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

Pediatric blepharokeratoconjunctivitis: A challenging ocular surface disease

Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic and recurrent ocular surface inflammatory disorder affecting children in early life. It is frequently under- or late- diagnosed, representing a potential cause of severe visual morbidity worldwide. An expert panel consensus recently agreed on its definition and proposed diagnostic criteria for suspected and definitive PBKC to reduce confusion and avoid varied terminology previously used in the literature, improving early and precise diagnosis. Previous evidence has pointed to the role of the adaptive immune system in recognizing and handling antigenic eyelid bacterial products, particularly from the cell wall, and the direct toxic and inflammatory effects of their cytolytic exotoxins on the ocular surface. PBKC is a frequent referral in pediatric and cornea clinics characterized by a history of recurrent chalazia, blepharitis, meibomian gland dysfunction, conjunctival hyperemia, phlyctenules formation, and corneal infiltrates with vascularization and scarring. The latter is a major cause of significant visual loss and amblyopia. Current treatment strategies aim to control inflammation on the ocular surface, halt disease progression, and avoid corneal involvement. Further research on pathogenic mechanisms will shed light on novel potential therapeutic strategies. Awareness of PBKC should enhance early diagnosis, prompt adequate treatment, and improve outcomes. We compile current evidence on epidemiology, pathophysiology, clinical spectrum of disease, diagnostic criteria, and management strategies for PBKC.

Efficacy and Safety of Oxymetazoline 1% Cream for the Treatment of Mild to Moderate Facial Rosacea

INTRODUCTION

Rosacea is a common skin condition that affects the physical and mental health of the patient. The objective of this study was to evaluate the efficacy and safety of oxymetazoline 1% cream, a specific α1A-adrenoceptor agonist, for the treatment of mild to moderate facial rosacea.

METHODS

In phase II of the before-after study, 15 patients with mild to moderate rosacea were enrolled and treated with oxymetazoline 1% cream twice daily for 4 weeks. The clinician's erythema assessment (CEA) and patient's self-assessment (PSA), as well as the skin biometric parameters (transepidermal water loss, sebum, stratum corneum hydration, temperature, erythema, melanin, and pH), dermal and epidermal thickness and echo-density, and capillaroscopic pattern were assessed and compared before and after treatment. p-Value < 0.05 was considered significant.

RESULTS

CEA and PSA indexes decreased significantly 2 and 4 weeks after the treatment (p-value: 0.001). The erythema index also decreased significantly in both 2 weeks (p-value: 0.001) and 4 weeks (p-value: 0.001) after the treatment. The capillaroscopic pattern of lesions showed a decrease in telangiectasia and a reddish background of skin. No side effects of treatment were experienced by any of the patients.

CONCLUSION

Oxymetazoline 1% cream was safe and effective in treating mild to moderate facial rosacea. The reduction in the skin's vascularity was also objectively confirmed.

Ocular Rosacea: An Updated Review

PURPOSE

Ocular rosacea is a chronic inflammatory disorder affecting the ocular surface, often associated with cutaneous rosacea. This review aims to explore its pathogenesis, treatment approaches, and future directions for management.

METHODS

A review of current literature on the pathophysiology, clinical features, and treatment strategies of ocular rosacea in adults and children (pediatric blepharokeratoconjunctivitis) was conducted. Emerging research on immune dysregulation, microbiome alterations, and potential therapeutic targets was analyzed.

RESULTS

Ocular rosacea involves dysregulation of the immune and neurovascular systems, with toll-like receptor activation and complement system involvement leading to chronic ocular surface inflammation. Alterations in the ocular microbiome have been implicated in disease progression. Treatment strategies emphasize a stepwise approach, incorporating ocular and skin hygiene, lifestyle modifications, and pharmacological interventions. Recent advancements in understanding the disease mechanisms have led to the exploration of targeted therapies, including biologics and small-molecule inhibitors.

CONCLUSIONS

Ocular rosacea remains challenging to diagnose and treat, particularly in children (pediatric blepharokeratoconjunctivitis), often leading to delayed intervention and poor outcomes. A multidisciplinary approach, including new therapeutic options, holds promise for improving patient care. Further research into the genetic and molecular basis of ocular rosacea may enable more personalized treatments.

Managing a Burning Face: Clinical Manifestations and Therapeutic Approaches for Neurogenic Rosacea

Rosacea is a common chronic inflammatory condition primarily affecting middle-aged women. It presents with flushing, erythema, telangiectasia, papules, pustules, phymatous changes, and ocular involvement. Although typically grouped into four subtypes-erythematotelangiectatic, papulopustular, ocular, and phymatous-overlapping features often favor a phenotypic diagnostic approach. Neurogenic rosacea (NR) has emerged as a distinct subgroup featuring distinguishing features such as peripheral facial erythema, severe burning and stinging sensations, and resistance to standard rosacea therapies. Recent insights into the pathophysiology of NR propose neural dysregulation as the main driver of the condition. Specifically, the activation of TRP channels at cutaneous sensory nerve endings in the dermis triggers the release of vasoactive peptides, driving neuroinflammation and resulting in burning and stinging. Additionally, there is a marked association with neuropsychiatric comorbidities, which would further mediate the pathogenesis of the condition. In line with this pathophysiological model, NR often fails to respond to conventional rosacea treatments. Instead, patients benefit more from antidepressants and neuroleptic agents that help modulate neuronal activity and alleviate symptoms. This review explores and summarizes the scientific evidence regarding the new insights on disease pathogenesis, clinical manifestations, and proposed treatments for NR.

Investigation of corneal topographic and ocular surface parameters in ocular rosacea based on skin subtypes

OBJECTIVE

To compare the corneal topographic parameters and ocular surface parameters of ocular rosacea (OR) patients across skin subtypes of the disease and healthy controls.

METHODS

This prospective study included 180 eyes of 90 OR patients and 60 eyes of 30 healthy controls. Among the OR patients, 30 had phymatous (60 eyes), 30 had erythematotelangiectatic (60 eyes) and 30 had papulopustular skin types (60 eyes). We measured the mean keratometry (Kmean), maximum keratometry (Kmax), thinnest corneal thickness (TCT), central corneal thickness (CCT) and corneal volume (CV) with a topography device (Sirius, Italy). Additionally, we measured tear-film breakup time (TBUT), Meiboscore and Schirmer's test from all participants. We compared parameters across OR skin groups as well as with controls.

RESULTS

Kmean and Kmax were significantly steeper in the OR group compared to controls (p<0.05). We found significant correlations between "Kmean-Kmax", "CV-TCT", "CV-CCT", and "TCT-CCT" in both groups, while significant correlations between "age-Kmean", "age-Kmax", and "Meiboscore-Kmax" were present only in OR patients. When patients were divided into subgroups according to their skin subtypes, the papulopustular and phymatous subgroups had steeper Kmean and Kmax compared to the erythematotelangiectatic and control groups (P<0.05). The papulopustular subgroup had lower CCT, lower TBUT and higher Meiboscore compared to the phymatous, erythematotelangiectatic and control groups but lower TCT compared to controls (P<0.05). In addition, there were significant correlations between "Kmax-CV", "Kmax-TCT", and "Kmax-meiboscore" only in the papulopustular subgroup (P<0.05).

CONCLUSION

It appears that the corneas of OR patients are steeper than those of healthy controls; corneal thinning and abnormalities of ocular surface parameters are more pronounced in papulopustular skin types.

Successful Treatment of Complex and Refractory Rosacea Using Platelet-Rich Plasma Injection Therapy: Case Series and Review of the Literature

BACKGROUND

Rosacea is a chronic inflammatory skin disease that affects a notable proportion of the adult population. Platelet-rich plasma (PRP) has been widely used to treat various inflammatory diseases due to its potent anti-inflammatory and antibacterial properties. Considering its therapeutic potential, PRP is emerging as a promising option for managing rosacea.

AIMS

To evaluate the efficacy and safety of PRP therapy in treating distinct clinical presentations of rosacea and explore its potential as an alternative to systemic treatments, particularly in cases where conventional therapies are contraindicated.

METHODS

Five patients of rosacea with distinct presentations were treated with PRP therapy. The treatment outcomes were analyzed, and a brief review of relevant literature was conducted to contextualize the findings. Clinical efficacy was assessed using clinical photographs captured at 0 and 30 days after baseline according to the National Rosacea Society Standard (NRSS) grading system. Additionally, the efficacy of combining PRP injections with delicate pulsed light therapy or botulinum toxin injections was assessed.

RESULTS

PRP therapy demonstrated significant efficacy and safety in treating rosacea, offering a viable alternative to systemic treatments. The combination of PRP with delicate pulsed light therapy or botulinum toxin injections showed enhanced therapeutic outcomes, not only alleviating rosacea symptoms but also reducing or eliminating patients' dependence on oral medications.

CONCLUSIONS

PRP therapy, both as a standalone treatment and in combination with other modalities, represents a promising approach for managing rosacea. These findings highlight the potential of PRP to address the limitations of conventional therapies and improve patient outcomes. Further research is warranted to validate these results and optimize treatment protocols.

Intradermal injection of botulinum toxin for erythema in rosacea: A scoping review and meta-analysis

Background Rosacea is a skin condition characterised by persistent facial erythema, flushing, papules, pustules, and telangiectasia. Botulinum toxin A (BoNT-A) has been used to treat a variety of conditions, but its effectiveness in improving facial erythema in rosacea patients is uncertain. Objectives The aim of the study is to evaluate the effectiveness and determine the optimal dose of BoNT-A treatment for rosacea. Methods An online database search (Pubmed, Cochrane Library and Embase) was conducted on 30th June 2023 to identify studies that used intradermal injection of BoNT-A to treat facial erythema in rosacea patients and excluded studies in which BoNT-A was used for facial erythema due to other known medical condition such as menopause, drug or pregnancy. The primary outcome measure for this study was the improvement in erythema score as objectively assessed. A random effect model was used in the meta-analysis. Results Seven studies involving a total of 167 rosacea patients were included in the meta-analysis. Meta-analysis of two randomised controlled trials showed improvement of erythema on the third month after treatment standardized mean difference (SMD): 1.676, 95% confidence interval (CI): 2.278-1.074, I2: 35.76%). A separate analysis of seven single-armed treatment studies found significant improvement in erythema with intradermal injection of BoNT-A at one, two and three months after treatment (first month: SMD: 2.712, 95% CI: 4.1182-1.243; second month: SMD:2.213, 95% CI: 3.702-0.725; third month: SMD: 1.912, 95% CI: 2.882-0.941). Adverse events, including mild facial paralysis and injectional purpura, were reported in some studies. Limitation The limitations of this study include heterogeneity in study design and a small sample size. Conclusion Intradermal injection of BoNT-A may be an effective treatment for facial erythema in rosacea. Unwanted facial muscle paralysis was seen in different BoNT-A concentration but not noted when the dose was less than 0.02ml per site. Future studies particularly randomised trials are required to identify the volume of injection required to reduce the erythema.

Characteristics of the Stool, Blood and Skin Microbiome in Rosacea Patients

Several research groups have confirmed that in the pathogenesis of the chronic inflammatory skin disorder rosacea, the composition of the skin and fecal microbiome of affected patients differs from that of healthy individuals. We studied the stool, blood and skin microbiomes of rosacea and control patients using 16S rRNA sequencing. Our goals were to determine 1. whether the microbiome characteristics of rosacea patients differ from that of healthy individuals, 2. whether the change experienced on the skin can be confirmed by alterations in the stool microbiome through the mediation of the blood and 3. whether the metabolic activity of the changed skin, blood or fecal microbiome can play a role in the pathogenesis of rosacea. The rosacea skin microbiome differed significantly from the healthy skin microbiome in both alpha and beta diversity, as well as in the abundance of the genera. Only a few genera abundances differed significantly in stool and blood samples. The most significant representatives of the rosacea skin microbiome, Staphylococcus, Cutibacterium, Corynebacterium and Neisseria, cannot be derived from the feces or blood. The metabolic pathways associated with healthy fecal microbiome contributed to the production of anti-inflammatory short-chain fatty acids. While the increased production of adenosylcobalamin, L-isoleucine and thiazole by the microbiome of healthy skin appeared to have a protective effect, the excessive heme and H2S production experienced in rosacea skin likely contribute to the deterioration of the pathology.

Assessment of Depressive and Anxiety Symptoms and Health-Related Quality of Life in Rosacea Patients: A Case-Control Study

Background: Rosacea, a chronic facial dermatosis, poses a substantial global prevalence burden. Its impact extends beyond physical symptoms, affecting patient quality of life, self-esteem, and psychosocial functioning. This study aims to assess the health-related quality of life and emotional well-being in Jordanian rosacea patients in comparison to healthy controls. Methods: A case-control study, matching for age and sex, was conducted among rosacea patients attending the outpatient department at a governmental secondary hospital in the north of Jordan between September 2022 and November 2023. Adult patients with a confirmed rosacea diagnosis for a duration of ≥ 3 months were paired with healthy controls. Health-related quality of life, anxiety, and depression were evaluated using the Dermatology Life Quality Index (DLQI) and the Hospital Anxiety and Depression Scale (HADS), respectively. Disease severity was assessed using the Clinician's Erythema Assessment (CEA) grading system. Results: The study included 198 rosacea patients and 198 healthy controls. Rosacea patients exhibited significantly higher DLQI scores (mean 11.32 ± 5.4) compared to controls (mean 4.28 ± 2.3), indicating diminished quality of life. Subscale analysis revealed prominent differences in symptoms/feelings and daily activities. Additionally, rosacea patients reported elevated scores on the HADS anxiety (mean 9.38 ± 3.2) and depression (mean 8.19 ± 4.3) subscales in contrast to controls (mean 3.88 ± 2.18 and mean 3.41 ± 1.87, respectively). More than half (57%) of rosacea patients experienced moderate or severe anxiety, and nearly a third (31%) reported moderate or severe depression. Regression analyses revealed that higher disease severity significantly predicted worse quality of life (β = 0.384), anxiety (β = 0.352), and depression (β = 0.312). Conclusion: The study demonstrated that rosacea patients in Jordan experience significantly diminished quality of life and higher rates of anxiety and depression compared to healthy controls. Disease severity and multiple facial lesions emerged as strong predictors of poor psychological outcomes, while female gender increased vulnerability and longer disease duration showed a protective effect. These findings emphasize the need for routine psychological screening and a holistic treatment approach, particularly for newly diagnosed patients with severe disease manifestations.

Improvement of Clinical Findings, Meibography and Tear Film Parameters in Pediatric Ocular Rosacea Patients After a Standard Treatment Protocol

PURPOSE

The objective of this study was to illustrate the changes in ocular findings, meibography, and tear break-up time (TBUT) values in pediatric patients with ocular rosacea following a standardized treatment.

METHODS

The study included consecutive patients diagnosed with ocular rosacea, referred to a tertiary hospital between 2021 and 2023. Each patient underwent biomicroscopic examinations, non-invasive TBUT assessments, corneal fluorescein staining (evaluated using the Oxford scoring system), and meibography. The standard treatment protocol involved warm compresses, eyelid hygiene, preservative-free sodium hyaluronate eye drops (administered four times daily), topical azithromycin 1.5% (twice daily for 3 days), topical steroids (loteprednol 0.5%, four times daily for 2 weeks), and either doxycycline 100 mg/day for 14 days or oral suspension of azithromycin 10 mg/kg for 3 days followed by an additional three-day course of treatment administered 10 days later (for patients above and below 14 years of age, respectively).

RESULTS

The study included 18 patients, with 10 (55.5%) being female and 8 (44.4%) being male, with a mean age of 9.7 ± 4.5 years (range: 3-18). Four patients displayed cutaneous involvement. The treatments resulted in significant improvements in the Oxford scores, reduction in corneal neovascularization, and increased TBUT (p < 0.001, p = 0.016, p < 0.001, respectively). Meibomian gland loss area also significantly improved post-treatment (27.4 ± 6.7% vs 39.2 ± 13.4%, p = 0.001).

CONCLUSION

This study demonstrated that pediatric ocular rosacea patients may exhibit improved meibomian gland function, regression of corneal neovascularization, and enhanced tear film parameters following a standardized treatment protocol that includes both topical and systemic approaches.

Rosacea in East Asian populations: Clinical manifestations and pathophysiological perspectives for accurate diagnosis

Rosacea is a chronic inflammatory disorder primarily affecting the facial skin, prominently involving the cheeks, nose, chin, forehead, and periorbital area. Cutaneous manifestations encompass persistent facial erythema, phymas, papules, pustules, telangiectasia, and flushing. The pathogenesis of rosacea is associated with various exacerbating or triggering factors, including microbial infestation, temperature fluctuations, sunlight exposure, physical exertion, emotional stress, consumption of hot beverages and spicy foods, and exposure to airborne pollen. These environmental factors interact with genetic predispositions in the development of rosacea. The roles of the lipophilic microbiome, ultraviolet radiation, nociceptive responses, and vascular alterations have been proposed as significant factors in the pathogenesis. These insights contribute to understanding the anatomical specificity of facial involvement and the progressive nature of rosacea. East Asian skin, predominantly classified as Fitzpatrick skin phototypes III to IV, is characterized by relatively diminished skin barrier function and increased sensitivity to irritants. Airborne pollen exposure may particularly act as a trigger in East Asian individuals, possibly mediated through toll-like receptors. The lack of specificity in objective clinical and histopathological findings leads to diagnostic challenges for individuals with colored skin, including East Asians, particularly when erythema is the sole objective manifestation. An alternative diagnostic scheme may thus be necessary. A diagnostic approach emphasizing vascular manifestations and nociceptive symptoms potentially holds promise for individuals with darker skin tones. More research focusing on potential variations in skin physiology across different racial groups is essential to establish more effective diagnostic schemes applicable to both dark and light skin colors.

Rosacea and autoimmune liver diseases: a two-sample Mendelian randomization study

Rosacea and autoimmune liver diseases (AILDs) are diseases closely associated with immune system abnormalities. AILDs primarily includes autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). Currently, research on the association between these two conditions is limited. Therefore, this study employed the bidirectional Mendelian randomization (MR) method to investigate potential causal relationships between rosacea and AILDs based on genetic predictions. Summary data related to Rosacea, AIH, PSC, and PBC were obtained from public genome-wide association studies (GWAS). The inverse variance weighted (IVW) method was used as the primary analytical approach, supplemented by the MR-Egger, weighted mode method, weighted median, and simple mode. A series of sensitivity analyses were also conducted to identify heterogeneity and pleiotropy effects. The MR analysis results indicated a significant increase in the risk of rosacea being associated with PBC (OR = 1.09, 95% CI = 1.02-1.18, P = 0.014), but no such association was found with AIH or PSC. Furthermore, this study did not find a significant impact of rosacea on the risk of AILDs. This study represents the first in-depth exploration of the potential causal relationship between rosacea and AILDs using MR analysis. Thes findings suggest an increased risk of rosacea among PBC patients.

Current state and future perspectives in the diagnosis of eyelid margin disease: clinical review

The eyelid margin is vital to ocular surface integrity. Much peer-reviewed literature has been established in eyelid margin inflammation, better known as blepharitis. The purpose was to review and understand the impact of eyelid margin disease. Anterior blepharitis causes inflammation at the eyelash base, ciliary follicles, and the palpebral skin. Posterior blepharitis occurs when there is inflammation with the posterior eyelid margin disease. In common usage, the term "blepharitis" used alone almost always refers to anterior blepharitis. Classification of eyelid margin disease should be based on etiopathogenesis, location, primary vs secondary, and chronicity. Blepharitis has several etiopathologies (infectious, inflammatory, and squamous). Meibomian gland dysfunction (MGD) can refer to the functional and/or structural problems with the meibomian gland. Meibomitis (or meibomianitis) occurs when there is inflammation associated with the MGD. The presence of blepharitis and/or MGD (with or without inflammation) can affect the ocular surface and thereby affect anterior segment and cataract surgeries. This review article evaluates the differential diagnoses of eyelid margin disease, including various forms of blepharitis, MGD, and meibomitis.

Efficacy of Treatments in Reducing Inflammatory Lesion Count in Rosacea: A Systematic Review

INTRODUCTION

Rosacea is a chronic inflammatory skin condition affecting approximately 5.5% of the global population. Patients present heterogeneously with a mix of features in the central facial region, of which papules and pustules are considered to be a major feature. The identification of effective treatments for reducing inflammatory lesions in rosacea can alleviate the psychosocial burden that many rosacea patients experience, including reduced self-esteem, anxiety, and social withdrawal. The objective of this systematic review is to determine the effectiveness of topical and systemic therapies in reducing lesion count in rosacea patients.

METHODS/RESULTS

Medline, Embase, and Cochrane CENTRAL databases were searched, resulting in the inclusion of 43 clinical trials reporting on a total of 18,347 rosacea patients. The most well-studied treatments include ivermectin, metronidazole, azelaic acid, minocycline, and doxycycline. Oral isotretinoin was the most effective treatment in reducing inflammatory lesions and may be recommended for severe recalcitrant cases of rosacea.

CONCLUSIONS

Several topical and systemic therapies have demonstrated efficacy in reducing inflammatory lesion count in rosacea patients, with mechanisms of action centred around suppressing inflammation and killing Demodex folliculorum mites. Additional research is required to determine effective combination therapies in rosacea.

Biomarkers in rosacea: A systematic review

Rosacea is a chronic and psychologically ladened disease affecting 1%-3% of people worldwide. The identification and validation of biomarkers in rosacea patients has the potential to improve disease progression, support diagnosis, provide objective measures for clinical trials and aid in management. The objective of this review is to systematically identify all rosacea biomarkers, categorize them by type and identify trends to improve disease expression. Eligibility criteria for this review (PROSPERO CRD42023397510) include randomized controlled trials, case-control studies, cohort studies and other observational studies. No restrictions were placed on patient demographics (age, sex, ethnicity) or language of publication until February 2023. Quality of studies was assessed using the National Institute of Health quality assessment tool. The literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 805 unique articles were screened based on the applied inclusion and exclusion criteria. After the articles were screened based on title/abstract and full-text, a total of 38 studies were included, reporting on a total of 119 unique biomarkers. The results of this review and current rosacea pathogenic mechanisms provide the greatest support for the innate cathelicidin and inflammasome, Th1 and Th17 pathways. The most commonly reported biomarkers include IL-1β, TNF-α, IL-37, IFN-γ and MMP-9. Biomarkers identified in this study support current theories of rosacea pathogenesis and provide direction for research to further our knowledge. However, more research is needed to identify biomarkers panels that can provide diagnostic utility. This may be difficult due to the heterogeneity of the disease and potential differences between rosacea subtypes.

The causal relationship between blood metabolites and rosacea: A Mendelian randomization

BACKGROUND

An increasing amount of research demonstrates that metabolic disorders are related to rosacea. However, the correlations and causal relationships among them remain unknown.

METHODS

We conducted not only forward 2-sample MR (Mendelian randomization) analyses but also reverse MR analyses which showed positive results in the forward MR analysis. In the forward MR analyses, inverse-variance weighted (IVW) and MR-Egger were performed as MR analyses. Cochran's Q test and the MR-Egger Intercept were used for sensitivity analyses. Concerning reverse MR analyses, IVW, MR-Egger, weighted median, simple mode, and weighted mode were applied. Cochran's Q test, MR-Egger Intercept, and MR pleiotropy residual sum and outlier (MR-PRESSO) outlier test were applied as sensitivity analyses.

RESULTS

A total of 24 metabolites and 1 metabolite ratio were shown to have a causal effect on rosacea. N-lactoyl phenylalanine (N-Lac-Phe) was estimated as statistically significant by Bonferroni correction. Interestingly, we found three metabolites that were negatively associated with rosacea, especially caffeine, which are in line with the results of a large cohort study of females. For reverse MR analysis, we revealed that rosacea could potentially decrease the generation of two metabolites: octadecenedioate (C18:1-DC) and methyl vanillate sulfate.

CONCLUSION

This study identified blood metabolites that may be associated with the development of rosacea. However, the exact mechanism by which these positive metabolites influence rosacea remains uncertain due to the paucity of experimental investigations. The combination of genetics and metabolomics offers novel viewpoints on the research of underlying mechanisms of rosacea and has significant value in screening and prevention of rosacea.

Internalized Stigma and Its Relationship With Quality of Life and Perceived Health Status in Rosacea and Acne Vulgaris: A Comparative Cross-Sectional Study

Background Internalized stigma (IS) is the acceptance of unfavorable stereotypes about the disease that society has created and withdrawing from society with feelings of shame and worthlessness. Due to the visibility feature of facial skin diseases such as rosacea and acne vulgaris (AV), it is possible for them to cause IS. Objective We aimed to examine the level of IS in AV and rosacea patients and compare these patient groups as well. Methods Fifty-three AV and 46 rosacea patients aged 18-65 were included in this study. Internalized Stigma Scale (ISS) adapted for AV and rosacea were applied to all the patients. They also responded to the "Dermatology Life Quality Index" (DLQI) questionnaire. The relationship between IS levels and DLQI was investigated, and then acne and rosacea patients were compared with each other. Results Total DLQI, total ISS, and its subscales' scores of all patients were found to be positively correlated with each other. When rosacea and AV patients were compared with each other, there was no difference regarding DLQI and ISS scores. Conclusion AV and rosacea patients experience high IS, and it is significantly related to low quality of life and health status. They also have similar IS levels when compared with each other.

Spontaneous bilateral corneal perforation in ocular Rosacea

PURPOSE

To report a rare case of a 19-year-old girl who presented with spontaneous bilateral corneal perforation in a setting of ocular rosacea.

METHODS

Ocular rosacea was diagnosed and treated with doxycycline. Cyanoacrylate glue was applied to treat corneal perforations.

RESULTS

At six months follow up there is good healing, visual acuity has improved, anterior chamber is deep with no Seidel.

CONCLUSIONS

Rosacea is a multifactorial disease with an unclear pathophysiology. The ocular manifestations of rosacea (ocular rosacea) may occur without skin involvement, are not specific and can range from mild blepharitis to sight-threatening conditions. This case shows how ocular rosacea can lead to serious vision-threatening complications with mild symptoms. Cyanoacrylate glue and systemic antibiotic treatment are effective treatments.

Efficacy and safety of botulinum toxin for rosacea with positive impact on quality of life and self-esteem

BACKGROUND

Rosacea is a prevalent chronic inflammatory skin disease with a multifactorial pathophysiology. It compromises several skin structures, including the proliferation and dilation of dermal blood vessels, primarily in the central areas of the face, accompanied by significant psychosocial impairment, leading to reduced quality of life (QoL) and self-esteem. There are consensus guidelines for its treatment, but few options for the erythema. This study hypothesizes that treating rosacea skin lesions with botulinum toxin (BTX) could improve signs and symptoms, resulting in enhanced QoL and self-esteem.

METHODS

This interventional, open, uncontrolled, and prospective study, conducted at a single center, included 33 individuals diagnosed with rosacea, treated with standard therapeutic options according to the rosacea subtype plus superficial injections of BTX, and followed up for 90 days. Botulinum toxin injections were applied on Days 1 and 14. Clinical features and side effects were assessed at each visit; QoL, self-esteem, and medication adherence questionnaires were administered on Days 1 and 90.

RESULTS

Treatment with BTX yielded improvement in the clinical signs of rosacea, registered by the investigators, and reported by 94% of the participants. Improved QoL scores (P < 0.05) and a notable increase in self-esteem scores (P < 0.001) were demonstrated. Rare adverse events were observed.

CONCLUSIONS

The utilization of BTX superficial injections in patients with rosacea was safe and effective, improving the clinical appearance of the lesions. Despite some limitations, to our knowledge, this is the first study that showed the positive impact of this treatment modality on both QoL and self-esteem.

Rosacea: Pathogenesis and Therapeutic Correlates

Rosacea is a chronic inflammatory condition of which there is no cure. The pathogenesis of rosacea is likely multifactorial, involving genetic and environmental contributions. Current understanding suggests that pro-inflammatory pathways involving cathelicidins and inflammasome complexes are central to rosacea pathogenesis. Common rosacea triggers modulate these pathways in a complex manner, which may contribute to the varying severity and clinical presentations of rosacea. Established and emerging rosacea treatments may owe their efficacy to their ability to target different players in these pro-inflammatory pathways. Improving our molecular understanding of rosacea will guide the development of new therapies and the use of combination therapies.

Recent Advances in the Management of Rosacea through Natural Compounds

Rosacea is a chronic skin disorder that affects more than 5% of the world's population, with the number increasing every year. Moreover, studies show that one-third of those suffering from rosacea report a degree of depression and are less compliant with treatment. Despite being the subject of prolonged studies, the pathogenesis of rosacea remains controversial and elusive. Since most medications used for the management of this pathology have side effects or simply do not yield the necessary results, many patients lose trust in the treatment and drop it altogether. Thus, dermato-cosmetic products with natural ingredients are gaining more and more notoriety in front of synthetic ones, due to the multiple benefits and the reduced number and intensity of side effects. This review is a comprehensive up-to-date report of studies that managed to prove the beneficial effects of different botanicals that may be useful in the short and long-term management of rosacea-affected skin. Based on recent preclinical and clinical studies, this review describes the mechanisms of action of a large array of phytochemicals responsible for alleviating the clinical symptomatology of the disease. This is useful in further aiding and better comprehending the way plant-based products may help in managing this complex condition, paving the way for research in this area of study.

Diagnostic Challenges of Ocular Rosacea

OBJECTIVE

This study aims to address the issues surrounding the diagnosis of ocular rosacea and to evaluate the development of the patients’ condition after treatment, as well as to distinguish between healthy and diseased patients using a glycomic analysis of tears.

METHODOLOGY

A prospective study was conducted to assess a total of 68 eyes in 34 patients over a six-week period. These patients were diagnosed with ocular rosacea based on subjective symptoms and clinical examination. The study monitored the development of objective and subjective values. The difference between patients with the pathology and healthy controls was established by means of analysis of glycans in tears.

RESULTS

Skin lesions were diagnosed in 94% of patients with ocular rosacea, with the most commonly observed phenotype being erythematotelangiectatic (68.8%). The mean duration of symptoms was 29.3 months (range 0.5–126 months) with a median of 12 months. Throughout the study, an improvement in all monitored parameters was observed, including Meibomian gland dysfunction, bulbar conjunctival hyperemia, telangiectasia of the eyelid margin, anterior blepharitis, uneven and reddened eyelid margins, and corneal neovascularization. The study also observed improvements in subjective manifestations of the disease, such as foreign body sensation, burning, dryness, lachrymation, itching eyes, photophobia, and morning discomfort. The analysis of glycans in tears partially separated tear samples based on their origin, which allowed for the differentiation of patients with rosacea from healthy controls. In the first sample, the pathology was determined in a total of 63 eyes (98.4%) of 32 patients, with further samples showing a change in the glycomic profile of patients’ tears during treatment.

CONCLUSION

The study demonstrated objective and subjective improvements in all the patients. Tear sampling and analysis could provide a means of timely diagnosis of ocular rosacea.

Long-term maintenance treatment of rosacea: experts' opinion

BACKGROUND

Rosacea is a chronic inflammatory dermatosis characterized by remissions and flares. Although the rosacea active treatment phase is well established, the long-term maintenance phase is still challenging.

OBJECTIVE

To discuss and make recommendations on how to treat patients during the long-term maintenance phase for the main rosacea phenotypes.

METHODS

A panel of six board-certified Brazilian dermatologists and one American dermatologist gathered to compose a consensus based upon an initial statement on how to treat rosacea during the long-term maintenance phase based on the methodology Nominal Group Technique. The experts discussed each factor based upon an initial statement on how to treat rosacea patients in the long-term maintenance phase. A sequence of comprehensive narrative reviews was performed; a questionnaire preparation about the definition of the maintenance phase and its management was presented; an interpersonal discussion and ranking of the ideas were conducted. Recommendations were made if the specialists had 75% agreement.

RESULTS

The maintenance treatment phase, which starts by achieving IGA 0 or 1 grades at the active phase, should be considered at least during the 9-month period after remission. The recommendations of all treatments target this period. Daily skincare regimen and sunscreen are crucial. Active treatment phase should be recommended if signs or symptoms reappear or worsen.

CONCLUSION

Maintenance phase success depends on patient's adherence to daily skin care, appropriate treatments, continued follow-up with dermatologist, and self-assessment to identify new signs and symptoms indicating disease relapse.

Rosacea: Clinical Aspects and Treatments

GENERAL PURPOSE

To review the clinical presentation and treatment of rosacea.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Distinguish the clinical manifestations of rosacea subtypes.2. Identify pharmacologic and nonpharmacologic treatment options for patients who have rosacea.

Cutaneous neurogenic inflammation mediated by TRPV1-NGF-TRKA pathway activation in rosacea is exacerbated by the presence of Demodex mites

BACKGROUND

Rosacea is a common chronic inflammatory skin condition that is often refractory to treatment, with frequent relapses. Alterations in the skin immunological response and Demodex mite infestation are the primary aetiologic factors targeted for treatment. Transient receptor potential cation channel subfamily V member 1 (TRPV1) is a nociceptive cation channel that plays a role in cutaneous neurogenic pain and can be activated by various rosacea triggers.

OBJECTIVES

We investigated the effects of TRPV1 modulation in rosacea, focussing on Demodex mite colonization and cutaneous neurogenic inflammation.

METHODS

We examined mRNA expression levels according to Demodex population counts. An in vitro study using capsazepine as a TRPV1 antagonist was performed to assess the influence of TRPV1 in keratinocytes. A rosacea-like mouse model was generated by the injection of the 37-amino acid C-terminal cathelicidin peptide (LL37), and changes in the skin, dorsal root ganglion (DRG) and ears were examined.

RESULTS

Increased Demodex mite population counts were associated with increased expression levels of TRPV1, tropomyosin receptor kinase A (TrkA) and nerve growth factor (NGF), and these levels could be reduced by capsazepine treatment in keratinocytes. In an in vivo study, the downstream effects of TRPV1 activation were investigated in the skin, DRG and ears of the rosacea-like mouse model.

CONCLUSIONS

The findings of this study are instrumental for understanding the underlying causes of rosacea and could potentially lead to the development of new treatments targeting the NGF-TrkA-TRPV1 pathway. The identification of this pathway as a therapeutic target could represent a major breakthrough for rosacea research, potentially resulting in more effective and targeted rosacea treatments. This study contributes to an improved understanding of rosacea pathophysiology, which may lead to the development of more effective treatments in the future.

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.

Detecting potential causal relationship between inflammatory bowel disease and rosacea using bi-directional Mendelian randomization

The association between rosacea and inflammatory bowel disease (IBD) has been studied in previous observational studies. It is unclear, however, whether the association is causal or not. Independent genetic variants for IBD were chosen as instruments from published Genome-wide association studies (GWAS) studies involving 38,155 cases with an IBD diagnosis and 48,485 controls in order to investigate the causal effect of IBD on rosacea. Summarized data for rosacea were gathered from various GWAS studies that included 1195 cases and 211,139 controls without rosacea. Reverse-direction Mendelian randomization (MR) analysis was done to investigate the relationship between genetically proxied rosacea and IBD. With the use of the inverse variance-weighted (IVW), MR-Egger, and weighted median approaches, a 2-sample Mendelian randomization study was carried out. Analysis of heterogeneity and sensitivity was performed to examine the pleiotropy and robustness of effect estimates. The forward-direction of the MR study was to reveal that genetic predisposition to IBD including its two main subtypes: Crohn's disease (CD) and ulcerative colitis (UC) was associated with an increased risk of rosacea. The reverse-direction MR analyses did not demonstrate that a genetic predisposition to rosacea was associated with total IBD, UC and CD. Our findings provided evidence for a causal impact of IBD, UC, and CD on rosacea, but not vice versa. The elevated incidence of rosacea in patients with IBD should be recognized by doctors to make an early diagnosis and initiate specialized therapy.

The role of macrophages in rosacea: implications for targeted therapies

Introduction

Rosacea, a widespread chronic skin condition, may be influenced by macrophages, key immune cells in the skin, although their exact role is not yet fully understood. This review delves into the function of macrophages, their potential contribution to rosacea pathogenesis, current treatments, and promising macrophage-targeted therapies. It concludes by identifying knowledge gaps and potential areas for future rosacea research.

Method

Leveraging systematic and narrative literature review techniques, we conducted a comprehensive search of databases such as PubMed, Embase, and Web of Science. Utilizing keywords like "rosacea" and "macrophages", we targeted English articles from the last 5 years (2018-2023). We manually checked reference lists of relevant articles for additional studies. We included only articles emphasizing macrophages' role in rosacea and/or the development of related therapies and published within the specified timeframe.

Results

The systematic search of electronic databases yielded a total of 4,263 articles. After applying the inclusion and exclusion criteria, 156 articles were selected for inclusion in this review. These articles included original research studies, review articles, and clinical trials that focused on the role of macrophages in rosacea and/or the development of macrophage-targeted therapies for the disease. The selected articles provided a comprehensive and up-to-date overview of the current state of research on macrophages in rosacea, including their function in the skin, the potential mechanisms through which they may contribute to rosacea pathogenesis, and the current treatments and therapies available for the disease. Additionally, the articles identified gaps in knowledge regarding the role of macrophages in rosacea and suggested potential areas for future research.

Conclusion

This literature review emphasizes the important role that macrophages, vital immune cells in the skin, may play in the pathogenesis of rosacea, a common chronic inflammatory skin disorder. The selected studies suggest potential mechanisms by which these cells might contribute to rosacea progression, although these mechanisms are not yet fully understood. The studies also spotlight current rosacea treatments and illuminate the promising potential of new macrophage-focused therapies. Despite these insights, significant gaps persist in our understanding of the precise role of macrophages in rosacea. Future research in this area could provide further insights into the pathogenesis of rosacea and contribute to the development of more effective, targeted therapeutic strategies.

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.

Conjunctival Microbiota and Blepharitis Symptom Scores in Patients With Ocular Rosacea

PURPOSE

Investigation of the relationship between blepharitis-related symptom scores, tear film functions, and conjunctival microbiota in patients with ocular rosacea (OR) compared with healthy controls was aimed.

METHODS

Consecutive 33 eyes of 33 patients with OR who were admitted from the dermatology clinic and age-matched and gender-matched 30 healthy controls were included in the study. Tear breakup time (TBUT), Schirmer score, and blepharitis symptom score (BLISS) were recorded for each patient. For the bacteriological examination, bacterial culture was obtained by inoculating the samples on chocolate agar, blood agar, and fluid thioglycollate medium. The growth of different colonies of bacteria was identified using matrix-assisted laser desorption or ionization time-of-flight mass spectrometry.

RESULTS

Bacterial culture positivity was observed in 13 eyes (39.4%) in the patients with OR and 10 eyes (33.3%) in the controls ( P =0.618). Patients with OR showed worse TBUT and Schirmer scores, and higher BLISSs ( P =0.005, P =0.007, and P =0.001, respectively). Patients with OR with conjunctival culture-positive results showed higher BLISSs (8.0±4.7) compared with those with negative results (4.7±2.3; P <0.001). The most frequent bacteria was Micrococcus luteus (18.2%) in patients with OR and Staphylococcus epidermidis (20.0%) in the controls.

CONCLUSION

This pilot study showed that patients with OR had similar conjunctival culture positivity compared with healthy controls. However, the observation of different dominant bacterial species in conjunctival microbiota and the observation of worse BLISSs in patients with OR with positive culture might suggest a potential role of conjunctival microbiota in the pathogenesis of OR.

Rosacea: The eyes have it

Rosacea is a chronic inflammatory dermatosis typically affecting the facial skin but also the eyes. With its chronic course with fluctuating episodes of flashing, redness, papulopustules, and nodules it poses a severe psychologic burden to the affected individuals. In addition to the facial changes, more than half of the patients have ocular involvement ranging from blepharitis and conjunctival hyperemia to more severe ophthalmic damage, and even blindness. Clinically, the ocular involvement in rosacea includes meibomian gland dysfunction with relapsing hordeola and chalazia, diffuse hyperemic conjunctivitis, photophobia, episcleritis, or kerato-conjunctivitis, and in rare cases, corneal ulcers. These are mainly observed in adult patients but can also occur in children. Depending on the degree of cutaneous or ocular findings, patients with rosacea may present first to the dermatologist or to the ophthalmologist. Both specialists should be aware of the potential oculocutaneous involvement. Any ocular complaints expressed by the patient in the setting of a dermatologist's office should be referred promptly for an ophthalmologic examination. Conversely, signs suggestive of rosacea in the eye should lead the ophthalmologist to consider underlying skin disease. A timely interdisciplinary collaboration is paramount for the earlier diagnosis and treatment, thus preventing permanent eye impairment in this chronic dermatosis.

Validity and reliability of the Rosacea Area and Severity Index: A novel scoring system for clinical assessment of rosacea severity

BACKGROUND

Rosacea is a common chronic inflammatory facial skin disorder. Standardized evaluation of the severity and extent of rosacea is important for baseline assessment and treatment effect. The currently used Investigator's Global Assessment (IGA) is unspecific and fails to consider subtypes/phenotypes of rosacea and area involvement. The Rosacea Area and Severity Index (RASI) was developed to give a more nuanced evaluation of rosacea features in four facial skin areas adjusted to the relative importance of each area of the face to obtain an overall severity score.

OBJECTIVES

To validate RASI against the IGA and to assess the inter- and intraobserver reliability for RASI.

METHODS

Sixteen dermatologists evaluated photographs of 60 adult patients with rosacea (3 photographs per patient, one from the front and one from each side). IGA and RASI scores were performed for interobserver reliability assessment. To determine intraobserver reliability, 14 dermatologists evaluated 10 other patients twice with at least 1 week interval.

RESULTS

The IGA and RASI correlated well (Spearman correlation coefficient (SCC) = 0.75, 95% confidence interval (CI) = 0.72-0.78). Interobserver reliability was moderate for RASI and poor to moderate for IGA. Reliability was strongest for rhinophyma, followed by papules/pustules and erythema, and rather weak for telangiectasia. For area scores, interobserver reliability was strongest for cheeks, followed by nose, chin and forehead. We found a moderate-to-strong intraobserver agreement both for IGA and RASI.

CONCLUSIONS

We have designed a new practical tool to examine clinical severity of rosacea. RASI proved simple and reliable in scoring clinical severity of rosacea with an agreement comparable to the currently used IGA although RASI will provide a more nuanced view of the current rosacea extent and severity. We suggest that RASI is used in the daily clinical setting as well as in clinical studies assessing the efficacy of rosacea therapies.

Objectively quantifying facial erythema in rosacea aided by the ImageJ analysis of VISIA red images

BACKGROUND

Facial erythema, a prominent characteristic of rosacea, causes concern to both the patient and doctor. In clinical practice, commonly used erythema severity subjective assessment tools lack objectivity and are less comprehensive. Even with images taken by the VISIA^® system, diffused erythema is difficult to segment and evaluate fully due to the automatic threshold segmentation method. This study aimed to explore a more objective and scientific erythema quantification tool with the aid of the ImageJ software analysis of the red area images taken by the VISIA^® system.

MATERIALS AND METHODS

Patients with rosacea were enrolled and assessed for the clinical severity of their illness using various stools-the standard grading systems (SGS) for rosacea, investigator's global assessment (IGA), and clinician's erythema assessment (CEA). Facial images in the red area mode of the VISIA^® system were further analyzed by the ImageJ for the relative intensity of redness and percentage of erythema area; the correlation with the scores of the subjective grading systems was evaluated.

RESULTS

This study included 201 patients (195 females and 6 males). The relative intensity of redness was positively correlated to the SGS, IGA, and CEA scores (0.688, 0.725, and 0.718, respectively) (p < 0.001). The percentage of erythema area was positively correlated to the SGS, IGA, and CEA scores (0.615, 0.666, and 0.656, respectively) (p < 0.001).

CONCLUSION

We demonstrated a more objective and precise method of assessing the severity of facial erythema rosacea, which could comprehensively assess the severity by both the area and intensity of facial erythema.

Combined therapy of 5-aminolevulinic acid photodynamic therapy and intense pulsed light for rosacea

Rosacea is difficult to treat. Therefore, new alternative modalities are necessary to demonstrate. The present study was conducted to assess the efficacy and safety of the combined therapy of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) and intense pulsed light (IPL) for rosacea to provide a new treatment option for rosacea. The study was conducted from November 2017 to April 2019 at the Department of Dermatology, The First Hospital of China Medical University. Patients aged 18-65 years and diagnosed clinically as erythematotelangiectatic (ET) or papulopustular (PP) rosacea were enrolled. Three times of ALA-PDT at 10 days interval followed by 3 times of IPL at 3-4 weeks interval were defined as 1 session and applied to the whole face of each patient. ALA-PDT: 5% ALA, red light (fluency dose 60-100 mW/cm2, 20 min); IPL: 560/590/640 nm, double/triple-pulse mode, pulse width 3.0 to 4.5 ms, delay time 30-40 ms, energy fluency 14-17 J/cm2. Ten patients were enrolled in the study. Among them, 4 patients received only 1 session, while 6 patients received 2 sessions. After all treatments, 50% of patients achieved 75-100% improvement, and 30% achieved 50-75% improvement. Forty percent of patients were graded very satisfaction and 30% graded moderate satisfaction. All noninvasive measurements showed no significant differences among all time points (p > 0.05). The side effects were pain, burning sensation, itching, erythema, desquamation, slight edema, slight exudation, and hyperpigmentation. All of which were tolerable and recovered in a few days. The combined therapy of ALA-PDT and IPL showed an effective option for rosacea with a safety profile.

A Cross-Sectional Study on the Relationship Between Rosacea Severity and Quality of Life or Psychological State

Background

Rosacea appears predominantly in highly visible areas of the facial region.

Objective

To investigate the psychological status and quality of life(QOL) of rosacea.

Methods

We used a hospital-based cross-sectional analytical study design between Jan 1, 2020, and Jan 1, 2021. We analyzed the differences and correlations in the severity of rosacea and its impacts on QOL and mental health, separately.

Results

469 patients with rosacea were included. The mean Dermatology Life Quality Index (DLQI) score was 12.6±7.7 and the affected level of DLQI was moderately severe. The total score of Rosacea-specific Quality-of-Life instrument (RosQol) was 2.34 ± 0.84, and the scores of emotion, symptoms, and function were 2.41 ± 0.99, 2.37 ±0.82, and 2.03 ± 0.89, respectively. 44.8% of patients suffered from anxiety and 37.5% from depression. There were statistically significant differences in the incidence of anxiety (p <0.001), the DLQL (p =0.02), RosQol emotion (p =0.04), symptom (p <0.01) and function (p =0.02) scores in the different severity. In addition, worsening QOL was significantly associated with increased disease severity [Spearman's rank correlation index (r) ranging from 0.171 to 0.266,p<0.01 (RosQol); r =0.104,p =0.024 (DLQI)]. There was also a positive correlation between anxiety [r =0.155; p<0.01] and the different severity levels.

Conclusion

Rosacea maybe has a greater significant impact on patient's QOL and mental health. And the impact of QOL and mental health tend to deteriorate significantly with increasing disease severity. The relationship suggests that QOL assessment is of great interest in clinical practice and should be further explored.

Mechanisms of rosacea pathogenesis. A phenotypic approach to therapeutic tactics

Rosacea is a widespread disease worldwide, affecting 5.5% of the human population and accompanied by a significant deterioration in the patient's quality of life. Currently, there are two classifications of rosacea, the first of which is based on a subtype approach (erythematous-telangiectatic, papulo-pustular, phimatous and ophthalmological subtypes), or on an individual analysis of the presented phenotype of rosacea. New data on the pathophysiology of rosacea have emerged, which show that genetic factors and environmental components can cause the initiation and exacerbation of rosacea due to a violation of the regulation of the innate and adaptive immune system. In addition, trigger factors can directly interact with the cutaneous nervous system and, with the help of neurovascular and neuroimmune active neuropeptides, lead to the manifestation of rosacea foci. The main mechanisms of rosacea pathogenesis are currently: activation of the immune system, disorders of neuro-immune regulation, genetic predisposition. New pathogenetic mechanisms of rosacea make it possible to continue the diagnostic search and therapeutic approaches with the personalization of management tactics for each patient, depending on the prevalence of clinical features of the course of the disease. It is necessary to evaluate the advantages and disadvantages of subtypical and phenotypic approaches to rosacea classification and choose the most optimal one. The article presents arguments on this issue, and also suggests assessing the need to switch to a new classification in order to improve the effectiveness of therapy and improve the quality of life of patients.

Skin microbiome considerations for long haul space flights

Dysbiosis of the human skin microbiome has long been associated with changes to the pH of the skin, dermal immune function and chronic skin conditions. Dermatological issues have been noted as the most prevalent medical presentation in the microgravity environment of space. The change in gravitational forces has been implicated in human immuno-suppression, also impacted by changes in the gastrointestinal-skin axis and its impact on Vitamin D metabolism, altered microbial gene expression in resident flora (leading changes in biofilm formation) and increased virulence factors in potential pathogens. There are also other stressors to the skin microbiome unique to space travel, including increased exposure to radiation, prolonged periods of dry washing technique, air quality and changes in microbe replication and growth parameters. Optimal microbiome health leads to enhanced skin barrier manufacture and maintenance, along with improved skin immune function and healing. In a microgravity environment expected to be experienced during long space flights, disruptions to the skin microbiome, coupled with increased virulence of pathological viruses and bacteria has implications for holistic skin health, astronaut cognitive function and mental health, and is coupled with slowed rates of wound healing. Scenario management for holistic skin health and restoration of microbiome homeostasis on long space flights require consideration.

Integrative skincare trial of intense pulsed light followed by the phyto-corrective mask, phyto-corrective gel, and resveratrol BE for decreasing post-procedure downtime and improving procedure outcomes in patients with rosacea

BACKGROUND

Rosacea is a chronic inflammatory skin condition of varying severity that can significantly impact patient quality of life. Intense pulsed light (IPL) is an established treatment for rosacea-associated telangiectasia, inflammation, and erythema. This study assessed whether application of a phyto-corrective mask, gel, and resveratrol antioxidant serum after IPL treatment can improve outcomes and reduce procedure-related adverse effects.

METHODS

In a prospective, open-label, split-face, 3-month study, 10 subjects with moderate-to-severe facial rosacea underwent IPL treatment on both sides of the face. The following were applied to the right side of the face only: phyto-corrective mask once weekly starting immediately after IPL; phyto-corrective gel twice daily; and resveratrol antioxidant treatment at night. Both sides of the face were treated with sunscreen. Subjects were assessed on Day 1, 1 and 3 months after IPL by three, independent evaluators using the 5-point Global Aesthetic Improvement Scale (GAIS). All subjects rated skin redness, hydration, and overall improvement on Day 1 and completed a patient satisfaction questionnaire at the 1- and 3-month visits.

RESULTS

Ten women were enrolled, aged 44-72 years old, with moderate (n = 6) to severe (n = 4) rosacea. IPL was effective at reducing symptoms with rosacea classified as absent in five women and mild in five at the final 3-month visit. GAIS scores also revealed improvements on both sides of the face, but the skincare treated side showed continuous improvement over 3 months with all patients remaining at least "Improved", whereas there appeared to be a waning effect after 1 month with IPL alone. On Day 1 after IPL, all women reported less redness, improved hydration, and improved skin appearance on the right side of the face. Patient satisfaction was consistently rated higher on the right side of the face.

CONCLUSION

Application of a phyto-corrective mask, gel, and resveratrol antioxidant serum may complement IPL treatment for rosacea by enhancing treatment outcomes and reducing procedure-related symptoms.

A novel multi-layer perceptron model for assessing the diagnostic value of non-invasive imaging instruments for rosacea

Background

Reflectance confocal microscopy (RCM), VISIA, and dermoscopy have emerged as promising tools for objective diagnosis and assessment of rosacea. However, little is known about the diagnostic value of these imaging systems for rosacea.

Objectives

To assess the diagnostic value of RCM, VISIA, and dermoscopy for rosacea by establishing a novel multilayer perceptron (MLP) model.

Methods

A total of 520 patients with rosacea and other facial diseases were included in this study. A total of 474 samples of dermoscopy data, 374 samples of RCM data, 434 samples of VISIA data, and 291 samples containing three data sources were collected. An MLP model was built with the total data to explore the association between the imageological features of each instrument and the probability of rosacea.

Results

Our MLP model revealed that the area under the receiver operating characteristic curve (AUROC) values of RCM, VISIA and dermoscopy for diagnosing rosacea were 0.5233, 0.5646 and 0.7971, respectively. The integration of these three tools with clinical data could further improve the accuracy of the predictive diagnosis to 0.8385. For the imageological features of each tool, abnormalities (hyperkeratosis or parakeratosis) in the stratum corneum were effective variables for excluding rosacea (odds ratio [OR], 0.4333) under RCM. The indicators of rosacea under VISIA included overall severity of erythema, erythema involving the cheek or superciliary arch, visible red blood vessels, and papules (OR = 2.2745, 3.1592, 1.8365, 2.8647, and 1.4260, respectively). The candidate variables of dermoscopy included yellow background, white background, uniform distribution of vessels, branched vessels, and reticular blood vessels (OR = 0.4259, 0.4949, 2.2858, 3.7444, and 2.4576, respectively).

Conclusions

RCM, dermoscopy, and VISIA each can present several imageological features and were of certain value for assisting rosacea diagnosis. The combined analysis of these three tools using our MLP model may be useful for improving the accuracy of diagnosing rosacea.

S2k guideline: Rosacea

This updated and upgraded S2k guideline deals with the diagnosis and treatment of rosacea, which is a common, chronic inflammatory skin disease mostly affecting the face. Initially, rosacea is characterized by recurrent erythema, telangiectasia and flushing. Later, the inflammatory component predominates, with persistent erythema with follicular papules, papulopustules and pustules. The development of phyma, which usually occurs on the acral localizations, is the most severe manifestation. For the treatment of rosacea, the interdisciplinary guideline committee, with representatives of the German Dermatological Society (DDG), the Professional Association of German Dermatologists (BVDD), the German Opthalmological Society (DOG), the Society for Dermopharmacy (GD), the Swiss Society for Dermatology and Venereology (SGDV) and the German Rosacea Aid e. V., recommends the avoidance of trigger factors and topical applications of metronidazole, azelaic acid or ivermectin. For symptomatic treatment of persistent centrofacial erythema, the topical vasoconstrictors brimonidine or oxymetazoline can also be used. Systemic therapy is recommended for therapy-resistant and severe forms of rosacea papulopustulosa. The drug of choice is low-dose doxycycline. Alternatively, low-dose isotretinoin can be recommended. Ocular rosacea should be treated with lid margin hygiene. For topical treatment, ciclosporin eye drops, azithromycin, ivermectin or metronidazole are suggested.

N2-Polarized Neutrophils Reduce Inflammation in Rosacea by Regulating Vascular Factors and Proliferation of CD4+ T Cells

The infiltration of neutrophils is implicated in rosacea, which is a common chronic inflammatory facial disease. This study explores the biological function of neutrophils and their underlying mechanism in rosacea. A rosacea-like mouse model was established to explore the polarization of neutrophils. RNA sequencing was used to investigate the underlying mechanisms. Our results show that neutrophils partly switched to N2 phenotypes in both patients with rosacea and rosacea-like mouse models. The rosacea-like phenotype and inflammation in both a genetic mutation (Genista mice) and the Gr-1 antibody‒induced neutropenia mice were significantly aggravated compared with that in the control groups. In vitro, lipopolysaccharide + IFN-γ and IL4 stimulation of neutrophils successfully induced the N1 and N2 polarization of neutrophils, respectively. Replenishment of N2 neutrophils in the lesions of wild-type and Genista mice ameliorated the rosacea-like phenotype and inflammation. RNA sequencing suggested that N2 neutrophils relieved the rosacea-like phenotype, possibly by regulating the expression of blood circulation‒associated factors, such as ACE, AGTR2, and NOS1. Finally, N2 neutrophils regulated the proliferation of CD4⁺ lymphocytes, which could explain the remission of inflammation in mice. Our results suggest that N2 polarization of neutrophils in rosacea exerts anti-inflammatory effects by regulating vascular factors and proliferation of CD4⁺ T cells.

Dermatology: how to manage rosacea in skin of colour

Rosacea is a common inflammatory skin disorder affecting the face. Common cutaneous symptoms include papules, pustules, persistent centrofacial erythema, telangiectasias, recurrent flushing, phymatous changes and a variety of ocular manifestations. Previous epidemiological studies have demonstrated that the incidence of rosacea is much lower in people with darker Fitzpatrick phototypes compared to fair-skinned individuals. In patients with darker skin, the centrofacial erythema can be masked and difficult to appreciate, impacting the ability for providers to make diagnoses and leading to misdiagnoses. Thus, it is difficult to say with certainty that the disparities in prevalence in rosacea amongst fair-skinned and darker individuals are true. The primary aim of this article is to raise awareness that rosacea is a global disease and to provide healthcare professionals with strategies to identify and manage rosacea amongst individuals with skin of colour.

Rosacea Granulomatosis in a Neutropenic Leukemic Patient

Rosacea granulomatosis is a common, chronic skin disorder that primarily affects the central face, namely the cheek, nose, chin, and central forehead. Although rosacea is mainly a disorder of innate and adaptive immunity, a variety of endogenous and exogenous triggers such as Demodex may stimulate it. Often found as commensal organisms in human skin, Demodex ​​​​​​​can be parasitic if there is a change in the host’s cutaneous environment. This is especially relevant for immunosuppressed patients, who need prompt treatment to prevent further complications. We review the literature regarding rosacea granulomatosis in immunosuppression and present an acute myelogenous leukemia patient with severe neutropenia, which may have promoted the development of rosacea due to Demodex ​​​​​​​mite proliferation. This local proliferation of the ectoparasite on the face can cause an atypical skin rash that mimics severe infections in the setting of neutropenia.

Rosacea and Dry Eye Disease

Ocular rosacea is a chronic potentially sight-threatening inflammatory condition, which can occur in approximately 20% of patients without skin involvement. However, an accurate diagnosis of ocular rosacea has not been defined yet due to its rather nonspecific symptoms and clinical findings. Therefore, this article updates the current recommendations for diagnosis and treatment of ocular rosacea and the previously published consensus recommendations from the ROSCO expert panel on the management of rosacea.

Case Series: Underdiagnosis of Ocular and Oculocutaneous Rosacea in an African American Pediatric Population

SIGNIFICANCE

As the global multiracial population grows, this case series highlights the current under- and misdiagnosis of ocular and oculocutaneous rosacea and the importance of properly identifying the condition in a darkly pigmented pediatric population.

PURPOSE

This series aims to report the clinical presentation of ocular and oculocutaneous rosacea and adverse sequelae of misdiagnosis in two pediatric African American patients.

CASE REPORT

One 11-year-old male and one 10-year-old female, both darkly pigmented African American patients, presented with a history of chronic ocular irritation. The male patient was seen by an eyecare provider eight times over the past seven years for recurrent anterior ocular inflammation. The female patient presented to the clinic with chronic anterior segment ocular inflammation for one year. Both patients were previously treated for their acute signs and symptoms. The male patient was diagnosed with ocular rosacea and the female patient was diagnosed with oculocutaneous rosacea. Both patients were subsequently treated for their underlying inflammatory condition, yielding an improvement in their ocular health.

CONCLUSIONS

These two cases bring attention to the under- and misdiagnosis of ocular and oculocutaneous rosacea in pediatric patients with darkly pigmented skin. Timely and accurate diagnosis is critical to minimize the risk of significant visual and dermatological sequelae.

The therapeutic effects in patients with rosacea: how do we evaluate them?

BACKGROUND

Rosacea is a common, chronic skin disorder with negative impacts on physical health and social function. The response to therapy plays a critical factor in determining the duration of treatment and developing new medicines. However, it is challenging to assess the efficacy due to its complicated clinical characteristics and nonspecific histopathological findings.

AIMS

This study aims to review the efficacy evaluation tools for rosacea.

METHODS

An extensive literature search was conducted using PubMed, Web of Science, and other databases for articles on efficacy evaluation methods for rosacea from 1995 to 2021.

RESULTS

In clinical practice and scientific research, various methods are available for assessing the curative effect. Evaluation tools based on phenotypes are the most commonly used because they are cheap and straightforward. Various questionnaires also exist to evaluate health-related quality of life. However, the inevitable subjectivity makes it challenging to compare the curative effect among different studies. By contrast, objective assessment tools are more precise and repeatable, such as consecutive standardized skin surface biopsies, computer-aided image analysis, and biophysical parameter assessments.

CONCLUSION

No single assessment method could balance convenience and accuracy. For improving outcomes and facilitating academic exchanges, a well-validated gold standard evaluation tool is still needed. This review provides an overview of the existing efficacy evaluation methods for rosacea and discusses the relevant details.