The toxic edge-A novel treatment for refractory erythema and flushing of rosacea

Percutaneous delivery of liquid tetracycline using a thermal resurfacing drug delivery system for the treatment of festoons

OBJECTIVES

To examine the effects of percutaneous tetracycline delivery to the malar area using a thermomechanical device (Tixel) in patients suffering from festoons.

METHODS

This retrospective study included patients who underwent combination treatment with a thermomechanical device (Tixel) followed by application of topical tetracycline 1% at two private clinics between 2019 and 2023. Demographic and medical data, treatment parameters along with before and after treatment photographs were retrieved retrospectively. All patients were asked to answer a questionnaire, assessing self-reported pre and posttreatment disturbance, patient global impression of change (PGIC) score, overall satisfaction with treatment, and the onset and duration of treatment effect. Finally, three masked reviewers evaluated and graded the severity of before and after treatment photographs.

RESULTS

Twenty healthy patients received the combination treatment. The mean age was 59.4 ± 8.2 years (range: 45-72 years), and 90.0% (n = 18) were female. The number of treatment sessions per patient ranged from 2 to 8, mean of 5.0 ± 1.9, performed at 5.4 ± 1.2-week intervals. The masked reviewers' grading scores demonstrated a significant improvement (2.81 ± 1.3 before vs. 1.6 ± 1.1 after, p < 0.001). The self-reported disturbance caused by the festoons improved significantly as well (4.7 ± 0.98 vs. 1.7 ± 1.1, p < 0.001). On the PGIC score, 85% (17/20) reported moderate (grade 5) to significant (grade 7) improvement of symptoms and life quality after treatment. Improvement onset was reported to occur 11.2 ± 6.6 days after the first treatment (range 2-30 days), and 90% (18/20) of the patients reported improvement lasting at least 4 months after completion of the second treatment.

CONCLUSIONS

Topical tetracycline application following Tixel treatment induced significant improvement in patient with festoons.

Health-related Quality of Life of Patients with Rosacea: A Systematic Review and Meta-analysis of Real-world Data

Patients with rosacea commonly experience stigmatization, which induces stress and thereby exacerbates their symptoms. Given the strong effects of rosacea on health-related quality of life (HRQoL), addressing the physical and psychosocial aspects of rosacea is essential. To examine the effects of rosacea on HRQoL, we conducted a systematic review and meta-analysis involving real-world data. PubMed, EMBASE, and the Cochrane Library were searched, and randomized controlled trials (RCTs), cross-sectional studies, and case series evaluating the HRQoL of patients with rosacea were included. HRQoL assessment tools such as the Dermatology Life Quality Index (DLQI) and Rosacea-Specific Quality-of-Life Questionnaire (RosaQoL) were used. Data on 13,453 patients were retrieved from 52 eligible studies: 4 RCTs, 15 case series, and 33 cross-sectional studies. Compared with healthy controls, patients with rosacea had significantly lower DLQI scores (standardized mean difference [SMD] = -1.09, 95% confidence interval [CI] = -0.81 to -1.37). The DLQI scores after treatment were higher than those before treatment (SMD = -1.451, 95% CI = -1.091 to -1.810). The pooled estimates for the overall DLQI and RosaQoL scores were 8.61 and 3.06, respectively. In conclusion, patients with rosacea have lower HRQoL compared with healthy individuals, and treatment for rosacea improves their HRQoL.

Treating rosacea with botulism toxin: Protocol for a systematic review and meta-analysis

BACKGROUND

Rosacea is a chronic inflammatory disease usually associated with persistent erythema and periodic flushing. This disease is difficult to treat, and the outcomes are often unsatisfactory and prone to recurrence. In recent years, botulinum toxin has been used as a new treatment for rosacea; however, its efficacy and safety remain under discussion. Although a systematic review of the effectiveness and safety of botulinum toxin has been previously conducted by other researchers, our systematic review and meta-analysis evaluate the efficacy of botulinum toxin from a more comprehensive and detailed perspective to provide evidence for clinicians.

METHODS

Any study using botulinum toxin for the treatment of rosacea was considered for the analysis.

RESULTS

A total of 22 studies were included, 9 of which were randomized controlled trials involving 720 subjects. After treatment, all studies showed varying degrees of improvement in patient signs and symptoms along with reduced Clinician's Erythema Assessment (CEA) scores. The improvement was maintained for several months, and the adverse effects were mild and self-limiting.

CONCLUSION

Botulinum toxin may be an effective treatment for patients with rosacea; however, further clinical evidence is needed to confirm its long-term efficacy and side effects. The study was preregistered with Prospero (CRD42022358911).

The Efficacy and Safety of Botulinum Toxin A for the Treatment of Rosacea: A Systematic Review

The off-label use of botulinum toxin type-A (BoNT-A) in treating rosacea seems encouraging, but the evidence is still lacking regarding its efficacy and safety. This study was conducted to summarize the evidence regarding the efficacy and safety of BoNT-A in the treatment of rosacea patients. A comprehensive literature search was conducted in several databases, and 17 studies were included. Before-after and split-face comparisons showed that BoNT-A significantly alleviated the symptoms of facial erythema and flushing and improved the patient's quality of life/satisfaction. However, the symptoms recurred three to six months post-injection, requiring repeated treatments in some patients. The pooled rates of post-injection localized erythema, ecchymosis, and facial muscle affection represented 24.6%, 5.1%, and 4.3%, respectively. BoNT-A seems to be effective in alleviating the symptoms of rosacea with a low rate of adverse events. However, the recurrence of the symptoms a few months after the injection requires repeated sessions, which may raise cost-effectiveness issues. Large-scale clinical trials are required to confirm the effectiveness and define the optimal dosing regimen and the rate of recurrence. Future studies should allow for an adequate follow-up after the treatment, with repeated measurements of the outcomes.

The effect of non-ablative thermomechanical skin treatment (Tixel®) on dry eye disease: A prospective two centre open-label trial

PURPOSE

To determine the effects of a thermo-mechanical action-based peri-orbital fractional skin treatment (Tixel®) on dry eye disease.

METHODS

This prospective, controlled, open labelled study was conducted at two study centres: Midland Eye, Solihull, UK, and Vallmedic Vision, Andorra. Participants were screened at the baseline visit (visit-1), received three Tixel® treatments at 2-weeks intervals including further assessment (visits 2, 3 and 4). Participants were followed up for three months post-treatment (visit 5). Vision, intraocular pressure (IOP), dry eye symptomatology were assessed, including the Ocular Surface Disease Index (OSDI) questionnaire, non-invasive tear break-up time (NIBUT) and tear osmolarity as well as detailed ophthalmic assessments.

RESULTS

Seventy-four participants (41 in Birmingham and 33 in Andorra) with periorbital wrinkles and moderate to severe dry eye disease (DED) were enrolled. The mean age was 59.3 ± 13.3 years and 57 were females. No adverse events, no change in vision (p = 0.310) or IOP (p = 0.419) were observed. Tixel treatment was associated with clinically and statistically significant improvement in the DED symptoms, which was supported by a reduction of 21.40 ± 15.08 (P < 0.001) of the OSDI index. Non-invasive tear break-up time improved by 2.10 ± 0.91 s (p < 0.001) in the Birmingham cohort and 6.60 ± 2.13 s (p < 0.001) in the Andorra cohort. Tear osmolarity reduced from 299.8 ± 13.3 mOsm/L to 298.8 ± 15.6 mOsm/L following the Tixel treatment (p = 0.271).

CONCLUSIONS

Thermo-mechanical action-based peri-orbital fractional skin treatment Tixel® could be an attractive, safe and effective treatment for DED. This treatment is associated with high clinical and statistically significant improvement in DED signs and symptoms with no adverse events.

Quality of life measurement in rosacea. Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa (ARHS) do not recommend the use of any generic instrument as a single method of Health Related (HR) QoL assessment in rosacea, except when comparing quimp (quality of life impairment) in rosacea patients with that in other non-dermatologic skin diseases and/or healthy controls. The EADV TFs on QoL and Patient-Oriented Outcomes and ARHS recommend the use of the dermatology-specific HRQoL instrument the Dermatology Life Quality Index (DLQI) and the rosacea-specific HRQoL instrument RosaQoL in rosacea patients. The DLQI minimal clinically important difference may be used as a marker of clinical efficacy of the treatment and DLQI score banding of 0 or 1 corresponding to no effect on patients' HRQoL could be an important treatment goal. This information may be added to consensuses and guidelines for rosacea.

The clinical effect of botulinum toxin on pigmentation

BACKGROUND

Botulinum toxin injection is a common cosmetic procedure often used to treat dynamic wrinkles, but it has also been observed to have a lightening effect on the skin. It is thought that this lightening effect develops due to muscle innervation blockage; however, the change in the amount of melanin levels has not been quantified.

METHOD

Thirty-one patients who presented to the dermatology clinic of a tertiary hospital for botulinum toxin injection for wrinkle treatment were included in the study. A standard dose of botulinum toxin was injected to each patient's forehead, glabellar, and crow's feet region, and then the melanin index (MI) was measured with the Mexameter® MX 18 (Courage + Khazaka Electronic, Köln).

RESULTS

After botulinum toxin treatment, a statistically significant decrease was found in the forehead and upper face MI. The upper face total baseline MI was significantly lower in the Glogau 1 group than in the Glogau 2 group (P = 0.033). The forehead 15th day MI was significantly lower in the Glogau 1 group than in the Glogau 2, 3, and 4 groups (P = 0.030).

DISCUSSION

Botulinum toxin application to healthy skin for wrinkle treatment can cause facial skin lightening by reducing MI. It was also remarkable that this decrease was more pronounced in the forehead, which is a region that is particularly vulnerable to sun exposure, compared to other regions. Younger people, who are included in the Glogau type 1 group, may benefit more from this lightening effect.

Botulinum Toxin A Alleviates Persistent Erythema and Flushing in Patients with Erythema Telangiectasia Rosacea

Introduction

The persistent erythema and flushing seen in some cases of rosacea do not respond effectively to, or may easily relapse after, oral medication or light-based therapies (laser or intense pulsed light). Intradermal botulinum toxin A (BTX-A) injection can be used to treat intractable erythema and flushing, but studies with large samples and long-term observation have not been conducted to determine its effectiveness and safety. The aim of this study is thus to investigate the effective duration and safety of intradermal BTX-A injection for intractable erythema and flushing.

Methods

Sixteen patients with rosacea with erythema telangiectasia were injected with BTX-A at 1-cm intervals between each point. Clinician Erythema Assessment (CEA) scores were obtained at baseline and 1 month after injection. Flushing assessment and survey using the Dermatological Quality of Life Index (DLQI) questionnaire were conducted at baseline and at 1, 3, and 6 months after injection.

Results

At 1 month after injection, CEA scores revealed significant improvements in erythema and flushing; the results of the questionnaire on flushing and DLQI indicated that the improvement of flushing usually lasted for 3–6 months, but the effect decreased significantly at 6 months, and individual patients needed another treatment.

Conclusions

BTX-A significantly improves the symptoms and quality of life of patients with refractory rosacea with few adverse effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00784-0.

The effect of thermo-mechanical device (Tixel) treatment on evaporative dry eye disease - A pilot prospective clinical trial

PURPOSE

To examine the effects of treatment with a thermomechanical skin device to the eyelid area on the clinical signs and symptoms of patients who suffer from dry eye disease (DED) secondary to meibomian gland dysfunction (MGD).

METHODS

Forty patients aged 45 years or older with DED due to MGD were recruited. Both eyes (n = 80) of each patient received three treatments with the Tixel device (Novoxel®, Israel), with each treatment separated by a 2-week period. Treatment was applied across the upper and lower eyelids, with the same intensity, tip protrusion distance, and contact duration. Two additional follow-up visits were performed at 2-week intervals after treatment cessation. DED status was evaluated during each visit via SPEED II questionnaire, tear break-up time (TBUT), corneal staining score (CSS), MGD score, and frequency of lubricant use. Visual acuity (VA) was recorded during first and last visits.

RESULTS

Mean age was 64.3 ± 12.4 years and 72.5 % (n = 29) were female. 45 % (n = 18) had a history of blepharitis, 12.5 % (n = 5) had chalazia, and 17.5 % (n = 7) suffered from allergic conjunctivitis. Mean follow-up time was 2.1 ± 0.6 months. Comparing the first and last visits, all parameters showed significant improvement after Tixel treatment: mean SPEED II scores (16.5 ± 5.9 to 11.8 ± 6.7, p < 0.001), CSS (2.0 ± 1.3 to 0.5 ± 0.9, p < 0.001), TBUT (2.7 ± 0.8 s to 6.5 ± 2.2 s, p < 0.001), MGD score (2.7 ± 0.5 to 1.2 ± 0.4, p < 0.001), and rate of lubricant use (3.4 ± 2.4 per day to 1.9 ± 2.0, p < 0.001). VA also improved (0.10 ± 0.11 logMAR to 0.08 ± 0.10 logMAR, p < 0.05). No major side effects were observed.

CONCLUSIONS

In this pilot study Tixel treatment induced significant improvement of signs and symptoms among patients with DED due to MGD. Benefits persisted for at least one month. Further randomized controlled double-blinded studies are needed.

Efficacy and safety of a thermal fractional skin rejuvenation system (Tixel) for the treatment of facial and/or scalp actinic keratoses

Actinic keratoses are common cutaneous lesions with a potential to progress to invasive squamous cell carcinoma. Therefore, treatment is crucial. The Tixel® is a noninvasive thermomechanical device designed to transfer heat to the upper dermis in a controlled manner according to a predetermined setting. This study aimed to evaluate the safety and efficacy of a thermomechanical fractional skin resurfacing technology for the treatment of facial and scalp actinic keratoses. A prospective, open-label, before-after study was conducted in a tertiary medical centre from May 2020 to April 2021. Patients presenting with facial/scalp actinic keratoses of mild-to-moderate thickness underwent 2 or 3 Tixel treatments (depending on clinical improvement), 3-4 weeks apart. The reduction in lesion count and overall improvement in appearance were assessed by clinical examination and digital photography. Findings were compared between baseline and follow-up at 3 months after the last treatment session. Patient satisfaction was evaluated by questionnaire, and adverse effects were documented. A total of 20 patients participated in the study. All completed 2-3 treatments and follow-up visits. Assessment of digital photographs was performed by 2 assessors blinded to the timepoint at which each photo was taken (before or after treatment). The average number of lesions at baseline was 9.8 (± 4.8) and the mean reduction in lesion count was 7.9 (± 4.4) (80.6%). Complete clearance was observed in 31.6% of patients. No adverse effects were noted during treatment and follow-up. Most patients reported being "very satisfied" or "satisfied" with the treatment results (85%) and experience (95%). Treating facial and scalp actinic keratoses with the Tixel device was found to be effective and safe.

Evaluation of Device-Based Cutaneous Channels Using Optical Coherence Tomography: Impact for Topical Drug Delivery

BACKGROUND

Topical medications play a large role in the management of cutaneous diseases, but penetration is limited. Device-assisted drug delivery using mechanical destruction, lasers, and other energy-based modalities can increase penetration and absorption through creation of transcutaneous channels.

OBJECTIVE

To examine real-time, in vivo cutaneous changes in response to various devices used to improve topical drug delivery through optical coherence tomography (OCT) imaging.

METHODS AND MATERIALS

Treatment was performed with 8 medical devices, including mechanical destruction, lasers, and other energy-based modalities. Optical coherence tomography was used for real-time, noninvasive, in vivo imaging.

RESULTS

Using OCT, microneedling and radiofrequency microneedling demonstrated no cutaneous channels. Both low-energy, low-density, fractional nonablative lasers produced transient channels, which closed within hours. The fractional nonablative 1,927-nm thulium fiber and 1,550-nm erbium fiber lasers created channels with epidermal debris within, which were still closing at 24 hours. The fractional thermomechanical ablative device and the fractional ablative CO2 laser produced channels that were still open at 24 hours. CO2 laser channels had thick rims of coagulated tissue and remained open for longer.

CONCLUSION

Demonstrable differences among the devices were seen, and only some can produce observable channels, the characteristics of which vary with each technology.

Efficacy and safety of thermomechanical fractional injury-assisted corticosteroid delivery versus intralesional corticosteroid injection for the treatment of hypertrophic scars: A randomized split-scar trial

BACKGROUND

Disruption of the natural skin barrier in a controlled manner may be used to deliver drugs that enhance scar resolution.

OBJECTIVE

To compare the efficacy and safety of thermomechanical fractional injury (TMFI)-assisted topical corticosteroid delivery with corticosteroid injection in the treatment of hypertrophic scar (HTS).

MATERIALS AND METHODS

This was a randomized, split-scar, double-blinded study. Twenty-one subjects with HTS on the abdomen received five split-scar treatments of TMFI + Steroid and steroid injection alone. Changes in scar thickness, scar volume, and Vancouver Scar Scale (VSS) were analyzed. Patient self-assessment, VAS scores, and adverse effects were also evaluated.

RESULTS

Scar thickness, volume, and VSS scores of both segments improved significantly compared to baseline. On every follow-up visit, there were no significant differences in mean scar thickness reduction between the two treatment groups except at the 6-month follow-up where the mean scar thickness reduction of the steroid injection segment was significantly lower than that of the TMFI + Steroid segment (95% confidence interval [CI], 0.09-0.35; p = 0.002). Scar volume, VSS scores, and patient self-assessment also showed no significant differences between both segments on all visits. The steroid injection segment was significantly more painful than the TMFI + Steroid segment (95% CI, -2.16 to -1.29; p < 0.001). Adverse effects of skin atrophy, telangiectasia, and post-inflammatory hyperpigmentation were noted in the steroid injection segment, while no adverse effects were observed at the TMFI + Steroid segment.

CONCLUSIONS

TMFI-assisted topical corticosteroid delivery is an effective treatment for HTS with a lower risk of adverse effects compared with corticosteroid injection.

Rosacea: Treatment targets based on new physiopathology data

Over the past 15 years, numerous clinical, epidemiological and physiopathological articles have been published on rosacea. There is now increasing evidence that rosacea is an inflammatory disease characterised by abnormal innate immune response, major vascular changes, and increased colonisation by Demodex mites, along with a genetic predisposition and multiple external aggravating factors. It is thus possible to define treatment targets and possible treatments: 1) permanent vascular changes (medical and instrumental treatments); 2) flushing (betablockers, botulinum toxin); 3) innate immunity (antibiotics, nonspecific antioxidants and anti-inflammatory molecules); 4) a neurovascular component (analgesics, antidepressants); 5) Demodex (antiparasitic drugs); 6) microbiome; 7) skin barrier impairment (cosmetics and certain systemic drugs); 8) sebaceous glands (isotretinoin, surgery); 9) environmental factors (alcohol, coffee, UV exposure). Treatment recommendations are now available in many countries and benefit from the new phenotypic approach to rosacea, in which every sign or symptom is considered separately rather than having to deal with overlapping subtypes. Since the 2000s, many good quality clinical trials have been published in the field of rosacea and many others are still ongoing. Rosacea is a complex disease involving many different mechanisms and with numerous possible treatments, but there are still some important unmet needs with regard to optimal care.

Emerging off-label esthetic uses of botulinum toxin in dermatology

Botulinum toxin is a neurotoxic protein produced by Clostridium botulinum, the bacterium responsible for botulism. Botulinum toxin was first used for therapeutic indications in the 1970s for the treatment of strabismus. With greater understanding of its underlying physiology and safety profile, the use of botulinum toxin has now expanded to a range of cosmetic and medical indications. We performed a systematic review of current literature on the applications of botulinum toxin on off-label esthetic uses. Electronic databases were searched for original published studies including randomized trials, observational or cohort studies, as well as relevant case reports. To add to the body of evidence, our review summarizes and synthesizes key study characteristics, results, and level of evidence for each use case. Although the body of evidence remains weak, there is increasing support for the use of botulinum toxin in emerging off-label esthetic uses of botulinum toxin in dermatology.

Role of botulinum toxin A in improving facial erythema and skin quality

Botulinum toxin A (BTX-A) injections have become the most popular noninvasive cosmetic procedures performed worldwide. With growing interest, investigators continue to uncover an expanding array of aesthetic indications for BTX-A. Botulinum toxin A has been used off-label in the management of masseter hypertrophy for facial slimming, platysmal bands, nasal 'bunny' lines, perioral rhytides, gummy smile and scars, to name a few. Interestingly, the injection of multiple microdroplets of dilute BTX-A into the dermis, sometimes referred to as 'microbotox', has been investigated as a tool for facial rejuvenation. A handful of prospective studies and case series have demonstrated the benefit of BTX-A in the treatment of facial erythema and improving skin texture. The aim of this review is to summarize and appraise currently available data on the role of BTX-A in treating facial erythema and skin quality, with a special focus on potential pathophysiologic mechanisms.

Use of Botulinum Toxin in Treating Rosacea: A Systematic Review

Background

Rosacea is a chronic skin disorder characterized by erythema, flushing, telangiectasia, papules and pustules, phymatous changes, and ocular involvement. The aim of this study was to examine all published research articles in which botulinum toxin was used to treat rosacea and to evaluate the efficacy and safety of this treatment.

Methods

PubMed, Embase, Cochrane Library, and Web of Science database were used to identify articles eligible for systematic review on March 26, 2021. Prospective or retrospective studies which directly used botulinum toxin to treat rosacea were included and reviewed.

Results

Nine studies were included in this systematic review. Two were randomized controlled trials, graded as Level 2 for the quality of evidence. The total number of participants was 130, and the number of participants in each study ranged from 1 to 25. The improvement was observed in all studies in signs and symptoms compared with baseline. Adverse events were transitory and self-limited.

Conclusion

Botulinum toxin could have overall satisfying efficacy and safety in the treatment of rosacea, though limited by small sample size, imperfect study design, and short follow-up visits.

Thermo-Mechanical Fractional Injury Therapy for Facial Skin Rejuvenation in Skin Types II to V: A Retrospective Double-Center Chart Review

BACKGROUND AND OBJECTIVES

Thermo-mechanical fractional injury (TMFI) therapy (Tixel®; Novoxel®, Netanya, Israel) is an innovative technology. Along with its drug delivery enhancement features, it is widely used for facial skin rejuvenation. Our study explores the beneficial effect of the Tixel® on the different features of facial skin rejuvenation along with patients' satisfaction rate, aiming to suggest practical recommendations for an optimal aesthetic result.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective chart review of 24 patients (20 women, 4 men, average age 56 years old) with skin types II-V who received 2 or 3 Tixel® treatments, 3-5 weeks apart in two medical centers (12 from Israel, 12 from the United Kingdom). Four experienced dermatologists compared standardized clinical photographs taken before each treatment and 3 months after the final treatment based on seven parameters that were set by 10 physicians and rated the difference on a scale of -1 to 4. Furthermore, epidemiology, treatment data, satisfaction, and safety were reviewed.

RESULTS

Out of the seven parameters that were compared (blood vessels and erythema, skin complexion, periorbital wrinkles, pigmentation and toning, pore size, vitality, wrinkles, and laxity), all features demonstrated an overall improvement, with the greatest improvement demonstrated in skin complexion (2.1 ± 0.49) and periorbital wrinkling (2.09 ± 0.65) followed by vitality (1.7 ± 0.49). Side effects were transient, including erythema and hyperpigmentation, and the average downtime was 1.7 days.

CONCLUSION

TMFI is a safe and effective method for improving facial skin quality. Addressing patient's expectations while maximizing the benefits of this novel technology will provide superior aesthetical results.

Botulinum toxin in treating Hailey-Hailey disease: A systematic review

BACKGROUND

Hailey-Hailey disease is a rare disorder characterized by recurrent painful blistering, erosions, maceration in the intertriginous regions. Botulinum toxin has been used in the treatment of Hailey-Hailey disease.

AIMS

This study aimed to examine all published articles on botulinum toxin in the treatment of Hailey-Hailey disease, and to evaluate its efficacy and safety.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were used to identify eligible articles on August 8, 2020. The searching strategy was "(Hailey Hailey or Hailey-Hailey or pemphigus) and botulinum."

RESULTS

Sixteen articles including 38 patients described the use of botulinum toxin in treating Hailey-Hailey disease. Only one case had no response, while the other patients all had partial or complete remission. No side effects were reported. Nine articles including 10 patients mainly described other treatment options, and the patients were only treated with botulinum toxin previously. Their responses to botulinum toxin were limited: one was mild improvement, one was partial response, and the other eight failed.

CONCLUSION

Botulinum toxin is not almighty, but a promising alternative option. We recommend botulinum toxin as an adjuvant or supplemental treatment modality for severe and recalcitrant Hailey-Hailey disease. Larger studies are warranted to confirm its efficacy, safety, long-term effects, and cost performance.

Therapeutic Use of Botulinum Neurotoxins in Dermatology: Systematic Review

Botulinum toxin is a superfamily of neurotoxins produced by the bacterium Clostridium Botulinum with well-established efficacy and safety profile in focal idiopathic hyperhidrosis. Recently, botulinum toxins have also been used in many other skin diseases, in off label regimen. The objective of this manuscript is to review and analyze the main therapeutic applications of botulinum toxins in skin diseases. A systematic review of the published data was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Botulinum toxins present several label and off-label indications of interest for dermatologists. The best-reported evidence concerns focal idiopathic hyperhidrosis, Raynaud phenomenon, suppurative hidradenitis, Hailey–Hailey disease, epidermolysis bullosa simplex Weber–Cockayne type, Darier’s disease, pachyonychia congenita, aquagenic keratoderma, alopecia, psoriasis, notalgia paresthetica, facial erythema and flushing, and oily skin. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and doses protocols for off label applications.

Willingness-to-Pay and Benefit-Cost Analysis of Botulinum Toxin for the Treatment of Rosacea in China: Findings from a Web-Based Survey

PURPOSE

Botulinum toxin (BTX) is a new treatment approach primarily aimed at relieving flushing and erythema for rosacea, but it is expensive and lacks economic benefit evaluation studies.This study aimed to investigate willingness-to-pay (WTP) of BTX treatment and conduct benefit-cost analysis (BCA) to assess if BTX treatment for rosacea is recommendable from a viewpoint of economics in China.

METHODS

WTP of BTX treatment in rosacea and information of sociodemographic and clinical characteristics were inquired via an online questionnaire among the Chinese rosacea patients. The WTP was inquired by photos of three cases with different severities of rosacea before and after BTX treatment. The benefit-cost ratio (BCR) was calculated by dividing WTP by cost. Factors associated with WTP were identified using logistic regression models.

RESULTS

The average costs of BTX treatment were USD410.09. The mean WTP for Case 1, Case 2, and Case 3 was USD295.53, 307.91, and 311.78, respectively (p<0.05 for Case 1 vs Case 3). 44.31% to 47.52% of Chinese rosacea patients were willing to pay for the BTX treatment. The BCRs were 0.72, 0.75, and 0.76 for Case 1, Case 2, and Case 3, respectively. A positive correlation between WTP and visiting frequency in the past year (OR=1.181-1.200, p=0.015-0.032, for Cases 1 and 2) or Dermatology Life Quality Index (DLQI) score (OR=2.022-2.266, all p<0.01) was observed, but duration (OR=0.521-0.564, p<0.05, for Cases 1 and 2) of rosacea was negatively correlated with WTP.

CONCLUSION

For rosacea patients with poor quality of life, and those with high visiting frequency, BTX should be regarded as a recommendable new treatment in China.

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.

Efficacy of non-ablative fractional 1440-nm laser therapy for treatment of facial acne scars in patients with rosacea: a prospective, interventional study

Acne scarring is one of the most common facial skin disorders. The appropriate treatments for acne scars in patients with rosacea have not been studied. This study was designed to evaluate the efficacy and safety of non-ablative fractional 1440-nm laser (1440-nm NAFL) therapy for treatment of atrophic acne scars in patients with rosacea. In this prospective, interventional study, 32 patients with rosacea and acne scars underwent three sessions of 1440-nm NAFL therapy. Therapy efficacy, epidermal barrier function, and side effects were evaluated. Thirty patients completed and the median acne scar scores significantly reduced from 45 (30, 50) to 15 (15, 30) after three treatments (P < 0.001). The improvement score of acne scars was 2.7 ± 0.7; 22 (73.3%) were satisfied or highly satisfied. The rosacea erythema scores changed from 2.1 ± 0.4 to 1.9 ± 0.5 (P = 0.326), and flushing, burning, and stinging were not worse. The oil content after treatments was significantly reduced (P < 0.001), while there was no significant difference in other indicators of skin barrier function. The quality-of-life score decreased from 17.5 ± 3.8 to 14.1 ± 3.0 (P < 0.001). No serious side effects were observed. The 1440-nm NAFL therapy is effective in the treatment of acne scaring in patients with rosacea with little damage to the skin barrier.