Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel

Clinical and erythema-directed imaging evaluation of papulo-pustular rosacea with topical ivermectin: a 32 weeks duration study

Background: Ivermectin (IVM) 1% cream represents an emerging therapy for papulo-pustular rosacea (PPR) and erythema-directed photography is a useful tool for evaluation of patient's erythema. Objective: The aim of our study was to assess the efficacy of IVM in PPR in achieving clear status at 8 weeks or at 20 weeks followed by respectively 24 and 12 weeks follow-up, using clinical/instrumental evaluation. Methods: Twenty patients with PPR were instructed to apply IVM for 8 weeks. At week 8, in case of complete response the therapy was stopped and a follow-up period up to 24 weeks was carried out, whereas in case of improvement the treatment was extended for additional 12 weeks followed by a 12 weeks follow-up. Instrumental evaluation was performed by erythema-directed digital photography (VISIA-CRTM- RBXTM). Results: At week 8, complete response was observed in 31.6% of cases along with a significant decrease of erythema degree. During treatment extension, additional improvement in terms of complete response, respectively at 12 (42%), 16 (47%) and 20 (58%) weeks, and reduction of erythema degree was observed. Conclusions: IVM is a valuable therapeutic option in mild/moderate PPR. Erythema-directed digital photography enhances erythema changes visualization compared to clinical observation alone.

Treatment of rosacea and demodicosis with benzyl benzoate: effects of different doses on Demodex density and clinical symptoms

BACKGROUND

Patients with rosacea or demodicosis have high facial skin Demodex densities (Dds). Topical ivermectin, benzyl benzoate (BB) and crotamiton have been shown to decrease Dds in vivo, but there are few data on the clinical and acaricidal effects of BB among patients with rosacea.

OBJECTIVE

To evaluate the impact of topical BB (+crotamiton) treatment on Dds and clinical symptoms of rosacea and demodicosis, and compare three BB treatment regimens.

METHODS

In this retrospective observational study, 394 patients (117 with rosacea, 277 with demodicosis) were included. Three BB (+crotamiton) treatment regimens were compared: 12% once daily, 12% twice daily and 20% once daily. Dds were measured using two consecutive standardized skin surface biopsies [superficial (SSSB1) and deep (SSSB2)] before treatment and at the first follow-up. Symptoms were evaluated using investigator global assessment. Treatment was considered effective if the Dd had normalized (SSSB1 ≤ 5 D/cm² AND SSSB2 ≤ 10 D/cm²) or symptoms had cleared and curative if the Dd had normalized and symptoms had cleared.

RESULTS

At an average of 2.7 months after treatment start, the total Dd (SSSB1 + 2) had decreased by 72.4 ± 2.6% from the initial value across the whole cohort. Dds had normalized in 139 patients (35%), and symptoms had cleared in 122 (31%). Treatment was effective in 183 (46%) patients and curative in 78 (20%). Compliance was good: 77% of patients correctly followed treatment instructions. Results were similar in patients with rosacea and those with demodicosis. The 12% once-daily regimen was less effective than the other doses and had poorer compliance than the 12% twice-daily regimen.

CONCLUSION

Topical treatment with BB (+crotamiton) may be an effective treatment for rosacea and demodicosis, indirectly supporting a key role of the mite in the pathophysiology of rosacea. The two higher dose regimens were more effective than the lower dose.

Dermatologic Problems Commonly Seen by the Allergist/Immunologist

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments

BACKGROUND

Rosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.

OBJECTIVES

To update our systematic review on interventions for rosacea.

METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk-of-bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence.

RESULTS

We included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light-based treatment. We present the most current evidence for rosacea management based on a phenotype-led approach.

CONCLUSIONS

For reducing temporarily persistent erythema there was high-certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low-to-moderate-certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high-certainty evidence for topical azelaic acid and topical ivermectin; moderate-to-high-certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate-certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low-certainty evidence for tetracycline and low-dose minocycline. For ocular rosacea, there was moderate-certainty evidence that oral omega-3 fatty acids were effective and low-certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.

Characterizing high-burden rosacea subjects: a multivariate risk factor analysis from a global survey

Objective: To characterize rosacea features suitable for identification of high-burden (HB) subjects in clinical practice.Design: Global online survey with subjects recruited using an online panel from the United States, Canada, Italy, United Kingdom, Germany and France. Subjects self-reported a physician's diagnosis of rosacea.Measurements: HB subjects were defined as those with ≥3/4 domains (quality of life, lifestyle adaptation, time trade-off, willingness to pay) greater than the median. Group characteristics were analyzed and multivariate-logistic modeling used to investigate factors most associated with HB.Results: 710 subjects completed the survey, including 158 HB subjects. HB was observed in all self-declared rosacea severities. HB subjects were more likely to spend more time daily on skin care and experienced approximately double the impact of health problems on work productivity in the past 7 days (p < .01). In the past 12 months, HB subjects were more likely to have at least one visit to the emergency room (41.8% vs 11.2%; p < .01). In the multivariate risk analysis, factors most associated with HB included rosacea severity, impact of health problems on regular daily activities and age at first symptoms.Conclusion: Rosacea has a distinct subset of HB subjects who can be successfully characterized.

Combined treatment of recalcitrant papulopustular rosacea involving pulsed dye laser and fractional microneedling radiofrequency with low-dose isotretinoin

BACKGROUND

While a considerable number of cases with papulopustular rosacea (PPR) are resistant to conventional medications, therapeutic regimens are not currently established. Pulsed dye laser (PDL) and fractional microneedling radiofrequency (FMR) have previously demonstrated satisfactory results for anti-angiogenesis, anti-inflammation, and dermal remodeling.

AIMS

To evaluate the efficacy and safety of novel combination regimen with low-dose oral isotretinoin, PDL, and FMR in the treatment of recalcitrant PPR.

PATIENTS AND METHODS

A retrospective study was undertaken for recalcitrant PPR patients to evaluate the clinical course of novel combination regimen. Twenty-five PPR patients who had failed in previous first-line therapies were enrolled. They were treated with three sessions of PDL and FMR consecutively at 4-week intervals, maintaining daily oral administration of 10 mg isotretinoin for 8 weeks. Objective assessments, erythema index measurement, and patients' subjective satisfaction were evaluated at each visit and 16 weeks after the final treatment.

RESULTS

At the final follow-up visit, the number of papules and pustules decreased by 71%, and erythema index by 54% compared with baseline (P < 0.05 for both). Physician's global assessment based on rosacea severity score and patients' subjective assessments paralleled with these results. No serious side effect was observed during whole study periods.

CONCLUSION

This novel combination regimen demonstrated satisfactory efficacy with reasonable safety profiles for the treatment of recalcitrant PPR.

Erythematotelangiectatic rosacea may be associated with a subclinical stage of demodicosis: a case-control study

BACKGROUND

Facial densities of Demodex mites have been observed to be greater in patients with demodicosis and papulopustular rosacea than in healthy control patients. In patients with erythematotelangiectatic rosacea (ETR), this density has been observed to be similar to or greater than that of healthy controls. Erythema and telangiectasia, characteristics of ETR, are often observed among patients with pityriasis folliculorum, a discreet demodicosis, suggesting a possible link between these conditions.

OBJECTIVES

To compare the facial Demodex densities of patients with clinical ETR and patients with healthy skin, demodicosis, rosacea with papulopustules, and other facial dermatoses.

METHODS

In this retrospective study, we recorded Demodex densities measured using two consecutive standardized skin surface biopsies (SSSB1 and SSSB2) in 23 patients with ETR, 20 healthy control patients, 590 patients with demodicosis, 254 with rosacea with papulopustules and 180 with other facial dermatoses.

RESULTS

Patients with ETR had higher Demodex densities (D cm^-2 ) than did the healthy controls (mean ± SEM; SSSB1: 15·7 ± 6·3 vs. 1·8 ± 1·1 D cm^-2 , P = 0·042; SSSB2: 38·0 ± 13·7 vs. 5·1 ± 2·1 D cm^-2 , P = 0·026) and patients with other dermatoses (SSSB1: 0·4 ± 0·1 D cm^-2 , P = 0·004; SSSB2: 1·3 ± 0·3 D cm^-2 , P = 0·004), but lower densities than patients with demodicosis (SSSB1: 82·7 ± 4·2 D cm^-2 , P = 0·008; SSSB2: 172·2 ± 7·7 D cm^-2 , P = 0·001) or rosacea with papulopustules (SSSB1: 86·6 ± 7·3 D cm^-2 , P = 0·027; SSSB2: 197·0 ± 12·1 D cm^-2 , P = 0·002).

CONCLUSIONS

ETR may be associated with nonvisible Demodex proliferation, possibly corresponding to a subclinical stage of demodicosis. Dermatologists should be aware of this potential association and look for subclinical demodicosis in patients with ETR, so that topical acaricidal treatment can be offered if Demodex density is high.

A novel moisturizer with high sun protection factor improves cutaneous barrier function and the visible appearance of rosacea-prone skin

Background

Consensus guidelines advocate general skincare for rosacea patients.

Objectives

Two independent studies were performed to assess whether a tinted daily SPF‐30 facial moisturizer (DFM30) improves barrier function of dry skin and the efficacy and tolerability of DFM30 on rosacea‐prone skin.

Methods

In study 1, electrical capacitance (EC) and transepidermal water loss (TEWL) were measured at baseline, 2, 4, 8, and 24 hours after a single application of DFM30 and on a control site in 21 healthy females with dry skin. Study 2 evaluated 33 females with mild to moderate rosacea and nontransient erythema. Efficacy and tolerability after once‐daily DFM30 were assessed using a chromameter, image analysis of photographs, and trained rater and patient evaluations up to day 22.

Results

In study 1, EC showed statistically significant increases at 2, 4, and 8 hours, and TEWL showed statistically significant decreases 2, 4, 8, and 24 hours after DFM30 application to healthy females compared to baseline. In study 2, covering skin redness improved significantly after DFM30 application on day 1; 33.3% showed improved covering skin redness compared to baseline. Patients reported significantly less redness on day 8 than day 3. Feelings of dryness and tightness/tension were lower 30 minutes after first application. Feeling of dryness was lower than baseline after 3 days, 1 and 3 weeks. Image analysis suggested redness was significantly lower on day 22 compared to baseline. Chromameter readings showed significantly lower erythema on the cheek compared to baseline. All patients stated that DFM30 relieves and neutralizes visible redness who also indicated that they would purchase DFM30, and the product was well tolerated.

Conclusions

These studies show that DFM30 is suitable as part of the skincare regimens advocated by ROSacea COnsensus (ROSCO) for rosacea patients. DFM30 is an effective moisturizer that improves cutaneous barrier function and the appearance of rosacea‐prone skin.

Recent advances in understanding and managing rosacea

Rosacea is a common chronic inflammatory skin disease of the central facial skin and is of unknown origin. Currently, two classifications of rosacea exist that are based on either "preformed" clinical subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) or patient-tailored analysis of the presented rosacea phenotype. Rosacea etiology and pathophysiology are poorly understood. However, recent findings indicate that genetic and environmental components can trigger rosacea initiation and aggravation by dysregulation of the innate and adaptive immune system. Trigger factors also lead to the release of various mediators such as keratinocytes (for example, cathelicidin, vascular endothelial growth factor, and endothelin-1), endothelial cells (nitric oxide), mast cells (cathelicidin and matrix metalloproteinases), macrophages (interferon-gamma, tumor necrosis factor, matrix metalloproteinases, and interleukin-26), and T helper type 1 (T _H1) and T _H17 cells. Additionally, trigger factors can directly communicate to the cutaneous nervous system and, by neurovascular and neuro-immune active neuropeptides, lead to the manifestation of rosacea lesions. Here, we aim to summarize the recent advances that preceded the new rosacea classification and address a symptom-based approach in the management of patients with rosacea.

Fluorescent light energy: Treating rosacea subtypes 1, 2, and 3

Kleresca® biophotonic platform utilizing fluorescent light energy effectively decreased the inflammatory and erythematous reaction common in rosacea subtypes 1, 2, and 3. Kleresca® may be considered as a single treatment for rosacea, targeting multiple features, or combined with invasive methods for an enhanced normalizing and healing profile of the skin.

Elevated Tear Human Neutrophil Peptides 1-3, Human Beta Defensin-2 Levels and Conjunctival Cathelicidin LL-37 Gene Expression in Ocular Rosacea

Purpose: To investigate the role of innate immunity in ocular rosacea. Methods: Thirty-two patients with ocular rosacea patients (group-1) and 28 healthy volunteers (group-2) who served as controls were enrolled in the study. Tear function parameters were assessed, conjunctival impression cytology was performed and tear samples were collected. Human-neutrophil-peptides (HNP) 1-3 and human-beta-defensin-2 (hBD-2) levels were measured in tears by using ELISA tests. Cathelicidin leucin-leucin-37 (LL-37), hBD-2, human-beta-defensin-9 (hBD-9) gene expression levels were measured in the conjunctival impression cytology samples using real-time polymerase chain reaction. Results: Tear HNP1-3 (p = 0.024), hBD-2 (p < 0.001), conjunctival LL-37 gene expression rate (p = 0.014) and ocular surface disease index scores (p = 0.001) were higher and the tear break-up time was lower (p = 0.003) in group-1. No other differences were found between the groups. Conclusion: The results of this study suggest the role of abnormal innate immunity in the pathophysiology of ocular rosacea by revealing elevated antimicrobial peptide levels.

A Rare Dermatologic Disease in Pregnancy: Rosacea Fulminans- Case Report and Review of the Literature

BACKGROUND:

Rosacea is a common, chronic disorder that can present with a variety of cutaneous or ocular manifestations. Skin involvement primarily affects the central face, with findings such as persistent centrofacial redness, papules, pustules, flushing, telangiectasia, and phymatous skin changes. The pathways that lead to the development of rosacea are not well understood. The relationship of pyoderma faciale (also known as rosacea fulminans) to rosacea also is uncertain. We aimed to write this article with the aim of showing how a pregnant patient who has been aggravated by the degree of lesions on the face during the first trimester of pregnancy is treated and to show what is in the literature in this issue.

CASE REPORT:

A 22-year-old woman complained of painful erythema, papules and pustules on the face. She had fever and malaise during the sixth week of her first pregnancy and a history of the mild eruption and seborrhea before her pregnancy with flaring over the preceding 4 weeks. Dermatologic examination revealed red erythema of all involved facial areas; the lesions consisted of papules, pustules and nodules. The case was diagnosed as rosacea fulminans (pyoderma faciale) by these findings. In the literature, there are some effective therapeutic options such as retinoids, tetracyclines, antiandrogenic contraceptives, and dapsone and these were not used because they are contraindicated in pregnancy. Amoxicillin-clavulanic acid 1 gr/day, wet compresses, and a fusidic acid cream were started. After the activity of the disease had been suppressed for 10 days, antibiotic was stopped, and the other treatment options were applied topically for the next month. One month after cessation of treatment, the lesions had disappeared with only mild erythema remaining. There was minimally flushing on the face and no telangiectasia.

CONCLUSION:

In conclusion, there is no substantial evidence as to the mechanism by which pregnancy may trigger this conditioner whether the gender of the fetus influences the development of rosacea fulminans, but is generally accepted that hormonal changes in pregnancy play an important role. The pathogenesis of rosacea fulminans remains uncertain, but it is obvious that the further basic and clinical research is required to optimise the management of this rare facial dermatosis.

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.

Topical Ivermectin in the Treatment of Papulopustular Rosacea: A Systematic Review of Evidence and Clinical Guideline Recommendations

Introduction

Rosacea is a chronic inflammatory skin disease with different phenotypes. There is accumulating evidence that the commensal Demodex mite is linked to papulopustular rosacea. Established treatment options, including topical metronidazole, azelaic acid, and tetracyclines, are thought to work through their anti-inflammatory effects. However, none of these therapies have been shown to be curative and are associated with frequent relapses. Therefore, new and improved treatment options are needed. Topical ivermectin 1.0% cream is a new option having both anti-inflammatory and acaricidal activity against Demodex mites which might pave the way to a more etiologic approach. Its use has now been widely adopted by clinical guidelines. The objective was to review the evidence and clinical guideline recommendations concerning ivermectin 1.0% cream in the treatment of papulopustular rosacea.

Methods

A systematic review of both medical literature and clinical guideline recommendations was conducted. Numbers needed to treat (NNT) were calculated for relevant dichotomous outcomes (e.g., relapse rate and achieving full lesion clearance) to compare ivermectin with other established treatment options for rosacea.

Results

The search identified three randomized trials, three extension studies, and two meta-analyses. Ivermectin has only been tested in moderate-to-severe papulopustular rosacea. Ivermectin is an effective treatment option for papulopustular rosacea and seems to be more effective than metronidazole (NNT = 10.5) at 12 weeks of treatment. Although ivermectin was numerically more effective than metronidazole at week 36 in preventing relapse (NNT = 17.5), relapse after discontinuation of treatment in both groups was common with 62.7% and 68.4% of patients relapsing. Based on limited generalizability of available evidence, clinical guidelines have yielded different treatment algorithms and, in some areas, conflicting recommendations.

Conclusion

Topical ivermectin is an effective option in the treatment of papulopustular rosacea. Although ivermectin seems to be more effective than topical metronidazole, with both treatment options about two-thirds of patient relapsed within 36 weeks after discontinuation of treatment. More research is needed to establish the clinical benefit of ivermectin’s acaricidal action in preventing relapse compared to other non-etiologic treatment approaches.

Incidence and prevalence of rosacea: a systematic review and meta-analysis

BACKGROUND

The exact prevalence and incidence of rosacea remain unknown, although it is a common condition associated with severe noncutaneous diseases.

OBJECTIVES

To perform a systematic review of the published literature to examine the global incidence and prevalence of rosacea.

METHODS

A systematic review of population-based and dermatological outpatient studies reporting the incidence and/or prevalence of rosacea was performed using three electronic medical databases: PubMed, Embase and Web of Science. Data were extracted and a proportion meta-analysis was performed to obtain pooled proportions.

RESULTS

In total 32 studies were included examining a total of 41 populations with 26 519 836 individuals. Twenty-two populations were from Europe, three from Africa, four from Asia, nine from North America and three from South America. The pooled proportion of individuals with rosacea was 5·46% [95% confidence interval (CI) 4·91-6·04] in the general population and 2·39% (95% CI 1·56-3·39) among dermatological outpatients. Self-reported rosacea gave higher prevalence estimates than rosacea diagnosed by clinical examination, suggesting a low specificity of questionnaires based on symptoms. Rosacea affected both women (5·41%, 95% CI 3·85-7·23) and men (3·90%, 95% CI 3·04-4·87), and mostly those aged 45-60 years.

CONCLUSIONS

We estimated the global prevalence of rosacea based on published data and found that 5·46% of the adult population is affected. However, the prevalence of rosacea depended on the diagnostic method, with higher estimates in questionnaire studies of rosacea symptoms and lower estimates in health registries with International Classification of Diseases codes.

Consensus criteria for the diagnosis of scabies: A Delphi study of international experts

Background

Scabies was added to the WHO Neglected Tropical Diseases portfolio in 2017, and further understanding of the disease burden is now required. There are no uniformly accepted test methods or examination procedures for diagnosis, which limits the interpretation of research and epidemiological findings. The International Alliance for the Control of Scabies (IACS) designated harmonization of diagnostic procedures as a priority for the development of a global control strategy. Therefore, we aimed to develop consensus criteria for the diagnosis of scabies.

Methodology / Principal findings

We conducted an iterative, consensus (Delphi) study involving international experts in the diagnosis of scabies. Panel members were recruited through expression of interest and targeted invitation of experts. The Delphi study consisted of four rounds of anonymous surveys. Rounds 1 and 2 involved generation and ranking an extensive list of possible features. In Rounds 3 and 4, participants were presented results from previous rounds and indicated agreement with a series of draft criteria. Panel participants (n = 34, range per Round 28–30) were predominantly highly experienced clinicians, representing a range of clinical expertise and all inhabited continents. Based on initial rounds, a draft set of criteria were developed, incorporating three levels of diagnostic certainty–Confirmed Scabies, Clinical Scabies and Suspected Scabies. Consensus was reached in Round 4, with a very high level of agreement (> 89%) for all levels of criteria and subcategories. Adoption of the criteria was supported by 96% of panel members.

Conclusions / Significance

Consensus criteria for scabies diagnosis were established with very high agreement. The 2018 IACS Criteria for the Diagnosis of Scabies can be implemented for scabies research and mapping projects, and for surveillance after control interventions. Validation of the criteria is required.

Scabies causes rash and severe itch and predisposes to serious infection and chronic diseases of the heart and kidneys. Despite scabies being an ancient disease found in all parts of the world, we currently lack reliable laboratory tests. Clinicians generally make an assessment based on history and skin examination. Variation in diagnosis causes problems when trying to determine the prevalence of scabies in a region, or when trying to investigate the effectiveness of a treatment or control strategy. We aimed to establish consensus among experts on how to diagnose scabies. Thirty-four international experts responded to anonymous questionnaires on how tests and clinical features of scabies should be used to form a diagnosis. Draft criteria were developed and refined, incorporating three levels of diagnostic certainty–Confirmed Scabies, Clinical Scabies and Suspected Scabies. After three rounds of surveys, 82% of participants supported the criteria. After four rounds, consensus was reached with very high agreement for all criteria (Confirmed Scabies, 96%; Clinical Scabies, 93%; Suspected Scabies, 100%) and 96% supported adoption of the criteria. It is hoped the 2018 IACS Criteria for the Diagnosis of Scabies will allow harmonization of diagnosis and reporting, and comparison between studies of scabies burden and treatments.

Papulopustular rosacea and rosacea-like demodicosis: two phenotypes of the same disease?

Background

Papulopustular rosacea and rosacea‐like demodicosis have numerous similarities, but they are generally considered as two distinct entities, mainly because the causal role of the Demodex mite in the development of rosacea is not yet widely accepted. Several clinical characteristics are traditionally considered to differentiate the two conditions; for example, papulopustular rosacea is typically characterized by central facial papulopustules and persistent erythema, whereas small superficial papulopustules and follicular scales rather suggest rosacea‐like demodicosis. However, none of these characteristics is exclusive to either entity.

Objective

To explore differences in Demodex densities according to clinical characteristics traditionally associated with these two conditions.

Methods

Retrospective, observational, case–control study of 242 patients with central face papulopustules. Demodex densities were measured on two consecutive standardized skin surface biopsies.

Results

In the whole cohort, Demodex densities were greater in patients with persistent erythema than in those without. In 132 patients without recent treatment or other facial dermatoses, 120 (91%) had persistent erythema, 119 (90%) small superficial papulopustules and 124 (94%) follicular scales; 116 (88%) simultaneously had clinical characteristics traditionally associated with both papulopustular rosacea and rosacea‐like demodicosis. Higher Demodex densities were linked to the presence of follicular scales, but not to papulopustules size, nor to the presence/absence of persistent erythema.

Conclusion

Our observations highlight the difficulty differentiating between these entities and suggest that rosacea‐like demodicosis and papulopustular rosacea should no longer be considered as two separate entities, but rather as two phenotypes of the same disease.

In Vitro Safety Pharmacology Profiling of Topical α-Adrenergic Agonist Treatments for Erythema of Rosacea

Background

Topical α-adrenergic agonist therapy has been developed to treat the persistent erythema of rosacea patients. Brimonidine and oxymetazoline are both topical α-adrenergic agonists.

Objectives

The objective of this in vitro safety pharmacology study was to compare the potential safety profiles of brimonidine and oxymetazoline.

Methods

Brimonidine and oxymetazoline underwent pharmacological profiling with a standard panel of 151 assays, including α-adrenergic receptors and 5-hydroxytryptamine (5-HT) receptors. A valvular interstitial cell (VIC) proliferation assay was performed with oxymetazoline hydrochloride.

Results

Brimonidine was highly selective for the α₂ adrenergic receptors, specifically α_2A, whereas oxymetazoline was found to be much less selective and was highly active against a wide range of targets. Negligible activity was observed with brimonidine at the 5-HT_2B receptor, whereas oxymetazoline had significant 5-HT_2B receptor agonist activity and caused proliferation of mitral VICs in vitro.

Conclusion

As the 5-HT_2B receptor is potentially involved in drug-induced valvulopathy, the benefit/risk ratio should be carefully considered, especially in patients with cardiovascular disease or other comorbidities.

[What's new in clinical dermatology?]

In addition to continuous medical education, medical journals offer to dermatologists a huge variety of news that differ by their content, validity, originality and clinical relevance. I collected here various articles relative to clinical dermatology that have been published between September, 2016 and September, 2017. These papers have been chosen in the aim of reflecting such diversity. I just excluded, as far as possible, articles dealing with other issues that the reader will find further in this booklet (such as research, pediatric, instrumental, oncologic or therapeutic dermatology, or dermatology and internal medicine). Space restriction required to skip some commentaries while keeping the references to the selected papers, which the reader will be able to read carefully in its original form.

Revisiting Rosacea Criteria: Where Have We Been, Where Are We Going, and How Will We Get There?

Rosacea is one of the most common and misunderstood dermatologic conditions. Currently, rosacea criteria are based on expert opinion; the definition of rosacea is primarily a reflection of opinion that is prone to bias. It has been more than a decade since the initial criteria were created by the National Rosacea Society. Revisiting the criteria and incorporating evidence-based techniques used by rheumatology and psychiatry can improve the validity and reliability of rosacea criteria. Literature from other specialties is reviewed and a method proposed for developing valid criteria. Examples are provided to motivate and highlight the importance of implementing such techniques.

Psychosocial Burden and Other Impacts of Rosacea on Patients' Quality of Life

Rosacea is a common and chronic skin disorder with substantial impact on a patients' quality of life. Its varying phenotypic features and facial localization can adversely affect the mental health and socialization of those affected. Although there are no curative interventions, certain therapies have greater effect in improving patient quality of life. This article summarizes the associated psychosocial implications of rosacea. Several skin disease and rosacea-specific quality-of-life measures and their application in clinical care and research studies are also summarized. The recognition and management of the psychosocial impact of rosacea is critical to improving patient outcomes.

Human Skin Permeation Studies with PPARγ Agonist to Improve Its Permeability and Efficacy in Inflammatory Processes

Rosacea is the most common inflammatory skin disease. It is characterized by erythema, inflammatory papules and pustules, visible blood vessels, and telangiectasia. The current treatment has limitations and unsatisfactory results. Pioglitazone (PGZ) is an agonist of peroxisome proliferator-activated receptors (PPARs), a nuclear receptor that regulates important cellular functions, including inflammatory responses. The purpose of this study was to evaluate the permeation of PGZ with a selection of penetration enhancers and to analyze its effectiveness for treating rosacea. The high-performance liquid chromatography (HPLC) method was validated for the quantitative determination of PGZ. Ex vivo permeation experiments were realized in Franz diffusion cells using human skin, in which PGZ with different penetration enhancers were assayed. The results showed that the limonene was the most effective penetration enhancer that promotes the permeation of PGZ through the skin. The cytotoxicity studies and the Draize test detected cell viability and the absence of skin irritation, respectively. The determination of the skin color using a skin colorimetric probe and the results of histopathological studies confirmed the ability of PGZ-limonene to reduce erythema and vasodilation. This study suggests new pharmacological indications of PGZ and its possible application in the treatment of skin diseases, namely rosacea.

Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

In 2002, the National Rosacea Society assembled an expert committee to develop the first standard classification of rosacea. This original classification was intended to be updated as scientific knowledge and clinical experience increased. Over the last 15 years, significant new insights into rosacea's pathogenesis and pathophysiology have emerged, and the disorder is now widely addressed in clinical practice. Growing knowledge of rosacea's pathophysiology has established that a consistent multivariate disease process underlies the various clinical manifestations of this disorder, and the clinical significance of each of these elements is increasing as more is understood. This review proposes an updated standard classification of rosacea that is based on phenotypes linked to our increased understanding of disease pathophysiology. This updated classification is intended to provide clearer parameters to conduct investigations, guide diagnosis, and improve treatment.

Rosacea: Epidemiology, pathogenesis, and treatment

Rosacea is a chronic relapsing inflammatory skin disease with a high prevalence among adults of Northern European heritage with fair skin. Symptoms present in various combinations and severity, often fluctuating between periods of exacerbation and remission. Based on morphological characteristics, rosacea is generally classified into four major subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular. Diverse environmental and endogenous factors have been shown to stimulate an augmented innate immune response and neurovascular dysregulation; however, rosacea's exact pathogenesis is still unclear. An evidence-based approach is essential in delineating differences between the many available treatments. Because of the diverse presentations of rosacea, approaches to treatment must be individualized based on the disease severity, quality-of-life implications, comorbidities, trigger factors, and the patient's commitment to therapy.

Long-term management of distinct facial flushing and persistent erythema of rosacea by treatment with carvedilol

BACKGROUND

The treatment of persistent erythema and flushing episodes in patients with rosacea remains a clinical challenge. A possible therapeutic option could be the use of antihypertensive drugs.

OBJECTIVES

We therefore evaluated the effect of the non-selective β-blocker carvedilol in five Caucasian patients.

METHODS

In a monocentric retrospective case study, the patients were treated with carvedilol titrated up to 12.5 mg twice a day over at least six months. Patients self assessment (PSA), clinicians erythema assessment (CEA), and the patients levels of embarrassment and satisfaction were performed by questionaires.

RESULTS

The CEA grade description as well as the PSA grade description decreased remarkably in all five patients. Furthermore, all patients reported to have a major improvement of their level of satisfaction and no feelings of embarrassment anymore.

CONCLUSIONS

These findings demonstrate that facial flushing and persistent erythema can be effectively treated by carvedilol long-term with a fast onset of improvement in a dose well tolerated.

[Rosacea: New data for better care]

In the last 10 years, numerous studies have been published that throw new light on rosacea, in all areas of the disease. This overview summarises all the key developments, based on the indexed bibliography appearing in Medline between 2007 and 2017. Recent epidemiological data show that the prevalence of the disease is doubtless greater than estimated hitherto (more than 10% of adults in some countries) and that we should not overlook rosacea in subjects with skin phototypes V or VI, a condition that exists on all continents. A new classification of rosacea by phenotype comprising major and minor signs has been put forward; it provides a more rational approach to suitable management based upon symptoms, the severity of which may be graded into 5 classes. The treatments with the best-demonstrated efficacy (updated Cochrane study) are topical metronidazole, azelaic acid and ivermectin, and oral doxycycline; isotretinoin is effective against resistant forms but is off-label. In ocular rosacea, the reference treatment is doxycycline in combination with topical therapy of the eyelids. The physiopathology is complex and involves several factors: vascular (vasodilatation, vascular growth factors), neurovascular (hypersensitivity, neuropathic pain, neuropeptides), infectious (Demodex folliculorum and its microbiota) and inflammatory (abnormal production of pro-inflammatory peptides of the innate immune system). In addition, there is a genetic predisposition as demonstrated by the weight of familial history and comparison of homozygous and heterozygous twins. There is also activation of several genes involved in immunity, inflammation and lipid metabolism; the theory of hydrolipid film anomalies has been posited once more. There has thus been a tremendous leap forward in the field of rosacea research, with therapeutic progress and improved understanding of the underlying mechanisms, which should enable the future development of more targeted treatments as well as global management of this disease, which has major social and emotional consequences on the life of patients.

Evaluation of a novel very high sun-protection-factor moisturizer in adults with rosacea-prone sensitive skin

Background/objective

Rosacea-prone sensitive skin requires high sun-protection factor (SPF) moisturizers. This study evaluated Daylong Extreme SPF 50+ lotion, a novel cream containing five ultraviolet filters, two emollients, and three skin conditioners.

Subjects and methods

This was an open-label, single-center study. On day 1, before treatment, subjects answered a questionnaire on their skin conditions and sunscreen habits, and both subjects and dermatologist evaluated skin status. Subjects applied the product once daily in the morning to the face for 21 days, and after approximately 3–5 minutes they assessed tolerability and short-term cosmetic acceptability in a questionnaire and daily diary. On day 22, the dermatologist and subjects evaluated skin status for long-term tolerance and cosmetic acceptability.

Results

The study enrolled 44 individuals (mean age 58.8 years, 91% female). At baseline, most subjects (39 of 44) showed erythema, and ~30% showed dryness and scaling. Dermatologists noted four cases of pustules and one case of papules. After 21 days’ treatment with the product, the dermatologist reported significantly less erythema, dryness and scaling, three cases of pustules and two cases of papules. At baseline, ~75% of subjects noted a feeling of dryness, >50% reported tension, and nearly 25% reported tickling. After using the product for 21 days, subjects reported significantly less tension, dryness, and tickling. Some subjects noted itching and burning before and after using the product. One subject noted papules during treatment. Most subjects said that the product was pleasant, did not irritate the skin or cause stinging/burning, was easy to apply, quickly absorbed, and nongreasy, improved skin moisturization, helped prevent sun-provoked facial redness, did not worsen rosacea, and was easily incorporated into their skincare regimen. Half would switch to the product, and 80% of subjects would buy and recommend the product.

Conclusion

The product was well tolerated in rosacea-prone subjects, producing objective and subjective improvements in skin status and symptoms.

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.