Rosacea, an infectious disease: why rosacea with papulopustules should be considered a demodicosis. A narrative review

Identification of the enzyme activity of human Demodex aspartic protease and its function to hydrolyse host macromolecules and skin cell proteins

Aspartic protease (ASP), a common proteolytic enzyme, plays an important role in the pathogenesis of numerous parasites. However, its role in Demodex remains unclear. Herein, we studied the expression, purification, enzymatic activity detection, and hydrolysis function of human Demodex ASP. The findings showed that recombinant ASP (rASP) possessed aspartic protease activity, which reached optimum levels at pH 2.5-3.0 and 35 °C. Furthermore, the activity of Demodex folliculorum rASP (Df.ASP) was considerably higher than that of Demodex brevis rASP (Db.rASP). Df.rASP also exhibited a more potent hydrolytic ability than Db.rASP. Df.rASP hydrolysed IgG, IgM, and fibronectin, whereas Db.rASP only slightly hydrolysed IgG. Mass spectrometry analysis revealed that Df.rASP exerted hydrolytic effects on 38 HaCaT proteins, more than the 23 proteins hydrolysed by Db.rASP. Sequence alignment and structure modelling of the substrate binding cleft identified three distinct amino acids between Df.ASP and Db.ASP, which should be the molecular basis for their difference in enzymatic activity and hydrolytic function. These results imply that Df.rASP may play a more critical role in the pathogenesis of human Demodex, and molecular data will provide a scientific basis for future analyses of their molecular pathogenesis.

Epidemiological survey of two morphotypes of Demodex folliculorum (Prostigmata: Demodicidade) in young people from southern Spain

Different morphotypes of Demodex from humans have been described. Among them, molecular studies have made it possible to discern between the Demodex folliculorum and Demodex brevis. Further studies showed two morphotypes of D. folliculorum harboured two different habits (human skin and human eyelashes), both of them with finger-shaped terminal opisthosoma difficult to differentiate and that can be assigned to D. folliculorum, Thus, a complete morphometric study of the species, which in this study are referred to as Demodex folliculorum species complex, was carried out. From this morphometric and meristic study two distinct morphological forms (short and long) could be identified within the Demodex folliculorum species complex. These forms differ significantly in four out of the six biometric parameters we analysed: gnathosomal length and width, podosomal width, and opisthosomal length. Moreover, a comprehensive survey of the two morphotypes from different habitats (skin and eyelashes), was carried out in young people of Southern Spain. Therefore, an analysis of 104 asymptomatic students, which were contact lens wearers, and the presence of D. folliculorum was carried out. A statistical analysis based on Bayesian zero inflated Poisson GLM has been applied to our sample data. For the age group considered (18-24 years old), the overall D. folliculorum prevalence for skin face or eye infections (at least one of them) was 19.31 % (51 people), with a statistically significant higher prevalence in males men. Furthermore, there is a slight statistical correlation between the presence of Demodex in silicone hydrogel soft contact lens wearers. This study confirms: i) the existence of two morphotypes of D. folliculorum that appear segregated due to the parasitization microhabitats,ii) a higher prevalence of mites in men than in women, iii) the existence of a high number of statistically supported double infections (skin-eyelashes). It also provides epidemiological data on the prevalence of long and short forms of D. folliculorum in a healthy young population.

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

INTRODUCTION

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

METHODS/RESULTS

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

CONCLUSIONS

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

Which factors influence Demodex mite density in standardized superficial skin biopsy in patients with rosacea? A prospective cross-sectional analysis

Rosacea is a chronic cutaneous disease that manifests with facial erythema, telangiectasia, papules and pustules on the central face. Although the pathogenesis is not well established, rosacea appears to have a close relationship with Demodex mites. The aim of the study was to elucidate the factors influencing Demodex mite density by standardized superficial skin biopsy (SSSB) in patients with rosacea. This prospective, cross-sectional study included 200 patients with rosacea. Clinical characteristics of the patients were recorded and SSSB was used to measure Demodex density (Dd). If Dd was < 5 D/cm2 in the first SSSB, SSSB was repeated 4 more times to avoid false negative results. Of 200 patients, 152 (76%) were females and 48 (24%) males with a mean age of 43.47 ± 11.87 years. Ninety-nine patients (49.5%) had erythematotelangiectatic (ETR) and 101 patients (50.5%) had papulopustular (PPR) subtype of rosacea. Among 200 patients, the ratio of cumulative positive results of the consecutive SSSBs were as follows: 1st SSSB = 125 (62.5%), 2nd SSSB = 155 (77.5%), 3rd SSSB = 170 (85%), 4th SSSB = 173 (86.5%) and 5th SSSB = 174 (87%). The ratio of detecting Demodex infestation in the first SSSB was significantly lower in patients with PPR (55/101, 54.5%) than in patients with ETR (70/99, 70.7%). Median total Demodex mite density and D. folliculorum density were significantly higher in the ETR group than in the PPR group. There was a statistically significant relationship between density of Demodex tails in dermoscopy and positive/negative results of Demodex infestation in SSSB. As a conclusion, Demodex mite density by SSSB was influenced by various factors such as subtypes of rosacea, types of Demodex species, and dermoscopic findings.

A Review of Dupilumab-Induced Adverse Events to Dermatologists and the Potential Pathogenesis in the Treatment of Atopic Dermatitis

Dupilumab, a monoclonal antibody targeting interleukin-4 antibody, is approved for use in many type 2 inflammatory diseases, including atopic dermatitis. It is generally well tolerated with no need of routine laboratory monitoring. However, several adverse events have been reported during real-world practice and in pivotal trials. We conducted a systematic literature research of the PubMed, Medline, and Embase databases to identify articles recording the clinical manifestation and potential pathogenesis of these adverse events with interests (AEIs) to dermatologists. In total, 547 cases from 134 studies have developed 39 AEIs 1 day to 2.5 years after dupilumab treatment. The most common AEIs are facial and neck dermatitis (299 cases), psoriasis (70 cases), arthralgia (56 cases), alopecia (21 cases), cutaneous T cell lymphoma (19 cases), severe ocular diseases (19 cases), and drug eruption (6 cases). Most of the AEIs recorded in this review resolved or improved after dupilumab discontinuation or the addition of another treatment, whereas 3 of the cases died of severe AEI. The potential pathogenesis included T help type 1 (Th1)/T help type 2 (Th2) imbalance, Th2/T help type 17 (Th17) imbalance, immune reconstitution, hypersensitivity reaction, transient hypereosinophilia related, and Th1 suppression. Clinicians should be alert of these AEIs for timely diagnosis and appropriate treatment.

Cloning, sequencing, expression, and purification of aspartic proteases isolated from two human Demodex species

Aspartic proteases (ASPs) are important hydrolases for parasitic invasion of host tissues or cells. This was the first study on Demodex ASP. First, the complete coding sequence (CDS) was amplified, cloned and sequenced. Then, the protein physical and chemical properties was analysed. Finally, the recombinant plasmid, expression and purification system was established. Results showed that the lengths of CDS of Demodex folliculorum and D. brevis were 1161 and 1173 bp, respectively. The molecular weight of the protein was approximately 40 KDa. It contained an aspartic acid residue, a substrate-binding site and signal peptide, yet lacked a transmembrane domain and was located in the membrane or extracellular matrix. The phylogenetic and conserved motif analyses showed that D. folliculorum and D. brevis clustered separately and then formed a single branch, which finally clustered with other Acariformes species. The prokaryotic expression systems for recombinant ASP with His-tag (rASP-His) and GST-tag (rASP-GST) were constructed. The inclusion bodies of rASP-His were renaturated by gradient urea and purified using NI beads, while those of rASP-GST were renaturated by sarkosyl and Triton X-100 and purified using GST beads. Conclusively, the prokaryotic expression and purification system of Demodex rASP was successfully established for further pathogenic mechanism research.

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.

A Prospective Randomized Controlled Pilot Study to Assess the Response and Tolerability of Cold Atmospheric Plasma for Rosacea

INTRODUCTION

Rosacea is a common, facial, chronic inflammatory skin disease. Due to its complex pathogenesis, adequate therapy of rosacea can be challenging. An innovative recent therapeutic tool is cold atmospheric plasma (CAP), which is already established in the treatment of chronic wounds and promising in different other skin diseases.

METHODS

In a split-face pilot study we investigated dielectric-barrier-discharged CAP in erythemato-telangiectatic (ETR) and/or papulopustular rosacea (PPR). CAP treatment was applied on lesional skin of a randomized side once daily (90 s/area) for 6 weeks. The other untreated side served as control. Co-primary endpoints were ≥1 improvement of the Investigator Global Assessment (IGA) score on the treated side compared to control and a decline of the Dermatology Life Quality Index (DLQI) after 6 weeks. Secondary endpoints included inflammatory lesion count (papules and pustules), skin redness intensity and erythema size. Adverse events (AEs) were recorded constantly. Additionally, participants were weekly assessed for symptoms, skin condition, trigger factors, skin care, treatment success, and local tolerance parameters. All p values were calculated using the Wilcoxon signed-rank test.

RESULTS

Twelve subjects (ETR, n = 3; ETR and PPR, n = 9) completed the study. DLQI was significantly improved after 6 weeks (p = 0.007). On the CAP-treated side, lesions (p = 0.007) and erythema size (p = 0.041) were significantly reduced compared to the control. IGA (p = 0.2) and skin redness intensity (p = 0.5) did not differ significantly between control and CAP-treated side. No serious AEs occurred and treatment was well tolerated.

CONCLUSION

CAP is a promising new treatment of rosacea, especially for PPR.

Comparison of in vitro Killing Effect of Thai Herbal Essential Oils, Tea Tree Oil, and Metronidazole 0.75% versus Ivermectin 1% on Demodex folliculorum

Background

Abnormal proliferation of Demodex mites causes a skin disorder called demodicosis and has been linked to rosacea. The development of alternative therapy against Demodex mites is currently required. The ability to kill Demodex mites of Thai herbal essential oils has never been explored. This study aimed to study and compare the in vitro killing effect of Thai herbal essential oils, tea tree oil, and metronidazole 0.75% with ivermectin 1% on D. folliculorum.

Materials and Methods

D. folliculorum mites were collected from the wastes of diagnostic standardized skin surface biopsy samples of demodicosis and rosacea patients for the trial. The microscopic evaluation started immediately after the mites were exposed to immersion oil (negative control), Thai herbal essential oils, tea tree oil, metronidazole 0.75%, and ivermectin 1% (positive control). The survival times of ten mites from each test agent were compared.

Results

The efficacy of Thai herbal essential oils and other test agents can be arranged in order as follows: lemongrass oil > sweet basil oil > clove oil > tea tree oil > lesser galangal oil > ginger oil, kaffir lime oil, peppermint oil > citronella oil > galangal oil > cajeput oil > ivermectin 1% > metronidazole 0.75%.

Conclusion

This current study demonstrated the in vitro killing efficacy on D. folliculorum: Thai herbal essential oils, Tea tree oil > ivermectin 1% > metronidazole 0.75%. Thai herbal essential oils have the potential to be an adjuvant or alternative therapy against Demodex mites. Further in vivo studies are necessary to determine the treatment efficacy and side effects.

Identification and genetic characterisatin of cathepsin L in Demodex

Owing to difficulties in obtaining functional gene sequences, molecular pathogenic mechanisms in Demodex have been understudied. In this study, overlap extension PCR was used to obtain the sequences of cathepsin L (CatL), a pathogenicity-related gene, to provide a foundation for subsequent functional research. Demodex folliculorum and Demodex brevis mites were obtained from the face skin of Chinese individuals, and Demodex canis mites were isolated from the skin lesions of a dog. RNA was extracted and used to synthesise double-stranded cDNA. PCR amplification, cloning, sequencing, and bioinformatics analysis of CatL were performed. CatL gene sequences of 1005, 1008, and 1008 bp were successfully amplified for D. brevis, D. folliculorum, and D. canis, respectively. These sequences showed 99.9 or 100% identity with templates previously obtained by RNA-seq. The Maximum Likelihood (ML) phylogenetic tree showed that D. folliculorum clustered with D. canis first, then with D. brevis, and finally with other Acariformes mite species. The three Demodex species had nine similar motifs to those of Sarcoptes scabies, Dermatophagoides pteronyssinus, and Dermatophagoides farinae, and motifs 10-13 were valuable for identification. CatL proteins of Demodex species were predicted to be approximately 38 kDa, be located in lysosomes, have a signal peptide but no transmembrane region, and have two functional domains, I29 and Pept_C1. However, interspecific differences were observed in secondary and tertiary protein structures. In conclusion, we successfully obtained CatL sequences of three Demodex species by overlap extension PCR, which creates conditions for further pathogenic mechanism studies.

Dietary supplementation of n-3 PUFAs ameliorates LL37-induced rosacea-like skin inflammation via inhibition of TLR2/MyD88/NF-κB pathway

Rosacea is a facial chronic inflammatory skin disease with dysfunction of immune and neurovascular system and treatments for rosacea are challenging. N-3 polyunsaturated fatty acids (PUFAs), one of essential fatty acids, are needed for health maintenance and exert anti-inflammation and immunomodulatory effects in a series of cutaneous diseases such as atopic dermatitis and photoaging through dietary supplementation. However, the role of n-3 PUFAs on rosacea remains to be elucidated. In this study, KEGG enrichment analysis and GO analysis indicated that the biological process and signaling pathways, including chemokine signaling pathway, regulated by n-3 PUFAs highly overlapped with those in the pathogenic biological process of rosacea, especially the erythema telangiectasia type. Next, mice were randomized to fed with a customized n-3 PUFAs diet. We showed that n-3 PUFAs ameliorated skin erythema, inhibited dermal inflammatory cell infiltration (mast cells, neutrophils, and CD4 +T cells) and suppressed elevated pro-inflammatory cytokines in LL37-induced rosacea-like mice. Besides, n-3 PUFAs were also verified to repress angiogenesis in LL37-induced mice skin. Further investigation revealed that n-3 PUFAs attenuated LL37-induced inflammation via TLR2/ MyD88/ NF-κB pathway both in mice and in keratinocytes. In conclusion, our findings underscore that dietary supplementation of n-3 PUFAs have the potential to become an efficient and safe clinical therapeutic candidate for rosacea.