Randomized placebo-controlled trial of a flavonoid-rich plant extract-based cream in the treatment of rosacea

Recent Advances in the Management of Rosacea through Natural Compounds

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

A prospective review of the health-promoting potential of Jing Si Herbal Tea

Traditional Chinese medicine (TCM) has gained considerable attention over the past few years for its multicomponent, multitarget, and multi-pathway approach to treating different diseases. Studies have shown that TCMs as adjuvant therapy along with conventional treatment may benefit in safely treating various disorders. However, investigations on finding effective herbal combinations are ongoing. A novel TCM formula, "Jing Si Herbal Tea (JSHT)," has been reported recently for their health-promoting effects in improving overall body and mental health. JSHT is a combination of eight herbs recognized in Chinese herbal pharmacopoeia for their anti-viral, anti-aging, and anti-cancer properties as well as protective effects against cardiovascular, metabolic, neural, digestive, and genitourinary diseases. Thus, to better understand the beneficial effects of the ingredients of JSHT on health, this review intends to summarize the preclinical and clinical studies of the ingredients of JSHT on human health and diseases, and possible therapeutic effects with the related mode of actions and future prospects for their application in complementary therapies.

The Role of Cosmetology in an Effective Treatment of Rosacea: A Narrative Review

Rosacea is a chronic inflammatory facial skin disease usually occurring in middle-aged patients. It manifests itself as an inflammatory condition with perivascular infiltrate, dilated blood vessels, lymphoedema, hyperplasia of sebaceous glands, and disorders of connective tissue structures brought on by fibrosis. Rosacea is characterized by multifactorial inflammatory mechanisms, and therefore it requires an interdisciplinary approach including adequate skin care, topical and/or systemic therapy, and physical modalities to successfully treat the various symptoms and disease subtypes. However, data regarding the possible role of cosmetologists in rosacea remains scanty and equivocal. The objectives of cosmetology therapy include restoration and regeneration, anti-inflammatory effects, the strengthening of blood vessels and regulation of their permeability, and the regulation of keratinization. Vascular abnormalities can be targeted with specific light and laser devices. Therefore, the present paper aims to review the latest advances and summarize different aspects concerning skin care in rosacea. Particular attention has been paid to the co-operation of cosmetologists with other specialists in order to bring about the interdisciplinary management of rosacea. It is also important to keep in mind that it is usually necessary to combine various methods of treatment, as this approach is more effective than monotherapy for attaining satisfactory cosmetic results in rosacea patients.

Comparative Analysis of Chemical Composition andAntibacterial and Anti-Inflammatory Activities of theEssential Oils from Chrysanthemum morifolium ofDifferent Flowering Stages and Different Parts

The inflorescence of Chrysanthemum morifolium Ramat., a well-known traditional Chinese herb, has been proved to have a certain inhibitory effect on some bacteria; however, its main components and acne bacteria inhibition effect remain to be elucidated. In this study, GC-MS was used to analyze the components of different flowering stages and different parts and to study the inhibitory effects of six essential oils on S. aureus and P. acnes and their alleviating effects on THP-1 cell inflammation. GC-MS combined with relative retention index method analyzed results stated that the 5 samples of C. morifolium to detect the 124 kinds of volatile components, including (E)-tibetin spiroether, are first detected in the volatile oil of the C. morifolium, and the content of (E)-tibetin spiroether is higher in immature inflorescence of C. morifolium and decreases as it extends its flowering period. Furthermore, the research results of inhibiting common acne-causing bacteria showed that the bacteriostatic effect of essential oils from JH at different flowering stages was better than that from JM and TJ, while the bacteriostatic effect of essential oil from stem and leaf of C. morifolium (SLC) at different parts was better than the roots of C. morifolium (RC). Finally, it was proved that the essential oil from SLC and C. morifolium could alleviate the inflammation of THP-1 cells induced by P. acnes. In conclusion, the antibacterial and anti-inflammatory effects of C. morifolium essential oil may be related to heterospiroolefins compounds, and the antibacterial activity decreases with the prolongation of flowering stage. It was suggested that volatile oil from C. morifolium and SLC could be used as effective components of antibacterial and anti-inflammatory cosmetics.

Cinnamtannin B1 attenuates rosacea-like signs via inhibition of pro-inflammatory cytokine production and down-regulation of the MAPK pathway

Background

Rosacea is a common inflammatory disease of facial skin. Dysregulation of innate immunity with enhanced inflammation and increased abundance of LL-37 at the epidermal site is a characteristic feature of rosacea. Cinnamtannin B1 (CB1) is a condensed tannin with anti-inflammatory and anti-microbial activities. The aims of the study were to evaluate the potential of CB1 as a therapy for rosacea and to characterize the potential mechanisms of action.

Methods

We intraperitoneally administered 20 mg/kg CB1 once daily for 2 days into the LL-37-induced mouse model of rosacea. The effects of CB1 in vivo were evaluated by the observations of lesions, histology, immunohistochemistry, and the transcription and translation of pro-inflammatory cytokines and chemokines. Human keratinocyte HaCaT and monocyte THP-1 were used to characterize the effects of CB1 on LL-37-induced inflammation in vitro. The changes in pro-inflammatory chemokine interleukin-8 (IL-8) were quantitated by enzyme-linked immunosorbent assay (ELISA), and the expressions of genes involved were determined by Western blotting.

Results

CB1 attenuated local redness, inflammation, and neutrophil recruitment in the mouse model of rosacea in vivo. CB1 suppressed myeloperoxidase (MPO) and macrophage inflammatory protein 2 (MIP-2) production, a functional homolog of interleukin-8 (IL-8), at the lesions. In vitro experiments confirmed that CB1 reversed the LL-37-induced IL-8 production in human keratinocytes HaCaT and monocyte THP-1 cells. CB1 inhibited IL-8 production through downregulating the phosphorylation of extracellular signal-regulated kinase (ERK) in the mitogen-activated protein kinase (MAPK) pathway.

Conclusion

CB1 attenuated LL-37-induced inflammation, specifically IL-8 production, through inhibiting the phosphorylation of ERK. CB1 has potential as a treatment for rosacea.

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

BACKGROUND

Rosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.

OBJECTIVES

To update our systematic review on interventions for rosacea.

METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk-of-bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence.

RESULTS

We included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light-based treatment. We present the most current evidence for rosacea management based on a phenotype-led approach.

CONCLUSIONS

For reducing temporarily persistent erythema there was high-certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low-to-moderate-certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high-certainty evidence for topical azelaic acid and topical ivermectin; moderate-to-high-certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate-certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low-certainty evidence for tetracycline and low-dose minocycline. For ocular rosacea, there was moderate-certainty evidence that oral omega-3 fatty acids were effective and low-certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.

Erythemato-telangiectatic rosacea: analysis of effectivity of treatment by flavonoid-rich topical agents

Rosacea is a common non-infectious disease with intricate aetiology involving endogenous, systemic or local, and environmental factors. Vascular changes may play a major role in rosacea pathogenesis. Chrysanthellum indicum extract contains a unique combination of component which has a beneficial effect on vascular wall permeability and increases the mechanical resistance of capillaries. The aim of the study is to investigate clinical and epidemiologic features of rosacea as well as to evaluate the efficacy and tolerability of external medication - flavonoid-rich plant extract-based cream Ruboril - in patients with erythemato-telangiectatic subtype of rosacea. Material and methods. We observed 52 patients (16 male and 36 female) aged from 23 to 69 with erythemato-telangiectatic subtype of rosacea. The diagnosis was established on the base of clinical presentation with regard to major and minor diagnostic criteria. In order to evaluate the efficacy of topical therapy with Ruboril cream a scale from 0 to 3 was used assessing the severity grade of erythema and teleangiectasias before treatment and after the 4th, 8th and 12th week of therapy. Results. Women were more often affected than men (69%). Patients of the age group from 40 years prevailed (75%). Fitzpatrick skin phototype II was revealed in 30 (58%) of patients. The most common provoking factors were meteorological (77%), emotional stress (67%), sauna/hot baths or alcohol (66%), hot drinks (48%). The prevailing areas of affection were cheeks (98%), forehead (54%), chin (48%), nose (52%). Moderate erythema was observed in 29 (56%) of patients, severe erythema in 15 (29%). Moderate grade of telangiectasias was registered in 30 (58%) of patients, numerous telangiectasias in 16 (31%). Topical application of cream Ruboril allowed to achieve good immediate results: the severity of erythema was reduced by 63%, the manifestation of telangiectasias decreased by 63%. Conclusion. Clinico-epidemiologic features of patients with erythemato-telangiectatic subtype of rosacea are as follows: erythematous and telangiectatic eruption on the cheeks, nose, and chin, weather and emotional influences, predominance of the female gender, skin phototype II, age > 40 years. The external medication Ruboril showed its high efficacy and safety in the treatment of patients with erythemato-telangiectatic subtype of rosacea which allowed to achieve good immediate results with erythema severity reduction of 63% and the decrease in the manifestation of telangiectasias of 63%.

The Potential of Plant Phenolics in Prevention and Therapy of Skin Disorders

Phenolic compounds constitute a group of secondary metabolites which have important functions in plants. Besides the beneficial effects on the plant host, phenolic metabolites (polyphenols) exhibit a series of biological properties that influence the human in a health-promoting manner. Evidence suggests that people can benefit from plant phenolics obtained either by the diet or through skin application, because they can alleviate symptoms and inhibit the development of various skin disorders. Due to their natural origin and low toxicity, phenolic compounds are a promising tool in eliminating the causes and effects of skin aging, skin diseases, and skin damage, including wounds and burns. Polyphenols also act protectively and help prevent or attenuate the progression of certain skin disorders, both embarrassing minor problems (e.g., wrinkles, acne) or serious, potentially life-threatening diseases such as cancer. This paper reviews the latest reports on the potential therapy of skin disorders through treatment with phenolic compounds, considering mostly a single specific compound or a combination of compounds in a plant extract.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective.

OBJECTIVES

To assess the efficacy and safety of treatments for rosacea.

SEARCH METHODS

We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors.

MAIN RESULTS

We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence).

AUTHORS' CONCLUSIONS

There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.

Effects of a facial cream containing the minor alkaloid anatabine on improving the appearance of the skin in mild to moderate rosacea: an open-label case series study

Background

Current medical and scientific research indicates that rosacea, a chronic and often debilitating skin condition that primarily affects the central face, may be caused by an overactive or excessive inflammatory immune response. Regardless of etiology, the accompanying redness and inflammation is unsightly and difficult for the patient. Anatabine is an alkaloid from the plant family Solanaceae that has been shown in several preclinical studies to modulate proinflammatory signaling pathways.

Objective

A cream containing anatabine was developed and evaluated in an open-label case series study for safety and effects on the appearance of the skin in 10 patients with mild to moderate rosacea.

Methods

Patients applied the cream to the face twice daily for a period of 30 days. Patients and the study physician completed safety and efficacy assessments at study end.

Results

Results showed that 50% of the patients self-reported improvement in the appearance of their skin, and the physician noted improvement in 70% of the patients. Photographs taken before and after 30 days of cream use provide visual evidence of the improvement in several patients. There were no complications or adverse events reported by any of the patients in the study, indicating that the anatabine cream was safe and very well tolerated.

Conclusion

The results of this open-label case series show that a facial cream containing anatabine can improve the appearance of the skin in patients with mild to moderate rosacea and suggest that a double-blind, vehicle-controlled trial in a larger number of subjects is warranted.

Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review

Rosacea is a common chronic skin disease affecting the face. There are numerous treatment options, but it is unclear which are the most effective. The aim of this review was to assess the evidence for the efficacy and safety of treatments for rosacea. Searches included the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers (updated February 2011). Randomized controlled trials in people with moderate to severe rosacea were included. Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. There was some evidence that topical metronidazole and azelaic acid were more effective than placebo. Two trials indicated that doxycycline 40mg was more effective than placebo. There was no statistically significant difference in effectiveness between doxycycline 40mg and 100mg but there were fewer adverse effects. One study reported that ciclosporin ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea. Although the majority of included studies were assessed as being at high or unclear risk of bias, there was some evidence to support the effectiveness of topical metronidazole, azelaic acid and doxycycline (40mg) in the treatment of moderate to severe rosacea, and ciclosporin 0·05% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately powered randomized controlled trials are required.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some patients. A range of treatment options are available but it is unclear which are the most effective.

OBJECTIVES

To assess the evidence for the efficacy and safety of treatments for rosacea.

SEARCH STRATEGY

In February 2011 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors.

MAIN RESULTS

Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. Only two studies assessed our primary outcome 'quality of life'.Pooled data from physician assessments in three trials provided some evidence that metronidazole was more effective compared to placebo (RR 1.95, 95% CI 1.48 to 2.56). Three trials provided data, based on participants' assessments, illustrating azelaic acid was more effective than placebo (RR 1.52, 95% CI 1.32 to 1.76).Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doses of doxycycline, but there was evidence of less adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54).One study reported that cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes).

AUTHORS' CONCLUSIONS

Although the majority of included studies were assessed as being at high or unclear risk of bias there was some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately-powered randomised controlled trials are required.

Alternative therapies for common dermatologic disorders, part 1

The exact pathophysiology and curative treatment of many common dermatologic conditions remain unclear. Often conventional treatments are only partially effective, leading patients to look for alternative treatments. Rosacea may be helped by azelaic acid. Seborrheic dermatitis may be helped by tea tree oil. Chronic urticaria may be helped by a focused dietary history and elimination of food additives and salicylates. Although various alternative treatments have been touted as useful in herpes simplex, few have proved efficacious.

Combined effects of silymarin and methylsulfonylmethane in the management of rosacea: clinical and instrumental evaluation

OBJECTIVE

This study aims to evaluate a topical treatment based on silymarin/methylsulfonilmethane (S-MSM) to improve erythematous-telangiectactic rosacea.

METHODS

Forty-six patients affected by stage I-III rosacea entered this double-blind, placebo-controlled study. Subjects were treated for 1 month. Clinical and instrumental evaluations were done at baseline, after 10 and 20 days, and at the end of the study. Itching, stinging, erythema, and papules were investigated clinically as well as hydration and erythema instrumentally with capacitance and color measurements.

RESULTS

A statistically significant improvement was observed in many clinical and instrumental parameters investigated (P < 0.001). In particular, improvement of skin redness, papules, itching, hydration, and skin color occurred.

CONCLUSIONS

The combination of silymarin and S-MSM can be useful in managing symptoms and condition of rosacea skin, especially in the rosacea subtype 1 erythemato-telangiectatic phase. The action can be considered multicentric and multiphase because of the direct modulating action on cytokines and angiokines normally involved and up-regulated in the case of such skin condition.