Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis

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.

Multi-Transcriptomic Analysis and Experimental Validation Implicate a Central Role of STAT3 in Skin Barrier Dysfunction Induced Aggravation of Rosacea

Objective

Methods

Results

Conclusion

The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review

Rosacea, a chronic condition usually recognized by its visible presentation, can be accompanied by invisible symptoms, such as burning and stinging. The aim of this review is to gather the most recent evidence on burning and stinging, in order to further emphasize the need to address these symptoms. Inflammatory pathways can explain both the signs and symptoms of rosacea, but available treatments are still evaluated primarily on their ability to treat visible signs. Recent evidence also highlights the adverse impact of symptoms, particularly burning and stinging, on quality of life. Despite an increasing understanding of symptoms and their impact, the management of burning and stinging as part of rosacea treatment has not been widely investigated. Clinicians often underestimate the impact of these symptoms and do not routinely include them as part of management. Available therapies for rosacea have the potential to treat beyond signs, and improve burning and stinging symptoms in parallel. Further investigation is needed to better understand these benefits and to optimize the management of rosacea.

Evaluation of fibromyalgia syndrome in patients with rosacea

Objectives

This study aims to investigate the frequency of fibromyalgia syndrome (FMS) in rosacea patients and the relationship between disease disability score of FMS and quality of life score of rosacea.

Patients and methods

This cross-sectional controlled clinical trial was performed between December 2017 and December 2018. One hundred female rosacea patients (mean age 43.2±10.1; range, 21 to 65 years) and 100 age- and sex-matched control subjects (mean age 41.2±11.1; range, 22 to 68 years) with no history of skin disease and systemic diseases including diabetes, cardiovascular, renal and hepatic diseases were recruited. Dermatology Life Quality Index (DLQI) scores were calculated using a 10-item self-administered questionnaire. The diagnosis of FMS was established according to 2010 American College of Rheumatology diagnostic criteria. Fibromyalgia Impact Questionnaire (FIQ) was used to determine the clinical severity and functional disability, while Visual Analog Scale (VAS) was used to determine pain severity in the patients with FMS.

Results

The frequency of FMS in patient group was significantly higher than control group (p=0.019). The mean duration of FMS in patient group was significantly higher than control group (p=0.001). There was no significant difference in terms of the age of onset of FMS, FIQ and VAS scores between groups (p=0.53, p=0.54, p=0.07, respectively). DLQI scores were significantly correlated with FIQ scores in the patient group (r=0.43, p=0.008).

Conclusion

The frequency of FMS in rosacea patients was significantly higher than control subjects without any skin disease and there was a correlation between disability score of FMS and quality of life score of rosacea. Investigating fibromyalgia symptoms in rosacea patients may be helpful for providing patient-based therapeutic approaches where neurologically based treatments may also be beneficial for rosacea.

Features of the Skin Microbiota in Common Inflammatory Skin Diseases

Many relatively common chronic inflammatory skin diseases manifest on the face (seborrheic dermatitis, rosacea, acne, perioral/periorificial dermatitis, periocular dermatitis, etc.), thereby significantly impairing patient appearance and quality of life. Given the yet unexplained pathogenesis and numerous factors involved, these diseases often present therapeutic challenges. The term “microbiome” comprises the totality of microorganisms (microbiota), their genomes, and environmental factors in a particular environment. Changes in human skin microbiota composition and/or functionality are believed to trigger immune dysregulation, and consequently an inflammatory response, thereby playing a potentially significant role in the clinical manifestations and treatment of these diseases. Although cultivation methods have traditionally been used in studies of bacterial microbiome species, a large number of bacterial strains cannot be grown in the laboratory. Since standard culture-dependent methods detect fewer than 1% of all bacterial species, a metagenomic approach could be used to detect bacteria that cannot be cultivated. The skin microbiome exhibits spatial distribution associated with the microenvironment (sebaceous, moist, and dry areas). However, although disturbance of the skin microbiome can lead to a number of pathological conditions and diseases, it is still not clear whether skin diseases result from change in the microbiome or cause such a change. Thus far, the skin microbiome has been studied in atopic dermatitis, seborrheic dermatitis, psoriasis, acne, and rosacea. Studies on the possible association between changes in the microbiome and their association with skin diseases have improved the understanding of disease development, diagnostics, and therapeutics. The identification of the bacterial markers associated with particular inflammatory skin diseases would significantly accelerate the diagnostics and reduce treatment costs. Microbiota research and determination could facilitate the identification of potential causes of skin diseases that cannot be detected by simpler methods, thereby contributing to the design and development of more effective therapies.

Efficacy and tolerability of a detergent and care component for rosacea patients: A split-face, vehicle-controlled, randomized trial

BACKGROUND

The treatment of facial erythema and subjective symptoms of rosacea patients remains challenging in clinical practice. Cosmeceuticals, care components containing active ingredients such as phytochemicals, play a growing role in treatment plans. However, well-designed studies on their efficacy and limitations are widely missing.

OBJECTIVE

A foam and a cream for rosacea patients were assessed based on objective and subjective methodology. The tolerability of skin and eyes was evaluated.

METHODS

A randomized, double-blinded, split-face, and vehicle-controlled trial was conducted. At baseline and after four weeks of product use, dermatological and ophthalmological investigations were performed, employing image analysis of facial erythema, clinical assessments, and questionnaires.

RESULTS

The patient cohort comprised 33 females with persistent facial erythema due to rosacea. No significant differences were found between the vehicle and the verum. According to the analysis of facial erythema, a "less pronounced" or "much less pronounced" appearance was seen in two thirds of patients comparing V1 to V0. Especially, the dryness of the skin improved by the use of the vehicle and the verum. Adverse subjective skin sensations decreased by 61.3% for the verum side and by 58.6% for the vehicle side. Subjective and objective analysis of ocular manifestation differed, with subjective manifestations reported more frequently, thus highlighting underdiagnosis of ocular rosacea.

CONCLUSIONS

As no clear differences between the verum and the vehicle were found, an optimal skin care regime itself seems to have a superior effect in the relief of facial erythema and foremost of subjective symptoms, rather than certain active ingredients.

Erythematotelangiectatic rosacea: The combination of 0.5% brimonidine tartrate gel and broadband pulse light therapy to reverse its effects

Rosacea is a common skin disease that is troublesome for both the patients and the dermatologists. Erythema, telangiectasia, papulopustular changes, and phymatous changes are the main problems faced by the patients and dermatologists in everyday practice. Due to the chronic and relapsing nature of the disease, patients are usually unsatisfied with conventional treatment methods. We report a case of a patient with rosacea, erythematotelangiectatic subtype with an eight-year history of progressive worsening and experience of combined therapy based on the broadband pulse light and topical 0.5% brimonidine tartrate gel. The effectiveness of the therapy was evaluated using multispectral skin imaging that enables to define morphological patterns of the pathological skin areas in a real-time mode as well as to create the map of hemoglobin distribution and to measure its concentration in the rosacea foci. In this case report, an efficacy and very good tolerability of the abovementioned treatment have been demonstrated.

A Randomized, Placebo-Controlled Trial of Gamma Linolenic Acid as an Add-on Therapy to Minocycline for the Treatment of Rosacea

Background

A recent study suggested a possible role of skin barrier dysfunction in the pathogenesis of rosacea, which leads to irritation symptoms. Gamma linolenic acid (GLA) is an essential omega-6 fatty acid that is known to restore defective epidermal skin barrier. GLA supplementation has not previously been performed in rosacea patients.

Objective

To investigate the efficacy and safety of adding GLA to minocycline compared to minocycline alone in rosacea patients.

Methods

This prospective, double-blind, randomized, placebo-controlled trial enrolled 31 rosacea patients. They were randomly assigned to receive 320 mg/day of GLA (Evoprim®) (n=16) or placebo (n=15) in addition to 100 mg/day of minocycline for 8 weeks. Investigator's global assessment (IGA) and patient's global assessment (PGA) were used to assess clinical severity at weeks 0, 4, 8, and 12. Biophysical parameters including melanin index, erythema index, transepidermal water loss (TEWL), lipid concentration, and stratum corneum hydration were measured.

Results

In the GLA group, a higher proportion of patients achieved treatment success (IGA≤1) at week 8 (68.75% vs. 33.33%) and patient satisfaction (PGA≥3) at weeks 8 (75.0% vs. 40.0%) and 12 (81.3% vs. 46.6%). Both groups, throughout 12 weeks of treatment, revealed a trend toward improvement in erythema index, melanin index, TEWL, and stratum corneum hydration. Particularly, there was a significant difference in TEWL and stratum corneum hydration over time between the two groups (p=0.033, p=0.003, respectively). No serious adverse event was observed in both groups.

Conclusion

GLA is beneficial as an additional therapeutic option for rosacea patients treated with minocycline.

Consensus on the therapeutic management of rosacea - Brazilian Society of Dermatology

BACKGROUND

Rosacea is a chronic inflammatory disease of the skin, relatively more frequent in women over 30 with a low phototype and proven genetic predisposition. Although its etiology is unknown and possibly multifactorial, the immunological abnormality, associated with neurovascular dysregulation and triggering factors, are important elements in its pathophysiology, which lead to the main changes of inflammation, vasodilation, and angiogenesis that are responsible for the clinical manifestations. Despite the lack of cure, numerous therapeutic options are available for the different clinical presentations of the disease, with satisfactory responses.

OBJECTIVE

To reach a consensus, with recommendations from experts, on the therapeutic management of rosacea suitable to the Brazilian setting.

METHODS

The study was conducted by five specialized dermatologists from university centers, representatives of the different Brazilian regions, with experience in rosacea, who were appointed by the Brazilian Society of Dermatology. Based on the adapted DELPHI methodology, the experts contributed through an updated bibliographic review of the scientific evidence, combined with personal experiences.

RESULTS

The group of experts reached a consensus on the relevant aspects in the therapeutic management of rosacea, providing information on epidemiology, pathophysiology, triggering factors, clinical condition, classification, quality of life, and comorbidities. Consensus was defined as approval by at least 90% of the panel.

CONCLUSION

Despite the impossibility of cure, there are several therapeutic alternatives specific to each patient that provide excellent results, with chances of total improvement and long periods of remission, promoting a positive impact on quality of life. This consensus provides detailed guidance for clinical practice and therapeutic decisions in rosacea.

Skin barrier damaging and repairing process: A new application field of dermoscopy

BACKGROUND

Although more and more noninvasive detection technologies have been used in assessing skin barrier integrity and functions, more accurate, intuitive, and convenient detective methods still needed to be explored and developed.

AIMS

To investigate the characteristic image changes under the dermoscopy and to explore the relationship with skin physiological indexes in skin barrier damaging and repairing process.

PATIENTS/METHODS

25 healthy subjects with normal skin in forearm were included and divided into different groups according to the operated strips numbers (30, 35, and 40 times). Before tape stripping, and immediately, 3, 7, 14, and 21 days after tape stripping, dermoscopic examination and skin transepidermal water loss (TEWL), surface hydration, and L*a*b* value were simultaneously tested in the same region.

RESULTS

Immediately after different times tape stripping, the amount of cuticle cells residues and the microvascular images were different. In skin barrier repairing process, the scab forming time observed under dermoscopy was day 14, day 7, and day 3 on 30 times, 35 times, and 40 times stripped skin, respectively. A small amount of cuticle cells and blurry vessels could be identified in hydration value <40 group, while there was no cuticle cell residue, and the branching vessels were obvious in hydration value >40 group.

CONCLUSIONS

Unique manifestations could be observed under dermoscopy in different time points of skin barrier with various degree of injury and in skin barrier repairing process. By combining dermoscopy and skin indexes assessing technologies, the skin barrier integrity and function could be observed and evaluated more accurately and precisely.

Organic osmolytes increase expression of specific tight junction proteins in skin and alter barrier function in keratinocytes

BACKGROUND

The epidermal barrier is important for water conservation, failure of which is evident in dry-skin conditions. Barrier function is fulfilled by the stratum corneum, tight junctions (TJs, which control extracellular water) and keratinocyte mechanisms, such as organic osmolyte transport, which regulate intracellular water homeostasis. Organic osmolyte transport by keratinocytes is largely unexplored and nothing is known regarding how cellular and extracellular mechanisms of water conservation may interact.

OBJECTIVES

We aimed to characterize osmolyte transporters in skin and keratinocytes, and, using transporter inhibitors, to investigate whether osmolytes can modify TJs. Such modification would suggest a possible link between intracellular and extracellular mechanisms of water regulation in skin.

METHODS

Immunostaining and quantitative polymerase chain reaction of organic osmolyte-treated organ-cultured skin were used to identify changes to organic osmolyte transporters, and TJ protein and gene expression. TJ functional assays were performed on organic osmolyte-treated primary human keratinocytes in culture.

RESULTS

Immunostaining demonstrated the expression of transporters for betaine, taurine and myo-inositol in transporter-specific patterns. Treatment of human skin with either betaine or taurine increased the expression of claudin-1, claudin-4 and occludin. Osmolyte transporter inhibition abolished this response. Betaine and taurine increased TJ function in primary human keratinocytes in vitro.

CONCLUSIONS

Treatment of skin with organic osmolytes modulates TJ structure and function, which could contribute to the epidermal barrier. This emphasizes a role for organic osmolytes beyond the maintenance of intracellular osmolarity. This could be harnessed to enhance topical therapies for diseases characterized by skin barrier dysfunction.

Rosacea is associated with conjoined interactions between physical barrier of the skin and microorganisms: A pilot study

Background

Rosacea is a common condition characterized by transient or persistent central facial erythema, and often papules and pustules. Currently, the role of bacterium in the development and progression of rosacea remains controversial. This study aimed to investigate the difference in the physiological conditions and microorganisms between the lesional and non‐lesional areas of papulopustular rosacea.

Methods

Twenty‐five French patients with papulopustular rosacea were enrolled in this pilot study. Each patient was subjected to clinical assessment, and the skin barrier function was tested in lesional and non‐lesional areas. In addition, samples from the lesional and non‐lesional areas were collected for bacterial culturing.

Results

Of all subjects included in the study, a lower skin conductivity was measured in lesional areas than in non‐lesional areas (43.5 ± 12.4 vs. 57.2 ± 11.6 U, P < .05), and a higher transepidermal water loss (TEWL) value was found in lesional areas than in non‐lesional areas (17.2 ± 5.9 vs. 14.2 ± 4.1 g/(m² h), P < .05). We found a lower TEWL in lesions in rosacea patients with bacterial dysbiosis than in those with bacterial balance (P < .05). In addition, there were significant differences in the skin conductivity and TEWL between lesional and non‐lesional areas in patients with bacterial dysbiosis (P < .001), and no significant differences were seen in patients with bacterial balance (P < .05).

Conclusion

The results of the present study demonstrate that the physiological features of rosacea are closely associated with the interactions between the host and the microorganisms.

Effects of skin care habits on the development of rosacea: A multi-center retrospective case-control survey in Chinese population

BACKGROUND

Certain cosmetic habits may trigger or aggravate rosacea, while there is little published epidemiologic evidence to support this point.

PURPOSE

To examine if daily skin care habits have an effect on the development of rosacea in Chinese population.

METHODS

A multi-center retrospective case-control survey of 1,245 rosacea cases and 1,538 skin-healthy controls was conducted in China. Participants completed the questionnaire comprised of demographic characteristics, socioeconomic data and daily skin care habits. Data were collected retrospectively and analyzed using the chi-square test and t-test. Multivariate logistic regression analyses were used to predict rosacea.

RESULTS

The multivariate logistic regression analysis highlighted some results: Dry, oily or mixed skin (OR = 6.3-6.9, P< .001), the usage of foaming cleanser (OR = 1.45, 95%CI 1.115-1.886, P = .01), make up more than 6 times a week (OR = 2.839, 95%CI 1.962-4.108, P< .001), using facial mask more than 4 times a week (OR = 2.56-3.069, P< .001), facial treatments at beauty salon more than once a week (OR = 4.946, 95%CI 2.005-12.198, P = .0018) and using beauty salon products (OR = 2.334, 95%CI 1.435-3.976, P = .0018) are positively correlated with the development of rosacea. Using of moisturizing products (OR = 0.602, 95%CI 0.386-0.983, P = .035) and sunscreen cream (OR = 0.303-0.507, P< .001 or P = .0167 for different frequency) presented significantly negative correlations with rosacea. Frequency of cleansing showed a nonlinear association with rosacea: using facial cleansers 1~3 times per week (OR = 0.647, 95%CI 0.429-0.975, P  =  .038) showed beneficial effects while using facial cleanser excessively (twice or more daily) (OR = 2.131, 95%CI 1.394-3.256, P< .001) positively correlated to rosacea strongly.

CONCLUSIONS

Excessive use of facial cleanser (twice or more a day) and facial mask (more than 4 times a week), frequent makeup (more than 6 times a week), regular skin care in beauty salon (more than once a week), and using beauty salon products were closely correlated to the development of rosacea in Chinese population.

Rosacea: a wholistic review and update from pathogenesis to diagnosis and therapy

Rosacea is a chronic inflammatory disorder of the central face with multiple overlapping presentations. Recent advancements are reshaping our understanding of rosacea from both a pathophysiologic perspective and clinical approach to therapy, introducing novel agents that have improved patient outcomes and reduced morbidity. In this article, we aim to outline the advancements in understanding, diagnosing, and managing rosacea and to familiarize physicians with the literature, thereby allowing us to better practice safe and effective medicine.

Noninvasive Skin Barrier Assessment: Multiparametric Approach and Pilot Study

The epidermal barrier function is disrupted in various inflammatory skin diseases. Accurate methods to measure skin barrier function are needed to assess the effect of therapeutic agents. Therefore, we developed a noninvasive multiparametric approach to measure four different parameters regarding the skin barrier. In the current pilot study, we evaluate this method in 14 healthy volunteers. We assessed erythema, transepidermal water loss (TEWL), water content, and epidermal thickness at both cheeks before and 30 min after application of Lanette and Vaseline-Lanette cream. For this, we used spectrophotometry, the Aquaflux device, the Epsilon device, and reflection confocal microscopy, respectively. Stratum corneum (SC) thickness was significantly increased after application of both creams (p < 0.05), and this increase was larger after Lanette cream compared to after Vaseline-Lanette cream (p = 0.035). Erythema, TEWL, and water content did not significantly change after cream application. Our multiparametric approach is promising and offers a feasible and practical way to quickly obtain multifaceted information about skin barrier function. Further exploration of this approach after prolonged use of cream and in conditions of disrupted skin barrier are recommended areas for future research.

Dual-Frequency Ultrasound as a New Treatment Modality for Refractory Rosacea: A Retrospective Study

BACKGROUND

Dual-frequency ultrasound (DFU) has emerged as a new treatment modality for improving inflammatory skin disorders. Although there have been few pilot studies, there are a limited number of studies that investigated efficacy of DFU on refractory rosacea.

OBJECTIVE

This study investigated the effect of DFU on patients with refractory rosacea.

MATERIALS AND METHODS

The authors retrospectively analyzed medical records of 42 patients with refractory rosacea (erythematotelangiectatic rosacea [ETR], n = 26; papulopustular rosacea [PPR], n = 14, mixed, n = 2). The patients were treated with DFU twice per week for the 1st week, and then once per week thereafter. Efficacy was assessed using erythema index (EI), transepithelial water loss (TEWL), and patient self-assessment (PSA).

RESULTS

Treatment with DFU resulted in significant decrease in EI, TEWL, and PSA. No significant difference was noted between ETR and PPR.

CONCLUSION

Application of DFU in patients with refractory rosacea resulted in improvement in persistent erythema, barrier dysfunction, and patient-reported symptoms. Dual-frequency ultrasound may be an additional treatment option for rosacea that is resistant to other treatments.

Swiss S1 guideline for the treatment of rosacea

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

An observational descriptive survey of rosacea in the Chinese population: clinical features based on the affected locations

BACKGROUND

There is currently no study that has evaluated the differences in epidemiological and clinical characteristics among rosacea patients according to different facial sites.

METHODS

Clinical and demographic data were obtained from 586 rosacea patients. The patients were divided into four groups based on the main sites involved with the rosacea lesions (full-face, cheeks, nose, or perioral involvement). Clinical signs were measured through self-reported, dermatologist-evaluated grading of symptoms, and physiological indicators of epidermal barrier function.

RESULTS

There were 471 (80.4%), 49 (8.4%), 52 (8.9%), and 14 (2.4%) cases in the full-face, cheek, nasal and perioral groups, respectively. Compared with the healthy control, the full-face group had lower water content and higher transepidermal water loss (TEWL) in the cheeks, and chin; the perioral group had lower water content and higher TEWL in the chin; while the nasal group had the normal water content and TEWL. Compared with the full-face group, the nasal group had more severe phymatous changes, less severe self-reported and dermatologist-evaluated grading of symptoms. All the patients in the perioral or the nasal group had their first rosacea lesions start and remain at the chin or on the nose. In the full-face group, 55.8% of patients had their lesions start with the full face, 40.1% on the cheek, and the rest (4.1%) on the nose.

CONCLUSION

Significant differences in clinical features were observed among rosacea patients with lesions at four different sites. The lesion localization of each group was relatively stable and barely transferred to other locations.

Fragility of epidermis in newborns, children and adolescents

Within their first days of life, newborns' skin undergoes various adaptation processes needed to accommodate the transition from the wet uterine environment to the dry atmosphere. The skin of newborns and infants is considered as a physiological fragile skin, a skin with lower resistance to aggressions. Fragile skin is divided into four categories up to its origin: physiological fragile skin (age, location), pathological fragile skin (acute and chronic), circumstantial fragile skin (due to environmental extrinsic factors or intrinsic factors such as stress) and iatrogenic fragile skin. Extensive research of the past 10 years have proven evidence that at birth albeit showing a nearly perfect appearance, newborn skin is structurally and functionally immature compared to adult skin undergoing a physiological maturation process after birth at least throughout the first year of life. This article is an overview of all known data about fragility of epidermis in 'fragile populations': newborns, children and adolescents. It includes the recent pathological, pathophysiological and clinical data about fragility of epidermis in various dermatological diseases, such as atopic dermatitis, acne, rosacea, contact dermatitis, irritative dermatitis and focus on UV protection.

Multidisciplinary Consideration of Potential Pathophysiologic Mechanisms of Paradoxical Erythema with Topical Brimonidine Therapy

Rosacea is a chronic inflammatory disease with transient and non-transient redness as key characteristics. Brimonidine is a selective α2-adrenergic receptor (AR) agonist approved for persistent facial erythema of rosacea based on significant efficacy and good safety data. The majority of patients treated with brimonidine report a benefit; however, there have been sporadic reports of worsening erythema after the initial response. A group of dermatologists, receptor physiology, and neuroimmunology scientists met to explore potential mechanisms contributing to side effects as well as differences in efficacy. We propose the following could contribute to erythema after application: (1) local inflammation and perivascular inflammatory cells with abnormally functioning ARs may lead to vasodilatation; (2) abnormal saturation and cells expressing different AR subtypes with varying ligand affinity; (3) barrier dysfunction and increased skin concentrations of brimonidine with increased actions at endothelial and presynaptic receptors, resulting in increased vasodilation; and (4) genetic predisposition and receptor polymorphism(s) leading to different smooth muscle responses. Approximately 80% of patients treated with brimonidine experience a significant improvement without erythema worsening as an adverse event. Attention to optimizing skin barrier function, setting patient expectations, and strategies to minimize potential problems may possibly reduce further the number of patients who experience side effects.

FUNDING

Galderma International S.A.S., Paris, France.

Skin barrier in rosacea

Recent studies about the cutaneous barrier demonstrated consistent evidence that the stratum corneum is a metabolically active structure and also has adaptive functions, may play a regulatory role in the inflammatory response with activation of keratinocytes, angiogenesis and fibroplasia, whose intensity depends primarily on the intensity the stimulus. There are few studies investigating the abnormalities of the skin barrier in rosacea, but the existing data already show that there are changes resulting from inflammation, which can generate a vicious circle caused a prolongation of flare-ups and worsening of symptoms. This article aims to gather the most relevant literature data about the characteristics and effects of the state of the skin barrier in rosacea.

Rosacea: Molecular Mechanisms and Management of a Chronic Cutaneous Inflammatory Condition

Rosacea is a chronic cutaneous inflammatory disease that affects the facial skin. Clinically, rosacea can be categorized into papulopustular, erythematotelangiectatic, ocular, and phymatous rosacea. However, the phenotypic presentations of rosacea are more heterogeneous. Although the pathophysiology of rosacea remains to be elucidated, immunologic alterations and neurovascular dysregulation are thought to have important roles in initiating and strengthening the clinical manifestations of rosacea. In this article, we present the possible molecular mechanisms of rosacea based on recent laboratory and clinical studies. We describe the genetic predisposition for rosacea along with its associated diseases, triggering factors, and suggested management options in detail based on the underlying molecular biology. Understanding the molecular pathomechanisms of rosacea will likely aid toward better comprehending its complex pathogenesis.

Topical Ivermectin 10 mg/g and Oral Doxycycline 40 mg Modified-Release: Current Evidence on the Complementary Use of Anti-Inflammatory Rosacea Treatments

Rosacea is a common, chronic inflammatory skin disease that can present with a variety of signs and symptoms. The potentially simultaneous occurrence of different signs and symptoms is due to different underlying inflammatory pathways, emphasizing the need for complementary treatment approaches. Topical ivermectin cream (10 mg/g) and systemic, oral anti-inflammatory doxycycline (40 mg modified-release) are both approved for the treatment of papulopustular rosacea (PPR). Whether or not a combined therapeutic approach may be more beneficial than monotherapy for patients with PPR remains to be tested. Here, we summarize underlying inflammatory pathways implicated in rosacea and clarify the impact of these two agents on selective pathways during inflammation, due to specific characteristics of their individual mechanisms of action (MoA). Based on the complementary MoA of doxycycline modified-release and ivermectin, a scientific rationale for a combined therapy targeting inflammatory lesions in rosacea is given. We propose that topical ivermectin cream is a promising new candidate as first-line treatment to target the inflammatory lesions of rosacea, which can be used in combination with systemic doxycycline modified-release to provide an optimal treatment approach considering all inflammatory pathways involved in PPR.

Funding Galderma.

Clinical assessment of rosacea severity: oriental score vs. quantitative assessment method with imaging and biomedical tools

BACKGROUND

Rosacea is a common chronic inflammatory disorder affecting facial skin. Currently, no accurate and objective method is available for assessing the severity of rosacea. Most studies use the National Rosacea Society Standard (NRSS) grading method, which lacks objectivity and yields varying results.

METHODS

Eighteen patients with rosacea were included. Clinical severity was assessed on the basis of the NRSS grade, Investigators' Global Assessment, Patients' Global Assessment, and Dermatology Quality of Life Index. A skin color analysis system was used to measure the facial area showing erythema, and biophysical parameters of facial skin (transepidermal water loss and skin surface hydration) were examined. To find statistical significant in classification severity of the rosacea, statistical analysis was performed with all parameters.

RESULTS

A significant correlation (P < 0.05) was found between the NRSS grade, facial area showing erythema, and biophysical parameters. The latter two factors differed significantly among patients with rosacea of different levels of severity (mild, moderate, severe; P < 0.05).

CONCLUSION

Color imaging systems can be useful and reliable for evaluating the severity of rosacea, in addition to biophysical parameter assessment. The combination of these two analytical methods enabled objective and quantitative evaluation of the severity of rosacea.

Canadian Clinical Practice Guidelines for Rosacea

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

Cutaneous rosacea: a thorough overview of pathogenesis, clinical presentations, and current recommendations on management

The review summarizes and systemizes available international data on the pathogenesis, clinical manifestations and current recommendations for the management of rosacea patients.

New developments in the treatment of rosacea - role of once-daily ivermectin cream

Rosacea is a chronic dermatological disorder with a variety of clinical manifestations localized largely to the central face. The unclear etiology of rosacea fosters therapeutic difficulty; however, subtle clinical improvement with pharmacologic treatments of various drug categories suggests a multifactorial etiology of the disease. Factors that may contribute to disease pathogenesis include immune abnormality, vascular abnormality, neurogenic dysregulation, presence of cutaneous microorganisms, UV damage, and skin barrier dysfunction. The role of ivermectin in the treatment of rosacea may be as an anti-inflammatory and anti-parasitic agent targeting Demodex mites. In comparing topical ivermectin and metronidazole, ivermectin was more effective; this treatment modality boasted more improved quality of life, reduced lesion counts, and more favorable participant and physician assessment of disease severity. Patients who received ivermectin 1% cream had an acceptable safety profile. Ivermectin is efficacious in decreasing inflammatory lesion counts and erythema.

Morphology-Based Diagnosis of Acneiform Eruptions

Acne is the most common skin disease. Distinguishing between true acne vulgaris and the various acneiform eruptions is important yet sometimes challenging. Given the common nature of acne and acneiform eruptions, the pediatrician must be aware of these lesion patterns and possess the skills to effectively evaluate the pediatric presentation of these eruptions. This article discusses several of the most common acneiform eruptions, including neonatal acne and cephalic pustulosis, periorificial dermatitis (perioral dermatitis), facial angiofibromas, iatrogenic acneiform drug eruptions, and childhood rosacea.

Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors

Rosacea is a chronic inflammatory skin condition that affects approximately 16 million Americans. Four distinct subtypes of rosacea have been recognized, with transient and nontransient facial flushing, telangiectasia, and inflammatory papules and pustules being among the more commonly recognized features. Although the exact pathogenesis of rosacea is unknown, dysregulation of the innate immune system, overgrowth of commensal skin organisms, and aberrant neurovascular signaling may all have a role in promoting the clinical features of rosacea.

Preliminary open-label clinical evaluation of the soothing and reepithelialization properties of a novel topical formulation for rosacea

Background

Rosacea is a common, incurable skin barrier disorder characterized by relapses and remissions.

Purpose

To evaluate the efficacy of Farmaka Rosacea Cream (FRC), a novel topical formulation for rosacea.

Methods

This single-center, open-label pilot study comprised a single-dose substudy in 20 healthy subjects and a long-term, repeat-dose substudy in 22 subjects with rosacea. The 2-hour, controlled, single-dose substudy assessed the soothing and reepithelialization properties of FRC after stripping-induced erythema based on the erythema index, transepidermal water loss, skin hydration, and clinical assessments of erythema. In the long-term substudy, subjects applied FRC twice daily for 8 weeks. Clinical assessments included vascular and pigmentary homogeneity and erythema and hemoglobin indices. Subjects completed questionnaires to assess FRC efficacy and cosmetic acceptability.

Results

Greater reductions were seen in FRC-treated areas compared with untreated areas for the erythema index (−16% versus −8%; P<0.001) and mean transepidermal water loss (−35.8% versus −10.1%; P<0.001) 30 minutes after stripping. Significant improvements over untreated areas were maintained 2 hours after stripping. Skin hydration and clinical erythema assessments also indicated that FRC soothed rosacea symptoms and promoted skin reepithelialization. Erythema and hemoglobin indices were significantly reduced from baseline after 4 and 8 weeks of treatment. Clinically assessed parameters were significantly improved following FRC application. Subjects assessed FRC positively.

Conclusion

Improvement of rosacea symptoms was noted with FRC application. The main film-forming ingredients of FRC (trehalose, cholesterol, ceramide, and fatty acids), combined with other soothing and calming ingredients and ultraviolet filters, could explain its efficacy.

Efficacy and Safety Results of a Drug-Free Cosmetic Fluid for Perioral Dermatitis: The Toleriane Fluide Efficacy in Perioral Dermatitis (TOLPOD) Study

BACKGROUND

Perioral dermatitis (POD) is a common inflammatory skin disease without standard therapy.

OBJECTIVE

We sought to evaluate the clinical value of a soothing fluid for the treatment of POD.

METHODS

We included 51 patients with POD in this 8-week clinical trial. The Toleriane Fluide Efficacy in Perioral Dermatitis (TOLPOD) study had an open-label design and involved twice-daily application of Toleriane Fluide, a soothing cosmetic fluid. Clinical assessment of POD was performed with a predefined questionnaire including the POD severity index (PODSI). Control visits were made after 4 and 8 weeks of treatment.

RESULTS

The results were compared with those of a historical control group treated with a vehicle cream. Patients treated with the soothing fluid showed a continuous and significant improvement of the PODSI over time. The improvement of PODSI observed with the soothing fluid was better, but not significantly better, than that observed in the historical controls. In addition, the subjective complaints of patients such as disease burden, itching, distension of the skin, and appearance improved during treatment.

CONCLUSION

A soothing fluid could be a clinically useful treatment option for POD.

[Off-label indications for topical tacrolimus]

The topical calcineurin antagonist tacrolimus plays an important role in the treatment of different forms of eczema because of its favorable risk profile. In addition, different off-label indications have been clinically tested where tacrolimus ointment has achieved clinical improvement. This article discusses off-label treatment of vitiligo, seborrheic dermatitis, steroid rosacea, perioral dermatitis, rosacea and lichen sclerosus.