic adverse effects due to its topical route of delivery.

OBJECTIVE

To determine the efficacy, safety, and tolerability of 12 weeks of treatment with FMX103 1.5% topical minocycline foam for papulopustular rosacea.

METHODS

Two 12-week, phase 3, randomized, multicenter, double-blind, vehicle-controlled, 2-arm studies were performed in patients with moderate to severe papulopustular rosacea.

RESULTS

Participants who received FMX103 1.5%, versus control individuals treated with vehicle, exhibited a significantly greater reduction in the number of inflammatory lesions (FX2016-11: -17.57 vs -15.65; P = .0031; FX2016-12: -18.54 vs -14.88; P < .0001) and higher rates of Investigator Global Assessment treatment success (FX2016-11: 52.1% vs 43.0%; P = .0273; FX2016-12: 49.1% vs 39.0%; P = .0077). No serious treatment-related treatment-emergent adverse events occurred.

LIMITATIONS

The generalizability of these data from a controlled clinical trial should be examined in a real-world setting.

CONCLUSIONS

FMX103 1.5% was efficacious for moderate to severe papulopustular rosacea and maintained a favorable safety profile.

The Use of Oral Antibiotics in the Management of Rosacea

Rosacea is common inflammatory facial dermatosis. Rosacea has variable manifestations including facial flushing, central facial erythema, telangiectasias, and papulopustular lesions. Treatment of rosacea is challenging given the varied manifestations and incompletely understood etiology, but the treatment of papulopustular presentations often relies on oral antibiotics. Tetracyclines, specifically doxycycline, are the most commonly prescribed antibiotics for rosacea. Other antibiotics that can be used include macrolides, commonly azithromycin, and rarely, metronidazole. This paper will review the evidence for the use of antibiotics in the treatment of rosacea. J Drugs Dermatol. 2019;18(6):506-513.

What Is PFE? It May Just Be Time You Found Out

With all the literature and research we have on acne and rosacea, there are still many unanswered questions. Over time, as we uncover more information on both preexisting and newly recognized pathophysiologic pathways, modes of drug action, alternative therapies, caveats related to basic skin care, and the potential roles for physical modalities, we often find that specific information that we thought was fact, is later altered, expanded, or corrected. What is interesting, and sometimes perplexing to me personally, is how difficult it is for the clinical dermatology community at large to incorporate well-published concepts into everyday clinical practice.

[PATHOGENETIC FEATURES AND METHODS FOR TREATMENT OF VARIOUS FORMS OF ROSACEA]

The aim of the work was to study the features of the pathogenesis of various clinical forms of rosacea (the presence of mite Demodex folliculorum, the determination of VEGF, IL-2 IL-6, IL-8) and, based on the obtained results, to ensure adequate methods of therapy. Mite identification was performed by microscopy. The concentration of cytokines in patients with various clinical forms of rosacea (papulopustular form 15 patients, steroid form - 15, erythematous telangiectic form - 10, Ophthalmo Rosacea - 3, rhinophyma - 3) was determined by enzyme immunoassay using appropriate monoclonal antibodies and expressed in samples. Based on the results we obtained in the local treatment of patients with papulopustular rosacea (with a high population density of demodicosis ticks and an increased concentration of IL-8 in the blood), 1% ivermectin cream was applied externally to the skin of the face 1 time per day every day for the entire course of treatment (3-4 months). In patients with erythematous-teloangiectatic form (with a high cytokine VEGF, IL-8), a combined phased use of 1% pimecrolimus cream 14 days and 0.5% bromonidine tartrate gel was administered once a day - 14 days (with a single course of 1 month). In patients with a steroid form of rosacea with a high concentration of cytokines (IL-2, IL-6, IL-8), 1% pimecrolimus was administered 2 times a day - 1 month, 1% ivermectin 1 time a day - 14 days. During therapy, patients with advanced treatment were divided into 2 groups. Patients of group 1, who received externally 1% ivermectin 1 time per day as the main therapy, in the evening for 16 weeks. Group 2 applied 1% ivermectin and 1% pimercolimus cream for 16 weeks. In group 2 patients showed a significant improvement in a shorter time (4 weeks compared to 8 weeks in 1 group of patients). Taking into account the torpid flow and the difficulty of rosacea therapy, the pathogenetic approach when choosing new external preparations, opens promising directions for further deeper study of the pathophysiological mechanisms underlying the individual clinical forms of dermatosis. At the same time, the efficacy and safety of using ivermectin, pimecrolimus, and brimonidine tartrate in the treatment of various forms of this dermatosis suggests their widespread use in practical dermatology.

Concerns and Treatment Satisfaction in Patients Being Treated With Azelaic Acid Foam for Rosacea

Objective: To describe patient characteristics, concerns, side effects, treatment satisfaction, and quality of life (QoL) of rosacea patients currently being treated with monotherapy azelaic acid foam based on patient-reported data. Methods: The study utilized a non-interventional, prospective, observational design. Patients were recruited in the United States and were eligible if the following criteria were met: diagnosed with rosacea by a medical professional, ≥18 years of age, currently receiving monotherapy with azelaic acid foam, and able to provide informed consent. Patients using other topical treatments for rosacea during enrollment were excluded. An online tool administered a survey of 3 questionnaires including the Rosacea Treatment Preference Questionnaire, Treatment Satisfaction with Medicines Questionnaire (SATMED-Q), and Dermatology Life Quality Index (DLQI). The survey collected demographics, clinical characteristics, treatment history, adverse events, and patient-reported outcomes related to treatment with azelaic acid foam and QoL with rosacea. Results: 54 patients met eligibility criteria. Participants were primarily female (90.7%), ranging from 26 to 63 years of age. The most common subtypes reported were erythematotelangiectatic and papulopustular (74.1% each) with 59.3% of participants reporting mild symptoms (16.7% “absent”; 24.1% “moderate”) in the 4 weeks before enrollment. The majority reported no concerns (74.1%) with their treatment. The biggest concern was cost (11.1%), with a mean importance score (IS) on a 10-point scale of 9.3. A majority (77.8%) of patients reported no side effects. Side effects reported included dryness (13%; IS: 5.3), stinging (7.4%, IS: 2.5), itching (5.6%; IS: 4.7), or burning (3.7%; IS: 7.0). Global satisfaction (SATMED-Q) mean score was 79.0 and treatment effectiveness mean score was 70.8. QoL impact of rosacea was minimal (mean DLQI score: 2.35). In regression models, increasing dryness was significantly associated with worsening outcomes in SATMED-Q and DLQI. Conclusions: Patient characteristics of the study population closely mirror the distribution of rosacea by gender and subtype as in previous estimates. Findings indicate minimal patient concerns with azelaic acid foam and primarily pertained to cost. Patient-reported side effects were rare. Minor patient-reported side effects and concerns do not appear to affect rosacea-related QoL and medication satisfaction. Compared to a previously conducted study of similar design with patients using metronidazole gel and metronidazole cream, more patients in the current study reported no concerns with their treatment, while the number of patients reporting no side effects, as well as mean SATMED-Q and DLQI scores, were similar. Further research is necessary to directly compare the results of these 2 studies. J Drugs Dermatol. 2019;18(4):381-386.

A Biologically Based Approach to Acne and Rosacea

Complementary and alternative medicine (CAM) therapies are increasing in popularity in the field of dermatology. Natural products and holistic approaches are in high demand among patients and research has begun to support their roles in acne and rosacea pathophysiology. In this article, commonly utilized biologically based complementary and alternative therapies for acne and rosacea are reviewed from an evidence-based perspective. Therapies discussed include vitamin C, nicotinamide, zinc, tea tree oil, green tea, resveratrol, curcumin, feverfew, licorice, chamomile, polypodium leucotomos, and nutrition-based approaches. J Drugs Dermatol. 2018;17(6):611-617.

Clinically Relevant Reduction in Persistent Facial Erythema of Rosacea on the First Day of Treatment With Oxymetazoline Cream 1.0

BACKGROUND

Persistent facial erythema is a clinically challenging feature of rosacea.

OBJECTIVE

To evaluate persistent erythema reduction on the first day of treatment from pooled data from two pivotal trials of topical oxymetazoline cream 1.0% (oxymetazoline) in persistent facial erythema of rosacea.

METHODS

In two identically designed, phase 3, multicenter trials, adults with moderate to severe persistent facial erythema of rosacea (Clinician Erythema Assessment [CEA] grade ≥3 and Subject Self-Assessment [SSA] grade ≥3) were randomized 1:1 to once-daily topical oxymetazoline or vehicle; the primary efficacy endpoint was ≥2-grade composite CEA and SSA improvement from baseline on day 29. This post hoc analysis evaluated the proportion of patients achieving ≥1-grade composite and individual CEA and SSA improvement at 1, 3, 6, 9, and 12 hours postdose on day 1 (N=885).

RESULTS

Significantly more patients achieved ≥1-grade composite and individual CEA and SSA improvement with the first application of oxymetazoline than with vehicle (P less than 0.001) at all postdose time points, beginning with hour 1. Day 1 safety assessments were similar between treatments.

LIMITATIONS

Short-term, post hoc analysis.

CONCLUSIONS

A ≥1-grade improvement in persistent erythema achieved after the first dose of once-daily topical oxymetazoline demonstrated clinically meaningful improvement from the beginning of therapy. J Drugs Dermatol. 2018;17(6):621-626.

Fifteen Minute Test May Save 15% or More on Rosacea Treatment

Rosacea is a common inflammatory skin condition that impacts a large portion of fair-skinned populations. The redness associated with rosacea can be a significant challenge. Brimonidine sulfate and oxymetazoline HCL were both recently approved by the FDA for the management of facial redness. These agents, however, are costly, and not all patients respond to the medication. Herein, we describe a clinical pearl that helps to optimize patient selection for the medications. This saves the patient and the health care system both time and money. J Drugs Dermatol. 2018;17(5):692-693.