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

Validation of a Photonumeric Scale for Evaluation of Telangiectasia in Rosacea

BACKGROUND

Telangiectasia is a prominent feature of rosacea leading to a high demand for effective treatment. To ensure consistent clinical and scientific evaluations and assess treatment response accurately, standardized assessment tools are necessary for grading the severity of telangiectasia. However, no validated grading scales for this condition are currently available.

AIM

To develop and validate a photonumeric scale for assessing the severity of telangiectasia in rosacea patients.

METHODS

The five-point photonumeric Telangiectasia in Rosacea Severity Assessment (TRoSA) scale was developed for the severity of telangiectasia in rosacea. Sixteen experts participated in the validation process, evaluating 50 images of rosacea patients in two rounds. Interrater and intrarater reliability were analyzed using the intraclass correlation coefficient (ICC) and weighted kappa, respectively.

RESULTS

Interrater reliability was found to be "almost perfect" in both validation rounds (Round 1: ICC 0.847; Round 2: ICC 0.828). The mean weighted kappa indicated "substantial" intrarater reliability between the two rounds with a weighted kappa of 0.719. A bubble plot of the two rounds illustrated a diagonal order, confirming the consistency of the intrarater agreement.

CONCLUSIONS

The TRoSA scale demonstrated high interrater and intrarater reliability indicating that it is a consistent and reproducible tool for grading the severity of telangiectasia in rosacea. This scale can standardize clinical assessments, assisting in diagnosis, treatment planning, and evaluation of therapeutic efficacy.

The relationship between smoking and rosacea: A Mendelian randomization study

BACKGROUND

Rosacea can be seen in many patients nowadays, and the related causes are complex. Despite a certain association between smoking and rosacea being reported by several studies, the actual causality has not been established for the possible bias and confounders.

METHODS

We used Mendelian randomization (MR) to evaluate a potential causal effect of smoking on rosacea risk. Statistics on smoking and rosacea were obtained from the FinnGen project and Neale Lab Consortium. The causal association was assessed by multiple methods including inverse variance weighted (IVW), MR Egger, weighted median, and weighted mode. Furthermore, sensitivity analyses were also conducted to address pleiotropy, along with the leave-one-out method.R version 4.2.3 was applied for the analyses.

RESULTS

The IVW estimation revealed that previous smoking has a deleterious effect on rosacea (odds ratio [OR] = 6.7729, 95% confidence interval [CI] = 1.5691-29.2356, p = 0.0104). By contrast, there was no statistically relationship between current smokers and rosacea (OR = 0.6180, 95% CI = 0.0605-6.3094, p = 0.6847). Results were similar in the analysis based on the weighted median method (previous smoking: OR = 8.6297, 95% CI = 1.0131-73.5071, p = 0.0486; current smoking: OR = 0.2896, 95% CI = 0.0106-7.9132, p = 0.4627). The stability of the causal effect estimates was supported by several sensitivity analyses and the leave-one-out method.

CONCLUSION

Our MR study found support forrosacea risk and previous smoking. Although no evidence was found to increase the risk of rosacea in current smokers, to prevent various diseases associated with smoking, the public should be encouraged to avoid smoking at the very beginning.

Efficacy and Safety of Microencapsulated Benzoyl Peroxide Cream, 5%, in Papulopustular Rosacea in Elderly Patients: Post-hoc Analysis of Results from Two Randomized, Phase III, Vehicle-controlled Trials

Objective

We sought to compare the efficacy and safety of encapsulated benzoyl peroxide (E-BPO) cream, 5%, versus vehicle in subjects <65 years of age versus subjects ≥65 with moderate to severe papulopustular rosacea.

Methods

This analysis used pooled results from two 12-week, randomized, vehicle-controlled Phase III trials (NCT03564119, NCT03448939) of E-BPO cream, 5%. These trials included 733 subjects randomized 2:1 to E-BPO or vehicle. The primary endpoints were success in the Investigator's Global Assessment (IGA) score and reduction in mean inflammatory lesion count at Week 12.

Results

Our analysis shows that E-BPO cream, 5%, was significantly superior to vehicle in achieving IGA success and reducing inflammatory lesions in both age groups. IGA success was achieved in 48.3% of subjects who received E-BPO versus 25.4% for vehicle in the intent-to-treat population. The E-BPO and vehicle IGA success percentages for subjects <65 were 45.7% and 23.8%, respectively, and those for subjects ≥65 were 60.0% and 28.1%, respectively. The absolute reduction from baseline in inflammatory lesions was -19.3 for subjects who received E-BPO versus -11.4 for those who received vehicle. The E-BPO and vehicle absolute reduction values for subjects <65 were -19.6 and -11.2, respectively, and 17.5 and -10.4 for subjects ≥65. There were no significant differences in the frequencies of adverse events or cutaneous tolerability.

Limitations

E-BPO was not compared to nonencapsulated BPO.

Conclusion

This combined analysis of results from the two Phase III, randomized, double-blind controlled studies of E-BPO cream, 5%, showed it was efficacious, tolerable, and safe, regardless of age.

Drug repositioning for rosacea disease: Biological TARGET identification, molecular docking, pharmacophore mapping, and molecular dynamics analysis

Rosacea is a chronic dermatological condition that currently lacks a clear treatment approach due to an uncomprehensive knowledge of its pathogenesis. The main obstacle lies in understanding its etiology and the mode of action of the different drugs used. This study aims to clarify these aspects by employing drug repositioning. Using an in silico approach, we performed a transcriptomic analysis comparing samples from individuals with diverse types of rosacea to those from healthy controls to identify genes deregulated in this disease. Subsequently, we realized molecular docking and molecular dynamics studies to assess the binding affinity of drugs currently used to treat rosacea and drugs that target proteins interacting with, and thus affecting, proteins deregulated in rosacea. Our findings revealed that the downregulation of SKAP2 and upregulation of S100A7A in rosacea, could be involved in the pathogenesis of the disease. Furthermore, considering the drugs currently used for rosacea management, we demonstrated stable interactions between isotretinoin and BFH772 with SKAP2, and permethrin and PAC-14028 with S100A7A. Similarly, considering drugs targeting SKAP2 and S100A7A interactome proteins, we found that pitavastatin and dasatinib exert stable interactions with SKAP2, and lovastatin and tirbanibulin with S100A7A. In addition, we determine that the types of bonds involved in the interactions were different in SKAP2 from S100A7A. The drug-SKAP2 interactions are hydrogen bonds, whereas the drug-S100A7A interactions are of the hydrophobic type. In conclusion, our study provides evidence for the possible contribution of SKAP2 and S100A7A to rosacea pathology. Furthermore, it provides significant information on the molecular interactions between drugs and these proteins, highlighting the importance of considering structural features and binding interactions in the design of targeted therapies for skin disorders such as rosacea.

A comparative study between fractional microneedling radiofrequency with systemic isotretinoin and fractional microneedling alone in the treatment of rosacea

Introduction

Rosacea is a chronic inflammatory disease presenting with facial flushing, non-transient erythema, papules/pustules, telangiectasia, and phymatous changes. Secondary manifestations, such as itching, burning, or stinging, are often observed in patients with rosacea. The pathogenesis of rosacea is not fully understood, but immune dysfunction, Demodex infection, neurovascular dysregulation, and exposure to ultraviolet radiation represent contributing factors.

Aim

To evaluate and compare effectiveness of fractional micro-needling radiofrequency with systemic isotretinoin and micro-needling alone in the treatment of rosacea.

Material and methods

A cross-sectional comparative study between fractional microneedling radiofrequency with systemic isotretinoin and micro-needling alone in the treatment of rosacea was carried out in a private outpatient clinic and Al-Yarmouk teaching hospital from January 2022 to June 2023. Group A comprised 25 patients treated with systemic isotretinoin (10 mg/day) for 6 weeks and fractional microneedling radiofrequency for 16 weeks. Patients received a session every 2 weeks during the first 2 months of treatment then one session per month. Group B comprised 25 patients treated with fractional microneedling radiofrequency for 16 weeks. The patients received a session every 2 weeks during the first 2 months of treatment then one session per month. Measurement of baseline serum lipid profile, complete blood count, and liver enzyme levels was done to all patients receiving isotretinoin. All patients in both groups were instructed to use sunscreen and emollients. Follow-up of all patients was carried out for 3 months after treatment. Patients were assessment according to the Grade system of rosacea, patient satisfaction, and relapse rate. Relapse rate: no relapse (0), relapse (1). Patient satisfaction: poor (0), fair (1), and good (2).

Results

There was no significant difference in the mean severity score for rosacea between group A and group B, before, after 8 weeks, and after 16 weeks. Patients in group A showed higher good satisfaction (72%) than group B (32%). During the follow-up period the relapse rate was higher in group B (32%) than in group A (16%), the percentage reduction (response rate) of the mean of severity score was 41.37% after 8 weeks and 91.37% after 16 weeks in group A, and 34.48% after 8 weeks and 82.75% after 16 weeks in group B.

Conclusions

Fractional microneedling radiofrequency is a safe and effective method in the treatment of rosacea, and so it can be used when there are contraindications to other lines of therapy, when patients are resistant to long-term oral therapy, and when patients (including pregnant women) choose not to take oral or topical drugs.

Plant Phenolics in the Prevention and Therapy of Acne: A Comprehensive Review

Plants are a rich source of secondary metabolites, among which phenolics are the most abundant. To date, over 8000 various polyphenolic compounds have been identified in plant species, among which phenolic acids, flavonoids, coumarins, stilbenes and lignans are the most important ones. Acne is one of the most commonly treated dermatological diseases, among which acne vulgaris and rosacea are the most frequently diagnosed. In the scientific literature, there is a lack of a detailed scientific presentation and discussion on the importance of plant phenolics in the treatment of the most common specific skin diseases, e.g., acne. Therefore, the aim of this review is to gather, present and discuss the current state of knowledge on the activity of various plant phenolics towards the prevention and treatment of acne, including in vitro, in vivo and human studies. It was revealed that because of their significant antibacterial, anti-inflammatory and antioxidant activities, phenolic compounds may be used in the treatment of various types of acne, individually as well as in combination with commonly used drugs like clindamycin and benzoyl peroxide. Among the various phenolics that have been tested, EGCG, quercetin and nobiletin seem to be the most promising ones; however, more studies, especially clinical trials, are needed to fully evaluate their efficacy in treating acne.

Treatment of Common Dermatologic Conditions

Dermatologic concerns are discussed in about a third of all primary care visits. This review discusses treatments for common dermatologic diagnoses addressed in primary care settings, with an emphasis on new and emerging treatments. Topical, oral, and injectable treatment of common forms of alopecia, facial rashes, atopic dermatitis, psoriasis, seborrheic dermatitis, and stasis dermatitis will be discussed to help increase comfort in prescribing and alert providers to common side effects or complications of more intensive treatments used by dermatologists.

A comparative exploration of immunohistochemical markers in patients with papulopustular rosacea undergoing treatment with oral isotretinoin versus doxycycline

BACKGROUND

Rosacea is a chronic inflammatory disease, and doxycycline is a widely recommended treatment for it due to its anti-inflammatory action. Oral isotretinoin reduces sebaceous gland activity and modulates toll-like receptors, reducing inflammation. Our aim was to investigate the effect of these two drugs on the expression of cutaneous immunohistochemical biomarkers related to etiopathogenic factors involved in rosacea.

METHODS

We conducted a randomized, comparative, and evaluator-blinded trial, including 40 participants with moderate and severe papulopustular and ocular rosacea. Participants were treated with doxycycline (DOXY) 100 mg or isotretinoin (ISO) 0.3 mg/kg daily. Immunohistochemistry at baseline and after 4 months was used to demonstrate the expression of the biomarker on the affected skin.

RESULTS

The following changes were detected: a reduction in the vessel count after using VEGF with DOXY (P = 0.010); a decrease in VEGF intensity with ISO (P < 0.001) and DOXY (P = 0.020); a reduction of nitric oxide synthase enzyme with both drugs in the inflammatory infiltrate (ISO P < 0.001; DOXY P = 0.003); however, only with ISO was there a significant (P = 0.030) decrease at the level of the sebaceous glands, indicating a reduction of nitric oxide synthesis; a reduction of TRPV-1 expression at the level of the sebaceous glands was observed only with DOXY (P = 0.041); a decrease of cathelicidin LL37 expression, a key antimicrobial peptide in the etiopathogenesis of rosacea, was noted with both drugs, although at the level of sebaceous glands, only with DOXY (P = 0.007).

CONCLUSIONS

Oral isotretinoin and doxycycline have modified the expression of cutaneous biomarkers related to rosacea etiopathogenesis, demonstrating their role in controlling inflammatory and vascular processes.

Erenumab for Treatment of Persistent Erythema and Flushing in Rosacea: A Nonrandomized Controlled Trial

Importance

Treatment of erythema and flushing in rosacea is challenging. Calcitonin gene-related peptide (CGRP) has been associated with the pathogenesis of rosacea, raising the possibility that inhibition of the CGRP pathway might improve certain features of the disease.

Objective

To examine the effectiveness, tolerability, and safety of erenumab, an anti-CGRP-receptor monoclonal antibody, for the treatment of rosacea-associated erythema and flushing.

Design, Setting, and Participants

This single-center, open-label, single-group, nonrandomized controlled trial was conducted between June 9, 2020, and May 11, 2021. Eligible participants included adults with rosacea with at least 15 days of either moderate to severe erythema and/or moderate to extreme flushing. No concomitant rosacea treatment was allowed throughout the study period. Visits took place at the Danish Headache Center, Copenhagen University Hospital, Rigshospitalet in Copenhagen, Denmark. Participants received 140 mg of erenumab subcutaneously every 4 weeks for 12 weeks. A safety follow-up visit was performed at week 20. Data analysis occurred from January 2023 to January 2024.

Intervention

140 mg of erenumab every 4 weeks for 12 weeks.

Main Outcomes and Measures

The primary outcome was mean change in the number of days with moderate to extreme flushing during weeks 9 through 12, compared with the 4-week run-in period (baseline). The mean change in number of days with moderate to severe erythema was a secondary outcome. Adverse events were recorded for participants who received at least 1 dose of erenumab. Differences in means were calculated with a paired t test.

Results

A total of 30 participants (mean [SD] age, 38.8 [13.1] years; 23 female [77%]; 7 male [23%]) were included, of whom 27 completed the 12-week study. The mean (SD) number of days with moderate to extreme flushing was reduced by -6.9 days (95% CI, -10.4 to -3.4 days; P < .001) from 23.6 (5.8) days at baseline. The mean (SD) number of days with moderate to severe erythema was reduced by -8.1 days (95% CI, -12.5 to -3.7 days; P < .001) from 15.2 (9.1) days at baseline. Adverse events included transient mild to moderate constipation (10 participants [33%]), transient worsening of flushing (4 participants [13%]), bloating (3 participants [10%]), and upper respiratory tract infections (3 participants [10%]), consistent with previous data. One participant discontinued the study due to a serious adverse event (hospital admission due to gallstones deemed unrelated to the study), and 2 participants withdrew consent due to lack of time.

Conclusions and Relevance

These findings suggest that erenumab might be effective in reducing rosacea-associated flushing and chronic erythema (participants generally tolerated the treatment well, which was consistent with previous data), and that CGRP-receptor inhibition holds potential in the treatment of erythema and flushing associated with rosacea. Larger randomized clinical trials are needed to confirm this finding.

Trial Registration

ClinicalTrials.gov Identifier: NCT04419259.

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.

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.

Oroxylin A suppress LL-37 generated rosacea-like skin inflammation through the modulation of SIRT3-SOD2-NF-κB signaling pathway

Rosacea is a long-term inflammatory skin disease associated with the dysfunction of vascular and immunological systems. Treatment options for rosacea are difficult to implement. Oroxylin A(OA), a traditional Chinese medicine, has anti-inflammation effects in a variety of inflammatory diseases. However, it is not known that whether OA exerts protective effects against LL-37-induced rosacea. In this study, bioinformatics analyses showed that the mechanisms of rosacea and the pharmacological targets of OA were highly overlapped. Subsequently, it was shown that the administration of OA resulted in a notable amelioration of rosacea-like skin lesions, as evidenced by a reduction in immune cell infiltration, modulation of cytokine production, and inhibition of angiogenesis. Plus, it was shown that OA effectively suppressed the generation of ROS generated by LL-37, as well as the subsequent activation of NF-κB signaling pathway. To explore further, we found that OA inhibited LL-37-induced ROS production via SIRT3-SOD2 signaling pathway in keratinocytes. Based on the aforementioned evidence, it can be inferred that OA exhibits a mitigating effect on the inflammatory response in rosacea by modulating the SIRT3-SOD2-NF-κB signaling pathway.

Microencapsulated Benzoyl Peroxide for Rosacea in Context: A Review of the Current Treatment Landscape

Rosacea, a chronic skin condition affecting millions of people in the USA, leads to significant social and professional stigmatization. Effective management strategies are crucial to alleviate symptoms and improve patients' quality of life. Encapsulated benzoyl peroxide 5% (E-BPO 5%) is a newly FDA-approved topical treatment for rosacea that shows promise in enhancing therapeutic response and minimizing skin irritation. This review aims to assess the role of recently FDA approved E-BPO 5% in the current treatment landscape for rosacea management, as it is not yet included in clinical guidelines that predominantly rely on older approved therapies. The review focuses on randomized controlled trials conducted in English-speaking adults. It evaluates the efficacy, safety, and tolerability of various US Food and Drug Administration (FDA)-approved agents used for rosacea treatment, including E-BPO cream, metronidazole gel, azelaic acid gel and foam, ivermectin cream, minocycline foam, oral doxycycline, brimonidine gel, and oxymetazoline HCl cream. Existing therapies have been effective in reducing papulopustular lesions and erythema associated with rosacea for many years. E-BPO 5% offers a promising addition to the treatment options due to its microencapsulation technology, which prolongs drug delivery time and aims to improve therapeutic response while minimizing skin irritation. Further research is necessary to determine the exact role of E-BPO 5% in the therapeutic landscape for rosacea. However, based on available evidence, E-BPO 5% shows potential as a valuable treatment option for managing inflammatory lesions of rosacea, and it may offer benefits to patients including: rapid onset of action, demonstrated efficacy by Week 2, excellent tolerability, and sustained long-term results for up to 52 weeks of treatment.

Deciphering Childhood Rosacea: A Comprehensive Review

Childhood rosacea is a lesser known, yet significant, skin condition presenting diagnostic and treatment challenges. Although often underdiagnosed due to unclear diagnostic criteria, it manifests similarly to adult rosacea, with features such as papulopustular, telangiectasia, granulomatous, idiopathic facial aseptic granuloma, and ocular rosacea. The complex pathophysiology involves genetic, immunological, and environmental factors. Distinguishing childhood rosacea from conditions like acne, steroid rosacea, sarcoidosis, and lupus vulgaris is crucial but complicated by the lack of established criteria. Treatment strategies, mainly extrapolated from adult management protocols, include topical therapies, systemic medications, and laser treatments, adapted for pediatric patients. Special attention is given to ocular rosacea, often preceding skin manifestations, necessitating multidisciplinary care. The review underscores the urgent need for clear diagnostic guidelines, increased awareness, and tailored pediatric treatment protocols to improve patient outcomes and mitigate the condition's evolution into adulthood.

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.

A Review of the Diagnostic and Therapeutic Gaps in Rosacea Management: Consensus Opinion

Rosacea is a common, chronic inflammatory disease characterized by both fluctuating and fixed heterogeneous signs such as facial erythema, papules/pustules, telangiectasia, acute vasodilation (flushing), and phymatous changes, and symptoms such as cutaneous stinging and burning. The shift to a phenotype-based approach to rosacea management has improved the consistency of recommendations across recent published guidelines. Consistent and thorough guidance for the classification, diagnosis, and management of the disease is difficult, as the mechanisms underlying the development of rosacea are still not completely understood nor universally accepted. Here, we provide a critical review of current published guidance, and gaps in the knowledge and management of rosacea. We present the recently approved microencapsulated benzoyl peroxide as an effective topical treatment option for papulopustular rosacea. Benzoyl peroxide (BPO) has been used in acne management for many years; however, many clinicians perceive treatment of rosacea with any BPO formulation to be counterintuitive because of concerns of potential skin irritation, while the lack of an accepted mechanism of action on rosacea pathophysiology means that others may be hesitant to use BPO as a treatment. Minocycline foam 1.5% is also an option for the treatment of inflammatory lesions in rosacea, with a decreased risk of systemic adverse events compared with oral minocycline.

Rosacea: Practical Guidance and Challenges for Clinical Management

Rosacea is a common chronic dermatosis. Clinically, rosacea can present with flushing, erythema, papules, pustules, telangiectasias, phymatous changes, pruritus, burning, and stinging. In 2017, the National Rosacea Society Expert Committee recommended a phenotype-based classification for therapy. In this review, we identify monotherapies and multimodal treatment approaches for the clinical management of rosacea including topical, systemic, laser and light, alternative, and combination therapies.

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.

The multiple uses of azelaic acid in dermatology: mechanism of action, preparations, and potential therapeutic applications

Azelaic acid (AZA) is a naturally occurring saturated dicarboxylic acid whose topical application has found multiple uses in dermatology. Its anti-inflammatory, antioxidant and antimicrobial properties against Propionibacterium acne are currently used in the treatment of various types of acne such as rosacea and acne vulgaris. AZA is an inhibitor of tyrosinase, mitochondrial respiratory chain enzymes and DNA synthesis, and is a scavenger of harmful free radicals and inhibits the production of reactive oxygen species by neutrophils. Interestingly, AZA also has anti-proliferative and cytotoxic effects on various cancer cells. To date, its inhibitory effect on melanocytes has been mainly used, making it widely used in the treatment of hyperpigmentation disorders such as melasma and post-inflammatory hyperpigmentation. Commercially available topical formulations with cosmetic and drug status contain 5% to 20% AZA in the form of gels and creams. The use of liposomal technology allows greater control over the pharmacokinetics and pharmacodynamics of the formulations. When applied topically, AZA is well tolerated, and side effects are limited to generally mild and transient local skin irritation. Importantly, liposomal technology has enabled the drug to penetrate all layers of the skin while maintaining a very high accumulation of the active ingredient. This solution could be revolutionary for the treatment of skin cancer, where until now the main obstacle was poor absorption through the skin, making the treatment require multiple applications to maintain long-term activity levels. In this review, we will present the mechanism of action and pharmacokinetics of AZA. We will summarize its use in the treatment of dermatoses and its potential in skin cancer therapy. We will provide an overview of the preparations available on the market, taking into consideration technologies used.

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.

Real-world Evidence for the Treatment of Rosacea with Sulfur or Metronidazole Preparation in Japanese Patients

Introduction

There remains to be lacking real-world evidence for the treatment of rosacea with a topical sulfur preparation (TSP) or topical metronidazole preparation (TMP) among Japanese patients. Therefore, in this study, we examined the effects of TSP and TMP on rosacea in Japanese patients in real-world clinical settings.

Methods

This retrospective observational analysis reviewed the medical records of 47 Japanese patients who were treated with TSP or TMP for more than 8 weeks in our clinic. Disease severity was evaluated using the Investigator Global Assessment (IGA) and the visual analog scale (VAS) for itching, burning sensation, flushing, and hypersensitivity before and 8 weeks after the initiation of the intervention.

Results

In total, 10 erythematotelangiectatic rosacea (ETR) and 12 papulopustular rosacea (PPR) patients treated with TSP and 12 ETR and 13 PPR patients treated with TMP were analyzed. IGA and VAS scores for itching, burning sensation, flushing, and hypersensitivity were noted to significantly improve in the ETR and PPR patient groups treated with TSP and both groups treated with TMP, except for the VAS score for itching in the TSP-treated ETR group. No significant differences were observed in terms of the improvement rates of IGA, VAS scores, or the prevalence of adverse events between the TSP- and TMP-treated groups.

Conclusions

As per our findings, TSP and TMP have similarly favorable effects on both ETR and PPR in Japanese patients in real-world settings.

A systematic review to evaluate the efficacy of azelaic acid in the management of acne, rosacea, melasma and skin aging

BACKGROUND

Topical azelaic acid (AA) is indicated for acne and rosacea, but there is some evidence for its use for other dermatological conditions.

AIMS

To assess the effectiveness and safety of topical AA for acne vulgaris, rosacea, hyperpigmentation/melasma, and skin aging.

METHODS

RCTs of at least 6 weeks' treatment duration were eligible for inclusion. Databases including MEDLINE, Embase, CINAHL, and ClinicalTrials.gov were searched up to December 2022. Two reviewers were involved in all stages of the systematic review process.

RESULTS

Forty-three RCTs met the inclusion criteria. Meta-analyses within 20 rosacea studies demonstrated that erythema severity, inflammatory lesion counts, overall improvement, and treatment success (achieving skin clarity) were significantly improved with AA compared with vehicle after 12 weeks. AA was more effective than metronidazole 0.75% for improved erythema severity, overall improvement, and inflammatory lesion counts. Sixteen acne studies suggest that AA is more effective than vehicle for improving global assessments and reducing acne severity. AA 20% also significantly reduced more lesions than erythromycin gel. Within seven melasma studies, AA 20% was significantly better than vehicle for both severity and global improvement. AA 20% demonstrated significantly better results compared with hydroquinone 2% for global improvement. Very few significant differences between AA and comparators were observed for commonly reported adverse events. No eligible RCTs were found that evaluated skin aging.

CONCLUSIONS

AA is more effective than vehicle for rosacea, acne and melasma. Comparisons between AA and other treatments were often equivalent. Where there is equivalence, AA may be a good option for some clinical situations. RCT evidence is needed to evaluate the effectiveness of AA on skin aging.

Diagnosis and Treatment of Morbihan's Disease: A Practical Approach based on Review of the Literature

Background

Morbihan's disease (MD), also known as solid persistent facial edema, solid facial lymphedema or rosacea lymphedema, is a rare condition.

Objective

Despite existing case reports and literature reviews, clinical guidance for diagnosis and management is lacking. This review aims to provide comprehensive information on the etiology, differential diagnoses, diagnostics, and management of MD.

Methods

PubMed was searched up to April 2023 for relevant studies on MD with no language restriction. Furthermore, references were checked of found reports.

Results

A comprehensive overview of the literature and clinical guidance for MD. We found 95 studies involving 166 patients (118 male, 46 female and 2 gender unreported) evaluating management options, categorized into: isotretinoin (16 studies), isotretinoin plus antihistamines (8), isotretinoin plus corticosteroids (8), antibiotics (13), antibiotics plus corticosteroids (7), surgical debulking (10) and miscellaneous/combination treatments (43). Some studies contributed to two categories. Treatment with isotretinoin as monotherapy or combined with antihistamines, doxycycline or minocycline as well as surgical procedures demonstrated mostly satisfactory results, although recurrences were common. Longer treatment duration, of at least 6 to 12 months, is recommended for pharmacological treatments. Adding systemic or intralesional corticosteroids to previous treatments may be beneficial. Manual lymph drainage seems to contribute to satisfying result.

Limitations

This is not a systematic review and randomized controlled trials are lacking.

Conclusion

Diagnosis of MD is based on specific clinical features and excluding diseases with similar appearance. Prolonged treatment is often necessary to obtain satisfactory results, which might be limited to a partial and/or temporary response.

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.

Efficacy and Safety of Microencapsulated Benzoyl Peroxide Cream, 5%, in Rosacea: Results From Two Phase III, Randomized, Vehicle-Controlled Trials

Objective

A new formulation of benzoyl peroxide (E-BPO cream, 5%) entraps benzoyl peroxide (BPO) in silica microcapsules. This study assesses the efficacy, safety, and tolerability of E-BPO cream, 5%, in rosacea in two Phase III clinical trials.

Methods

In two 12-week, randomized, double-blind, vehicle cream-controlled Phase III trials, 733 subjects at least 18 years old with moderate to severe rosacea were randomized (2:1) to once-daily E-BPO cream, 5%, or vehicle.

Results

In Study 1, the proportion of subjects achieving IGA clear/almost clear at Week 12 was 43.5 percent for E-BPO cream, 5%, and 16.1 percent for vehicle. In Study 2, the respective values were 50.1 percent and 25.9 percent. In Study 1, the decrease in lesion count from baseline to Week 12 was -17.4 for E-BPO cream, 5%, versus -9.5 for vehicle. In Study 2, the respective values were -20.3 and -13.3 (all P<0.001). The difference was also significant at Week 2. There were no treatment-related serious adverse events; 1.4 percent of subjects (1.8% E-BPO cream, 5%, 0.4% vehicle) discontinued due to adverse events. Assessed local tolerability was found to be similar among subjects in both E-BPO and vehicle.

E-BPO was not compared with unencapsulated BPO.

Conclusion

E-BPO is an effective and well tolerated treatment for rosacea. Clinicaltrials.gov Identifiers: NCT03564119, NCT03448939.

Long-term Efficacy and Safety of Microencapsulated Benzoyl Peroxide Cream, 5%, in Rosacea: Results From an Extension of Two Phase III, Vehicle-controlled Trials

Objective

We sought to assess the long-term safety and tolerability of microencapsulated benzoyl peroxide cream, 5% (E-BPO cream, 5%), in subjects with rosacea. Efficacy and tolerability have been previously demonstrated in two 12-week, randomized, double-blind, vehicle-controlled Phase III trials.

Methods

In this open-label extension study (NCT03564145; clinicaltrials.gov), all subjects from the initial placebo-controlled Phase III trials could receive E-BPO cream, 5%, for up to an additional 40 weeks, up to a total of 52 weeks of E-BPO cream, 5%, exposure. If a subject was assessed at study visits as "clear" or "almost clear" using the 5-point Investigator Global Assessment (IGA) scale (IGA 0 or 1), E-BPO cream, 5%, was not dispensed. If a subject was assessed as "mild to severe" (IGA 2+), E-BPO cream, 5%, was applied daily until they reached "clear" or "almost clear."

Results

The safety and tolerability profile for E-BPO cream, 5%, was similar to that reported in the Phase III studies. Five subjects (0.9%) discontinued study drug due to treatment-related adverse events, and 17 subjects (3.2%) experienced an adverse event considered related to study drug. IGA success after 40 weeks of active treatment was 66.5 percent for subjects continuing from the Phase III vehicle group (n=172) and 67.6 percent for subjects who continued Phase III E-BPO cream, 5% (n=363). The study ended early in accordance with the protocol.

Limitations

Safety and tolerability of E-BPO were not compared with those of unencapsulated BPO.

Conclusion

E-BPO cream, 5%, showed a favorable safety and tolerability profile during this 40-week, open-label extension study.

Preferred practice patterns and review on rosacea

Rosacea is a chronic, inflammatory facial dermatosis commonly found in fair skin tone population. Recent studies have shown the increasing prevalence in the dark skin tone population as well. Ocular involvement is very common and can occur without cutaneous features. Common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring, and rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. The management ranges from local therapy to systemic treatment, depending on the severity of the disease. There is a positive association between demodicosis and rosacea; however, causality is always argued. In this review, we describe the epidemiology, clinical features, and treatment of rosacea and ocular rosacea.

Role of the skin microbiota and intestinal microbiome in rosacea

Rosacea is a chronic inflammatory cutaneous disorder of uncertain etiology that mainly affects the centrofacial region, including cheeks, nose, chin, forehead, and eyes. The pathogenesis of rosacea remains unclear because it involves several complex factors. Additionally, the potential treatment methods need to be explored. We reviewed the common bacterial species in the skin microbiota and gut microbiota of rosacea patients such as Demodex folliculorum, Staphylococcus epidermidis, Bacillus oleronius, Cutibacterium acnes, and Helicobacter pylori and identified their role in the pathogenesis. Besides, we summarized the influence factors such as temperature and age on rosacea patients. We also systematically reviewed the commonly used clinical treatment methods, including antibiotics, probiotics. as well as their treatment mechanism and application precautions.

Fractional treatment of rosacea by LBO 532 nm laser with “one shot” procedure: A preliminary study

Rosacea is a chronic skin disease prevalently affecting the center of the face. The permanent erythema of skin face represents its typical sign. Further common features are face flushing, telangiectasias, and inflammatory presence of oedema, papules and pustules. The aim of this study was to investigate the use of LBO 532nm laser in the treatment of this disease. Ten subjects of both sex and middle age affected by rosacea in erithemato/teleangectatic stage were treated by a LBO 532nm laser single session. Discomfort evaluation during and after the treatment, one session results as well as incidence of the side effects were evaluated, with 6 months follow up. Positive results were obtained after only one session in total safety with minimal patients discomfort and without undesired effects during treatment. The study confirmed International literature data suggesting the use of laser and light devices as elective treatment of this disease. IPL, dye lasers and 532nm laser are the devices more used and the last seems to represent the gold standard for 1,2,3 phototypes. This clinical trial, with the limitations due to the small number of patients, indicated that “one session LBO 532nm laser treatment” represents an interesting and innovative approach in the therapy of the erythemato/telangectatic rosacea.

Aberrant amino acid metabolism promotes neurovascular reactivity in rosacea

Rosacea is a chronic skin disorder characterized by abnormal neurovascular and inflammatory conditions on the central face. Despite increasing evidence suggesting that rosacea is associated with metabolic disorders, the role of metabolism in rosacea pathogenesis remains unknown. Here, via a targeted metabolomics approach, we characterized significantly altered metabolic signatures in patients with rosacea, especially for amino acid-related metabolic pathways. Among these, glutamic acid and aspartic acid were highlighted and positively correlated with the disease severity in patients with rosacea. We further demonstrated that glutamic acid and aspartic acid can facilitate the development of erythema and telangiectasia, typical features of rosacea, in the skin of mice. Mechanistically, glutamic acid and aspartic acid stimulated the production of vasodilation-related neuropeptides from peripheral neurons and keratinocytes and induced the release of nitric oxide from endothelial cells and keratinocytes. Interestingly, we provided evidence showing that doxycycline can improve the symptoms of patients with rosacea possibly by targeting the amino acid metabolic pathway. These findings reveal that abnormal amino acid metabolism promotes neurovascular reactivity in rosacea and raise the possibility of targeting dysregulated metabolism as a promising strategy for clinical treatment.

An overview of biomedical applications of choline geranate (CAGE): a major breakthrough in drug delivery

A number of studies are on the way to advancing the field of biomedical sciences using ionic liquids (ILs) and deep eutectic solvents (DESs) in view of their unique properties and inherent tunability. These significant solvents tend to enhance the physical properties of the drug, increase their bioavailability and promote the delivery of recalcitrant drugs to the body. One such widely investigated tempting multipurpose IL/DES system is choline geranate (CAGE), which has gained significant interest due to its biocompatible and highly potent antiseptic behavior, which also facilitates its sanitizing ability to combat the coronavirus. This review focuses on total advancements in biomedical applications of CAGE. This biocompatible IL/DES has made facile the solubilization of hydrophobic and hydrophilic drugs and delivery of intractable drugs through physiological barriers by stabilizing proteins and nucleic acids. Therefore, it has been used as a transdermal, subcutaneous, and oral delivery carrier and as an antimicrobial agent to treat infectious diseases and wounds as approved by laboratory and clinical translations. Moreover, current challenges and future outlooks are also highlighted to explore them more purposefully.

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.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Hydroxocobalamin: An Effective Treatment for Flushing and Persistent Erythema in Rosacea

BACKGROUND

Expression of inducible nitric oxide synthase (NOS) is higher in rosacea skin samples than in normal skin controls. Hydroxocobalamin is a potent inhibitor of all isoforms of NOS, capable of reducing the vasodilatations induced by nitric oxide.

OBJECTIVE

We aimed to evaluate the role of hydroxocobalamin in treating facial flushing and persistent erythema of rosacea.

METHODS

Thirteen patients with rosacea who displayed facial flushing and persistent erythema received 1 to 4 weekly intramuscular injections of hydroxocobalamin 1 to 2 mg. The outcomes were measured using the Clinician's Erythema Assessment (CEA) by photography and an infrared thermometer to evaluate the difference in skin surface temperature (SST) of the cheeks before and after treatment.

RESULTS

Thirty minutes after the first dose of intramuscular injection of hydroxocobalamin, the mean CEA significantly reduced from 2.2± 0.6 to 1.2±0.4 (p<0.001), and average SST also significantly reduced from 36.7±0.70°C to 36.2±0.61°C (p<0.001) on the cheeks.

CONCLUSION

In our patient sample, intramuscular administration of hydroxocobalamin was effective for immediate reduction of facial erythema associated with rosacea.

Antibiotic resistance in dermatology: The scope of the problem and strategies to address it

Antibiotic resistance is a growing health concern that has attracted increasing attention from clinicians and scientists in recent years. Although resistance is an inevitable consequence of bacterial evolution and natural selection, misuse and overuse of antibiotics play a significant role in its acceleration. Antibiotics are the mainstay of therapy for common dermatoses, including acne and rosacea, as well as for skin and soft tissue infections. Therefore, it is critical for dermatologists and physicians across all disciplines to identify, appropriately manage, and prevent cases of antibiotic resistance. This review explores dermatologic conditions in which the development of antibiotic resistance is a risk and discusses mechanisms underlying the development of resistance. We discuss disease-specific strategies for overcoming resistant strains and improving antimicrobial stewardship along with recent advances in the development of novel approaches to counter antibiotic resistance.

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.

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.

Rosacea: Treatment targets based on new physiopathology data

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

Rosacea and Diet: What is New in 2021?

OBJECTIVE

Rosacea is a common inflammatory cutaneous condition with a complex yet unknown etiopathogenesis. Diet and certain food items are known to trigger or worsen rosacea symptoms, but conflicting and often inconsistent advice is given to patients regarding this link. We provide an up-to-date literature review on the relationship between rosacea and diet.

METHODS

Using the keywords "alcohol," "diet," "flushing," "food," "inflammation," "rosacea," "skin-gut axis" and "spice" we systemically searched the databases PubMed, MEDLINE and EMBASE for English-language articles in July 2020.

RESULTS

The most frequently reported triggers implicated in rosacea include alcohol, spicy food, cinnamaldehyde-containing foods (e.g., tomatoes, citrus fruits, chocolate), hot drinks, and histamine-rich foods (e.g., aged cheese, wine, processed meats). Some food items appear to play a protective role, such as omega-3, which appears to protect against ocular rosacea. The relationship between certain food items and the subtype of rosacea is varied, with inconsistent results shown in the few studies that examined this. As an example, alcohol worsens flushing and fatty food triggers both erythematotelangiectatatic and phymatous rosacea in susceptible individuals.

CONCLUSION

While several food types appear to be associated with exacerbation of rosacea, there are no recommendations that can be applied to all patients. Further studies are needed to examine the exact link between diet and rosacea subtypes.

Nonantibiotic Properties of Tetracyclines in Rosacea and Their Clinical Implications

Rosacea is one of the most common inflammatory skin diseases in the United States, with a complex pathophysiology. One of the major components of the pathophysiology of rosacea is an abnormal immune detection and response to stimuli. Tetracyclines and their derivatives, including minocycline and doxycycline, have anti-inflammatory properties independent of their antibacterial activity that correlate with certain aspects of the pathophysiology, and these drugs are often used by dermatologists to treat rosacea. Biological actions of tetracyclines correlating with rosacea include anti-inflammatory and antioxidative activities, inhibitory effects on angiogenesis, and proteolysis. The objective of this review is to re-establish the current understanding of tetracyclines and their mechanism of action as they relate to the pathophysiology and treatment of rosacea for clinicians. This includes reviewing the inflammatory aspects of rosacea that correlate with the known nonantibiotic properties of tetracyclines and providing the most up-to-date clinical evidence supporting the use of tetracyclines to treat rosacea. Given the evolving and multifactorial nature of pathophysiology, this review offers clinicians a unified picture that includes research on the links between rosacea pathophysiology and clinical presentation, the nonantibiotic properties of tetracyclines that relate to pathophysiologic pathways in rosacea, and the potential for clinical application of tetracyclines in rosacea therapy.

Rosacea: New Concepts in Classification and Treatment

Rosacea is a chronic inflammatory dermatosis mainly affecting the cheeks, nose, chin, and forehead. Rosacea is characterized by recurrent episodes of flushing or transient erythema, persistent erythema, phymatous changes, papules, pustules, and telangiectasia. The eyes may also be involved. Due to rosacea affecting the face, it has a profound negative impact on quality of life, self-esteem, and well-being. In addition to general skin care, there are several approved treatment options available for addressing these features, both topical and systemic. For some features, intense pulse light, laser, and surgery are of value. Recent advances in fundamental scientific research have underscored the roles of the innate and adaptive immune systems as well as neurovascular dysregulation underlying the spectrum of clinical features of rosacea. Endogenous and exogenous stimuli may initiate and aggravate several pathways in patients with rosacea. This review covers the new phenotype-based diagnosis and classification system reflecting pathophysiology, and new and emerging treatment options and approaches. We address new topical and systemic formulations, as well as recent evidence on treatment combinations. In addition, ongoing studies investigating novel therapeutic interventions will be summarized.

Light-based therapies in the management of rosacea: a systematic review with meta-analysis

BACKGROUND

The current scenario and position of laser and light-based therapies (LLBT) in the therapeutic rosacea scheme are lacking evidence-based recommendations and comparisons on efficacy and tolerability among different devices. This article aimed to systematically compare the efficacy, acceptability, and tolerability of the pulsed dye laser (PDL) versus other devices.

METHOD

A literature search was conducted in March 2020. Four domains were analyzed throughout the following six outcomes: Spectrophotometer erythema index and percentage of reduction for background erythema, telangiectasia grading scale for telangiectasias, visual analog scale for pain, and physician's assessment and patient's satisfaction for treatment success.

RESULTS

Our search yielded 423 potentially relevant studies. After removing the excluded and duplicated records, 12 records were assessed for eligibility in the meta-analysis. Erythema (RR:0.38 95%CI: -0.20-0.95), telangiectasias (RR:0.54 95%CI: -0.87-1.94), and the treatment success throughout the physician's assessment (RR:1.23 95%CI: 0.74-2.04) and the patient's satisfaction (RR:1.15 95%CI: 0.73-1.82) were not significantly different between pulsed dye laser and other LLBT. In the pain domain, PDL was as painful as other LLBT (RR:-0.23 95%CI: -0.96-0.49) but more painful than neodymium: yttrium-aluminum-garnet laser (RR:0.84 95%CI: 0.53-1.14) and less than intense pulsed light (RR:-1.18 95%CI: -1.56-0.80).

CONCLUSION

This work based on previously published literature demonstrates that the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence, although in the meta-analysis the effectiveness was comparable to other LLBT, such as neodymium: yttrium-aluminum-garnet laser (Nd-YAG) or IPL.

Clinical translation of choline and geranic acid deep eutectic solvent

Choline geranate deep eutectic solvent/ionic liquid (CAGE) has shown several desirable therapeutic properties including antimicrobial activity and ability to deliver drugs transdermally in research laboratories. Here, we describe the first report of clinical translation of CAGE from the lab into the clinic for the treatment of rosacea, a common chronic inflammatory skin disorder that affects the face. We describe the seven steps of clinical translation including (a) scale-up, (b) characterization, (c) stability analysis, (d) mechanism of action, (e) dose determination, (f) GLP toxicity study, and (g) human clinical study. We describe the challenges and outcomes in these steps, especially those that uniquely arise from the deep eutectic nature of CAGE. Our translational efforts led to a 12-week open-label phase 1b cosmetic study with CAGE1:2 gel (CGB400) in mild-moderate facial rosacea in 26 patients where CGB400 exhibited a marked reduction in the number of inflammatory lesions. These results demonstrate the therapeutic potential of CGB400 for treating rosacea as well as it provides insights into the translational journey of deep eutectic solvents, in particular CAGE, for dermatological applications.

Granulomas in Dermatopathology: Principal Diagnoses - Part 1

This series of 2 articles on dermatopathologic diagnoses reviews conditions in which granulomas form. Part 1 clarifies concepts, discusses the presentation of different types of granulomas and giant cells, and considers a large variety of noninfectious diseases. Some granulomatous diseases have a metabolic origin, as in necrobiosis lipoidica. Others, such as granulomatous mycosis fungoides, are related to lymphomas. Still others, such as rosacea, are so common that dermatologists see them nearly daily in clinical practice.

Rhinophyma: patient management

Rhinophyma is a rare subtype of rosacea, which is a thickening of the skin in the nasal area due to an overgrowth of the sebaceous glands and the underlying connective tissue. The exact pathogenesis of rhinophyma is unknown, but potential factors include a combination of neurovascular disorders, innate immune responses, and the presence of microorganisms. The article presents current data on the treatment of rosacea, in particular, rhinophyma. A clinical case of a 67-year-old patient with a combination of papulo-pustular subtype of rosacea and rhinophyma is presented. The high effectiveness of the therapy with systemic isotretinoin was demonstrated.