The Role of Topical Brimonidine Tartrate Gel as a Novel Therapeutic Option for Persistent Facial Erythema Associated with Rosacea

Rosacea in Older Adults and Pharmacologic Treatments

Rosacea is a chronic inflammatory skin condition that is often more severe in older patients. The main clinical features are erythema, telangiectasia, and inflammatory lesions of the face. The pathogenesis of this condition is not fully understood but certainly multifaceted. Immune and inflammatory dysregulation, genetics, neurogenic dysregulation, microbiome dysbiosis, and systemic disease have all been implicated in rosacea pathogenesis. As we better understand the various pathways that lead to rosacea, we acknowledge that the different symptoms may have unique underlying triggers and mechanisms. Aging also impacts rosacea diagnosis and treatment. Older adults have more severe rosacea symptoms while also having more sensitive and fragile skin than younger patients; therefore, rosacea treatments for older patients require a balance between delivering adequate potency while also minimizing skin irritation and other adverse effects. Until recently, rosacea diagnoses were based on concrete subtypes that did not necessarily capture each patient's manifestation of rosacea. There is now an emphasis on more personalized phenotype-based diagnoses and treatments, which allows for more emphasis on treating individual symptoms and accounting for the unique characteristics of older patients. Centrofacial erythema is best treated with brimonidine and oxymetazoline, while phymatous change and telangiectasia are best treated with surgery and laser ablation. Treatment for rosacea papules and pustules ranges from topicals, such as azelaic acid, ivermectin, metronidazole, minocycline, and encapsulated benzoyl peroxide, to systemics, such as doxycycline and isotretinoin. It is important to understand these treatments in relation to adverse effects and drug interactions that may specifically arise in older populations to provide optimal care. As we advance in understanding rosacea's pathogenesis and adopt personalized phenotype-based approaches, optimizing care for older patients becomes crucial. Continued research into novel treatments is essential to address their unique needs.

Topical 10% Tranexamic Acid with and without Microneedling in the Treatment of Erythematotelangiectatic Rosacea: A Split-face Comparative Study

Objective

Erythematotelangiectatic rosacea (ETR) is recognized by flushing, persistent centrofacial erythema, and telangiectasia. Many lines of topical treatments have been used for ETR with variable outcomes. We aimed to evaluate the efficacy of 10% topical tranexamic acid (TXA) with and without microneedling in treating ETR.

Methods

All patients received treatment on both sides of the face, the right side was treated with microneedling combined with 10% topical TXA, and the left side was treated with 10% topical TXA only. All patients received three sessions at two weeks intervals. The final evaluation was done three months after the last treatment session.

Results

The study included 45 females. Their age ranged between 20 and 48 years. The duration of the disease ranged from two months to five years. Both sides of the face showed improvement after treatment. There was a clinically and dermoscopic significant improvement in the side treated with microneedling + TXA compared to the side of the face treated with TXA alone.

Limitations

The small sample size and the lack of long-term follow-up.

Conclusion

This study showed that TXA is an effective and safe treatment modality for ETR. Microneedling can enhance the delivery of TXA and lead to better outcomes regarding erythema and telangiectasia.

Rosacea Topical Treatment and Care: From Traditional to New Drug Delivery Systems

Rosacea is a multifactorial chronic inflammatory dermatosis characterized by flushing, nontransient erythema, papules and pustules, telangiectasia, and phymatous alterations accompanied by itching, burning, or stinging, the pathophysiology of which is not yet fully understood. Conventional topical treatments usually show limited efficacy due to the physical barrier property of the skin that hinders skin penetration of the active ingredients, thereby hampering proper drug skin delivery and the respective therapeutic or cosmetic effects. New advances regarding the physiopathological understanding of the disease and the underlying mechanisms suggest the potential of new active ingredients as promising therapeutic and cosmetic approaches to this dermatosis. Additionally, the development of new drug delivery systems for skin delivery, particularly the potential of nanoparticles for the topical treatment and care of rosacea, has been described. Emphasis has been placed on their reduced nanometric size, which contributes to a significant improvement in the attainment of targeted skin drug delivery. In addition to the exposition of the known pathophysiology, epidemiology, diagnosis, and preventive measures, this Review covers the topical approaches used in the control of rosacea, including skin care, cosmetics, and topical therapies, as well as the future perspectives on these strategies.

Comparative Efficacy Between Intense Pulsed Light Narrow Spectrum and Broad Spectrum in the Treatment of Post-Acne Erythema (PAE)

Purpose

Post-acne erythema (PAE) is one of the most common physical sequelae of acne regression, PAE can resolve spontaneously, but in some patients it may last for years. This study aimed to evaluate the efficacy and safety of narrow and broad spectrum filters of intense pulsed light (IPL) for the treatment of PAE.

Patients and Methods

This prospective study evaluated 60 patients with PAE for at least 6 months, assigned equally to three groups: 1st group received narrow-spectrum with vascular filter (530-650 nm and 900-1200 nm), 2nd group received broad-spectrum with (560/590-1200 nm) filters, the appropriate adjustments were made according to patient's skin colour. Every patient received four sessions one month apart. 3rd group is blank control group did not receive any treatment. CAT (CEA (Clinical Erythema Assessment), Area, and Telangiectasia) used to grade clearance of PAE before and after treatment, Investigators Global Assessment (IGA) used to assess the improvement score after the treatment, and Cardiff Acne Disability Index (CADI) used to evaluate the impact of PAE on patients' Quality of Life (QoL). Self-satisfaction scale completed at the follow-up. Adverse events and acne relapse were recorded.

Results

A significant decrease of CAT score in vascular group (P<0.05). IGA scale showed significant improvement after vascular treatment. A significant decrease in CADI (P<0.05) after vascular treatment. Patient satisfaction was higher in vascular group than control and blank control groups. Acne relapse observed in control and blank control groups (40% and 15%, respectively).10% of patients showed pigmentation, 15% had blisters after 590 nm treatment.

Conclusion

IPL vascular filter (530-650 nm and 900-1200 nm) have efficacy in the treatment of PAE. CADI score, patient satisfaction, and acne relapse were significantly better after vascular narrow spectrum treatment than broad-spectrum treatment.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Topical brimonidine reduces IPL-induced erythema without affecting efficacy: A randomized controlled trial in patients with facial telangiectasias

BACKGROUND

Laser and intense pulsed light (IPL) are standard symptomatic treatments for superficial telangiectasias, but postoperative erythema, oedema, and pain may prolong downtime.

OBJECTIVES

To investigate whether topical brimonidine reduces IPL-induced inflammation in patients with moderate to severe facial telangiectasias.

METHODS

A randomized, two-centre, single-blinded, split-face trial on adjuvant brimonidine and air-cooling versus air-cooling alone (control) in 19 patients treated in Denmark (n = 10 patients) and Belgium (n = 9). Brimonidine was applied to the allocated side after each of three facial IPL-treatments, given at 3-week intervals. Patients were assessed up to 1 month after the final treatment. Outcome measures included blinded clinical on-site evaluation of erythema and oedema (5-point-scales), objective erythema-scores (red-filter analysis), patient-evaluated pain (Visual Analogue Scale), IPL-efficacy (blinded photo-evaluation of telangiectasia clearance), and patient preference.

RESULTS

In total, 19 patients were enrolled and completed the study. IPL induced moderate to severe erythema after each treatment. Application of brimonidine, reduced erythema to baseline values compared to air-cooling alone and sustained efficacy 24 hours after treatment (median difference reduction: score 1 at each assessment, P ≤ 0.022). Objective erythema-scores supported clinical findings, demonstrating a median erythema reduction of 50-95% after application of brimonidine and air-cooling compared to 9-28% reduction after air-cooling alone (P ≥ 0.002). No difference in reduction of IPL-induced oedema was observed between facial sides (P ≥ 0.227). Brimonidine and air-cooling slightly and consistently reduced postoperative pain compared to air-cooling alone (VAS 1.0 after brimonidine versus VAS 1.5-2.0 after air-cooling alone at treatment 1-3, P ≤ 0.032). At 1-month follow-up, patients experienced excellent clearance of telangiectasias (75-100% clearance) on both facial sides (P = 1.000). Patient preference supported clinical data and 79% of patients preferred brimonidine to control (P = 0.019).

CONCLUSION

Compared to air-cooling alone, adjuvant brimonidine reduces IPL-induced erythema and associated pain while maintaining a high IPL-efficacy. Lasers Surg. Med. 50:1002-1009, 2018. © 2018 Wiley Periodicals, Inc.

Multifunctional Serine Protease Inhibitor-Coated Water-Soluble Gold Nanoparticles as a Novel Targeted Approach for the Treatment of Inflammatory Skin Diseases

The overexpression and increased activity of the serine protease Kallikrein 5 (KLK5) is characteristic of inflammatory skin diseases such as Rosacea. The use of inhibitors of this enzyme-such as 4-(2-aminoethyl)benzenesulfonyl fluoride hydrochloride (AEBSF·HCl) or the anti-human recombinant Kallikrein 5 (anti-KLK5) antibody-in the treatment of the disease has been limited due to their low bioavailability, for which their immobilization in drug delivery agents can contribute to making serine protease inhibitors clinically useful. In this work, we synthesized gold nanoparticles (GNP) coated with a mixture of hydroxyl- and carboxyl-terminated thiolates (GNP.OH/COOH), whose carboxyl groups were used to further functionalize the nanoparticles with the serine protease inhibitor AEBSF·HCl either electrostatically or covalently (GNP.COOH AEBSF and GNP.AEBSF, respectively), or with the anti-KLK5 antibody (GNP.antiKLK5). The synthesized and functionalized GNP were highly water-soluble, and they were extensively characterized using UV-vis absorption spectroscopy, Transmission Electron Microscopy (TEM), Dynamic Light Scattering (DLS), and Thermogravimetric Analysis (TGA). GNP.OH/COOH and their subsequent functionalizations effectively inhibited KLK5 in vitro. Internalization of fluorophore-coated GNP.OH/COOH in human keratinocytes (HaCaT cells) was proven using confocal fluorescence microscopy. Cell viability assays revealed that the cytotoxicity of free AEBSF is importantly decreased when it is incorporated in the nanoparticles, either ionically (GNP.COOH AEBSF) or, most importantly, covalently (GNP.AEBSF). The functionalized nanoparticles GNP.AEBSF and GNP.antiKLK5 inhibited intracellular KLK5 activity in HaCaT cells and diminished secretion of IL-8 under inflammatory conditions triggered by TLR-2 ligands. This study points to the great potential of these GNP as a new intracellular delivery strategy for both small drugs and antibodies in the treatment of skin diseases such as Rosacea.

Severe Rosacea: A Case Report

PURPOSE

To describe a case of severe rosacea with ocular involvement.

CASE REPORT

A 28-year-old female patient presented with extensive facial and ocular eruptions. She had a history of treatment with oral prednisolone due to the clinical diagnosis of lupus erythematosus (LE), which had resulted in transient improvement of the lesions, but was followed by exacerbation of the lesions. With the clinical diagnosis of severe oculofacial rosacea, she was successfully treated with oral doxycycline, steroid eye drops, and ocular lubricants. Histopathological features of skin biopsy were consistent with rosacea in the context of infection with Demodexfolliculorum. After four years, a relapse of the oculofacial lesions occurred, for which retreatment with oral tetracycline, steroid eye drops, and ocular lubricants was administered.

CONCLUSION

Rosacea can be extremely severe and disfiguring, and it can be misdiagnosed as the pathognomonic butterfly rash of LE. Demodex carriage in rosacea is consistent and may play a significant role in the severe forms.

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.

Swiss S1 guideline for the treatment of rosacea

Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.

Erythema of Rosacea Impairs Health-Related Quality of Life: Results of a Meta-analysis

INTRODUCTION

The central diagnostic feature of rosacea is diffuse central-facial erythema. The objective was to summarize published and unpublished health-related quality of life (HRQoL) data from seven previous studies in rosacea patients.

METHODS

A meta-analysis was performed on baseline HRQoL data of subjects with erythema of rosacea from five randomized controlled trials, one open-label safety study and one epidemiological study. The data from four questionnaires were analyzed, including the Euro QoL 5-dimension (EQ5D) generic questionnaire, the Dermatology Life Quality Index (DLQI) dermatology-specific quality of life instrument, the Productivity and Social Life Questionnaire and the Facial Redness Questionnaire.

RESULTS

The global EQ5D index score was 0.859 and the domains of pain/discomfort (31.5% moderate or extreme pain) and anxiety/depression (26.4% moderate or extreme) were most affected. Worse scores were observed with erythema of rosacea in the absence of inflammatory lesions (EQ5D score of 0.832 for no lesions vs 0.919 for subjects with ≥1 lesion). Almost half (43%) the subjects had at least moderately impaired HRQoL, including 19.8% with a DLQI total score of ≥11 indicating severely impaired HRQoL; symptoms/feelings was the most affected domain. Subjects with a patient self-assessment (PSA) of severe erythema of rosacea had a worse mean DLQI score than moderate PSA subjects (8.6 vs 6.0). Work life and social life were affected, especially in subjects with severe PSA (62% with social life at least somewhat affected).

CONCLUSION

Erythema of rosacea causes a marked decrease in HRQoL in most patients, especially those with self-perceived severe erythema and without inflammatory lesions, and should thus be considered as an important medical problem requiring medical intervention.

FUNDING

Galderma UK.