Oxymetazoline Inhibits Proinflammatory Reactions: Effect on Arachidonic Acid-Derived Metabolites

Emerging Medical Therapies in Rosacea: A Narrative Review

Rosacea is a chronic inflammatory disease with a multifactorial pathogenesis. The wide spectrum of clinical phenotypes, including erythema, telangiectasia, inflammatory papules and pustules, and phyma, demand an individualized approach to treatment. This narrative review offers an updated reference for rosacea management by covering the latest developments in both topical and systemic treatments, including data from newly approved therapies, updates to current treatment modalities and ongoing clinical trials. Although use of benzoyl peroxide as a treatment for rosacea has typically been limited due to irritation, the improved tolerability due to microencapsulation of benzoyl peroxide 5% cream provides a new therapeutic option for patients with rosacea. Minocycline foam and topical ivermectin cream add to our armamentarium of treatment options, particularly for inflammatory papules and pustules. Sarecycline has a narrower spectrum of antibacterial activity, which might reduce the development of antibiotic resistance and disruption of the microbiome compared to other oral antibiotics. Brimonidine gel and oxymetazoline cream provide topical options for redness and flushing. There is emerging evidence about the role of hydroxychloroquine and intradermal botulinum toxin A, which may improve rosacea through their effects on mast cells. The clinical trials pipeline includes agents with a variety of mechanisms, including mast cell stabilization, antimicrobial, anti-inflammatory, and vasoconstrictive effects. However, the clinical pipeline for rosacea appears limited, and there remain important unmet needs for patients with more recalcitrant rosacea or phymatous disease. In addition, there is a need for comparative effectiveness studies to identify the highest value treatment approaches for patients with rosacea.

Efficacy and safety of oxymetazoline for the treatment of rosacea: A meta-analysis

BACKGROUND

Since there is currently no conclusion on the efficacy and adverse effects of oxymetazoline, this meta-analysis attempts to explore its efficacy and adverse events, so as to provide guidance for clinical medication.

METHODS

We searched PubMed, Embase, and Cochrane Library from the establishment of the database to May 2021. We included studies that patients were randomly assigned to receive oxymetazoline or vehicle, and we excluded duplicate publications, research without full text, incomplete information or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. STATA 15.1 was used to analyze the data.

RESULTS

The pooled results show that the 3 (RR = 1.76, 95% CI: 1.53-2.03), 6 (RR = 1.71, 95% CI: 1.47-2.00), 9 (RR = 1.63, 95% CI: 1.40-1.90), 12 (RR = 1.41, 95% CI: 1.18-1.67) -hours CEA success rate and the 3 (RR = 1.65, 95% CI: 1.34-2.03), 6 (RR = 1.75, 95% CI: 1.43-2.14), 9 (RR = 1.63, 95% CI: 1.33-2.00), 12 (RR = 1.78, 95% CI: 1.45-2.18) -hours SSA success rate after oxymetazoline treatment for rosacea is significantly higher than that of vehicle. Additionally, the pooled results show that the incidence of TEAEs after treatment with oxymetazoline is significantly higher than that of vehicle (RR = 1.34, 95% CI: 1.10-1.2). However, our analysis of specific adverse events found that the oxymetazoline group was only significantly higher than the vehicle group in the incidence of application-site dermatitis (RR = 8.91, 95% CI: 1.76-45.23), and there was no statistical significance in the difference in the incidence of other adverse events.

CONCLUSION

Oxymetazoline is effective and can be selected for the treatment of persistent facial erythema of rosacea. Additionally, application-site dermatitis was the most important one.

The role of the topical nasal decongestant oxymetazoline as a novel therapeutic option for post-acne erythema: A split-face, double-blind, randomized, placebo-controlled trial

Post-acne erythema (PAE) is one of the most common sequelae of acne inflammation. Unfortunately, the treatment of PAE remains challenging due to limited effective topical treatments. The objectives of this study were to evaluate the efficacy and safety of topical oxymetazoline hydrochloride (OxH) 0.05% solution for PAE. This study was a split-face, participants-and investigators-blinded, randomized, placebo-controlled trial conducted between December 2021 and March 2022 in Bangkok, Thailand. Healthy adults aged from 18 to 45 years with mild to severe PAE, according to the Clinician's Erythema Assessment (CEA), on both sides of the face were eligible. After randomization, each participant applied the OxH to one side of their face and a placebo to the contralateral face twice daily for 12 weeks. The primary outcome was PAE lesion counts. The secondary outcomes were erythema index, clinical response rate at week 12 ("clear," "almost clear," or "at least two-grade improvement" by CEA), and patient satisfaction scores. A total of 30 participants were enrolled. The OxH-treated skin showed a significantly greater mean difference (MD) reduction in PAE lesion counts than the placebo after 8 weeks of treatment (4.30, 95% confidence interval [CI] 1.42-7.18). Similarly, the MD reduction of the erythema index was higher in the OxH-treated skin from the second week (11.82, 95% CI 8.48-15.15). Additionally, the OxH-treated side also achieved a higher clinical response rate after 8 weeks of treatment (40.00% vs. 6.67%; p = 0.002) and rated higher satisfaction than those using the placebo at the end of the study (mean [standard deviation] satisfaction score 8.30 [0.18] vs 7.40 [0.18], P < 0.001). There were no serious adverse events or flares of erythema during the study. In conclusion, our study demonstrated that the topical OxH 0.05% solution was effective, well-tolerated, and safe for reducing PAE without a rebound effect. It could be a choice of PAE management. Trial Registration: Thai Clinical Trials Registry No. TCTR20211207004.

Adverse Events Associated with Intranasal Sprays: An Analysis of the Food and Drug Administration Database and Literature Review

BACKGROUND

Intranasal sprays (INSs) are commonly used medications for the treatment of many rhinologic conditions. Despite their popularity, an analysis of a nationwide reporting database and comparison to the available literature has never been performed.

METHODS

The Food and Drug Administration Adverse Event Reporting System (FAERS) database was accessed to obtain adverse event (AE) records from 2014 to 2019 for varying INSs, including: 10 corticosteroids, 1 alpha adrenergic, and 3 antihistamines. The Proportional Reporting Ratios (PRR) and Reporting Odds Ratios (ROR) were calculated for dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache. A PRR ≥ 2 or ROR ≥ 1 was considered significant.

RESULTS

Corticosteroids had 98 864 total reported AEs to the database, followed by antihistamines (7011) and alpha adrenergics (2071). In total, dyspnea was reported 5843 times, followed by headache (4230), epistaxis (1205), ageusia/dysgeusia (920), and anosmia (312). Overall, PRR and ROR values for dyspnea ranged from 0.51 to 4.25 and 0.51 to 4.49; for dysgeusia/ageusia from 0.56 to 6.09 and 0.56 to 6.12; and for epistaxis from 1.03 to 27.24 and 1.03 to 30.76, respectively. All medications which listed anosmia within the top AEs had PRR and ROR values exceeding 2 and 1, respectively. The PRR for headache exceeded 2 for 1 medication and the ROR exceeded 1 in 7 medications.

CONCLUSION

The AEs of dyspnea, anosmia, ageusia/dysgeusia, epistaxis, and headache are reported within the FAERS database for commonly prescribed INSs. When compared against the existing scientific literature, the clinical significance of this reporting tool from the FDA for these classes of medications remains unvalidated.

Acute allergic rhinitis

Allergic rhinitis is a common and troubling condition. Basic management of this condition has been well described. However, acute exacerbations of the chronic condition allergic rhinitis are a seldom discussed or described problem despite the fact that even well-controlled patients frequently have exacerbations. This consideration means that a new approach is necessary to define the management of these patients. There are three important events that illustrate the need for a new therapeutic approach:

A person who gets a new diagnosis of allergic rhinitis, but has symptoms for many months or years

A sufferer of allergic rhinitis who is exposed to an environment that triggers an exacerbation

A person who has an exacerbation related to another trigger.

Recognition of triggers and management strategies to correctly use ‘relief’ therapies such as topical nasal decongestants is the key to successful management. In addition, the use of an ‘action plan’, as for asthma, is useful.

Successful treatment of the face post acne erythema using a topically applied selective alpha 1-Adrenergic receptor agonist, oxymetazoline 1.5%, a controlled left to right face comparative trial

BACKGROUND

Post-inflammatory erythema (PIE) is a common sequalae of acne inflammation, persistent post acne erythema (PAE) is cosmetically unacceptable and sometimes its complete clearance could not be achieved. Oxymetazoline (OXZ) is a synthetic, direct-acting, sympathomimetic agonist that is highly selective for the 1α-adrenoceptor. It is a potent vasoconstrictor and well known for its ability to clinically 'get the red out'.

AIM

The aim of this study was to evaluate the efficacy and safety of topical oxymetazoline (OXZ) 1.5% in treatment of post acne erythema (PAE) in a left to right face comparative study.

METHODS

This study was conducted on 40 patients diagnosed with post acne erythema for at least 3 months, the left side of the face was treated with topical OXZ 1.5% in liposomal base and was compared to the right side to which topical lipogel was applied as a control.

RESULTS

According to the investigator's global assessment of photographs and the analysis of erythema with image analysis software, topical OXZ was significantly effective in diminishing PAE when compared to topical placebo lipogel.

CONCLUSION

Topical OXZ is a safe and effective treatment for post-acne erythema.

Does oxymetazoline increase the efficacy of nasal steroids in treating nasal polyposis?

BACKGROUND

Although nasal steroids are the mainstay treatments in nasal polyposis, up to one-half of patients do not respond and need surgical treatment. This study aimed to evaluate whether oxymetazoline administration produces any additive effect on nasal steroid therapy and whether rebound congestion develops after oxymetazoline treatment.

METHODS

Sixty-eight patients with nasal polyposis were randomly assigned in a 1:1 ratio to receive either oxymetazoline plus mometasone furoate nasal spray (MFNS) or placebo plus MFNS, 2 sprays per nostril twice daily, with an interval of 5 minutes between each medication for 4 weeks. All the patients were then treated with MFNS, 2 sprays per nostril twice daily for 2 weeks. The nasal symptoms score, peak inspiratory flow index, nasal mucociliary clearance time (NMCCT), and total nasal polyps score were used to evaluate treatment outcomes. An intention-to-treat analysis was performed, and a worst case sensitivity analysis was applied to missing cases.

RESULTS

Thirty-four patients were allocated to the oxymetazoline-MFNS group, and 34 to the placebo-MFNS group. One patient in each group was lost to last-visit follow-up. At 4 weeks after beginning treatment, the oxymetazoline-MFNS group showed significantly greater improvement in blocked nose, hyposmia, peak flow, NMCCT, and total nasal polyps score than the placebo-MFNS group. During the nasal steroid phase, both groups showed continuing improvement in all outcome variables. However, the oxymetazoline-MFNS group still showed significantly greater improvement in blocked nose, hyposmia, NMCCT, and total nasal polyps score, but not peak flow, than the placebo-MFNS group at the end of the study.

CONCLUSION

The use of nasal steroids with oxymetazoline was more effective over 6 weeks than nasal steroids alone in improving blocked nose, hyposmia, nasal mucociliary clearance, and polyp size in treatment of nasal polyposis. There was no evidence of rebound congestion after 4 weeks of oxymetazoline treatment.

Combination of mometasone furoate and oxymetazoline for the treatment of adenoid hypertrophy concomitant with allergic rhinitis: A randomized controlled trial

In the clinic, approximately 30% of children with adenoid hypertrophy (AH) concomitant with allergic rhinitis (AR) report poor responses to intranasal steroids. To determine whether the combination of mometasone furoate (MF) and oxymetazoline (OXY) is more effective than either agent alone, we performed a two-stage, parallel, randomized, double-blind, double-dummy, clinical trial with 240 AH children with concomitant perennial AR. During the first stage, all children were randomly assigned to the MF or control group for six weeks of treatment. During the second stage, the non-responders from stage one were randomly assigned to 4 groups for 8 weeks of treatment that involved receiving the following treatments: MF/OXY, MF/placebo, placebo/OXY, or placebo/placebo. During the first stage of treatment, 39% of the responders treated with MF achieved greater reductions in total and individual symptom scores than did those on placebo. During the second stage of treatment, the nasal congestion scores of the MF/OXY group significantly decreased. The adenoid/choana ratio of the MF/OXY-treated group decreased and the nasal volume increased significantly. Our results suggest that the combination of OXY and MF is effective and safe for the treatment of AH children with concomitant AR and has a rapid onset of action.

Brimonidine tartrate for the treatment of facial flushing and erythema in rosacea

Rosacea is a chronic inflammatory dermatologic condition that can often be disfiguring with significant negative impact on patients' quality of life. Sanrosa (brimonidine tartate) is a novel therapeutic agent targeting the facial flushing and erythema of rosacea through its α₂ adrenergic receptor agonist activity. The goal of this article is to discuss current treatment options for rosacea and the properties of brimonidine tartate as well as the evidence surrounding its efficacy and safety profile.

Ultrafine particles affect the balance of endogenous pro- and anti-inflammatory lipid mediators in the lung: in-vitro and in-vivo studies

Background

Exposure to ultrafine particles exerts diverse harmful effects including aggravation of pulmonary diseases like asthma. Recently we demonstrated in a mouse model for allergic airway inflammation that particle-derived oxidative stress plays a crucial role during augmentation of allergen-induced lung inflammation by ultrafine carbon particle (UfCP) inhalation. The mechanisms how particle inhalation might change the inflammatory balance in the lungs, leading to accelerated inflammatory reactions, remain unclear. Lipid mediators, known to be immediately generated in response to tissue injury, might be strong candidates for priming this particle-triggered change of the inflammatory balance.

Methods

We hypothesize that inhalation of UfCP may disturb the balance of pro- and anti-inflammatory lipid mediators in: i) a model for acute allergic pulmonary inflammation, exposing mice for 24 h before allergen challenge to UfCP inhalation (51.7 nm, 507 μg/m³), and ii) an in-vitro model with primary rat alveolar macrophages (AM) incubated with UfCP (10 μg/1 x 10⁶ cells/ml) for 1 h. Lungs and AM were analysed for pro- and anti-inflammatory lipid mediators, namely leukotriene B₄ (LTB₄), prostaglandin E₂ (PGE₂), 15(S)-hydroxy-eicosatetraenoic acid (15(S)-HETE), lipoxin A₄ (LXA₄) and oxidative stress marker 8-isoprostane by enzyme immunoassays and immunohistochemistry.

Results

In non-sensitized mice UfCP exposure induced a light non-significant increase of all lipid mediators. Similarly but significantly in rat AM all lipid mediators were induced already within 1 h of UfCP stimulation. Also sensitized and challenge mice exposed to filtered air showed a partially significant increase in all lipid mediators. In sensitized and challenged mice UfCP exposure induced highest significant levels of all lipid mediators in the lungs together with the peak of allergic airway inflammation on day 7 after UfCP inhalation. The levels of LTB₄, 8-isoprostane and PGE₂ were significantly increased also one day after UfCP exposure. Immunohistochemistry localized highest concentrations of PGE₂ especially in AM one day after UfCP exposure.

Conclusion

Our results suggest that UfCP exposure affects the balance between pro- and anti-inflammatory lipid mediators. In allergic mice, where the endogenous balance of pro- and anti-inflammatory mediators is already altered, UfCP exposure aggravates the inflammation and the increase in anti-inflammatory, pro-resolving lipid mediators is insufficient to counterbalance the extensive inflammatory response. This may be a contributing mechanism that explains the increased susceptibility of asthmatic patients towards particle exposure.

Neuropeptide levels in nasal secretions from patients with and without chronic cough

BACKGROUND

The pathophysiology of upper airway cough syndrome is not well understood.

OBJECTIVE

To investigate the levels of neuropeptides found in nasal mucus of subjects with and without the complaint of chronic cough.

METHODS

Preformed nasal mucus from 26 subjects complaining of postnasal drip with chronic cough and 17 without self-reported chronic cough was collected at the time of presentation. The nasal secretions were assayed for 3 neuropeptides-substance P (SP), calcitonin gene-related peptide (CGRP), and Neurokinin A (NKA)-that have been previously linked to chronic cough.

RESULTS

Coughing subjects with postnasal drip have significantly higher levels of CGRP and SP than noncoughing subjects with postnasal drip (69.0 ng vs 4.6 ng, P < .001 and 4.5 ng vs 3.4 ng, P = .004). The differences in NKA levels in nasal secretions between coughing and noncoughing subjects did not reach statistical significance (16.3 ng vs 3.4 ng, P = .067).

CONCLUSIONS

Both CGRP and SP levels are elevated in preformed nasal secretions of coughing subjects when compared with noncoughing subjects. Additional studies are needed to clarify whether CGRP and SP levels in preformed nasal secretions may assist in diagnosis or predicting treatment response in patients presenting with chronic cough.

Decreased rhinovirus shedding after intranasal oxymetazoline application in adults with induced colds compared with intranasal saline

BACKGROUND

Intranasal oxymetazoline (OMZ) is used as a decongestant during common colds. Recently, intracellular adhesion molecule (ICAM) 1 receptor expression in vitro has been shown to be diminished by OMZ. ICAM-1 is the major receptor used by rhinovirus to gain entry to human cells. The objective of this study was to assess the effect of OMZ on geometric mean titer of rhinovirus in nasal lavage fluid after rhinovirus inoculation.

METHODS

Volunteers with antibody titers of ≤1:4 to rhinovirus type 39 were enrolled in a randomized, reference-controlled, double-blind study. Beginning 3 hours after intranasal challenge with 100-300 tissue culture infectious dose (TCID)₅₀ of virus, subjects received active 0.05% OMZ (45 μL containing 22.5 μg of OMZ hydrochloride in citrate buffer) or reference control (physiological saline solution [PSS]) three times daily for 5 days. Rhinovirus was detected in fibroblast cultures.

RESULTS

Geometric mean viral titer (log₁₀) in 34 rhinovirus-infected subjects receiving OMZ was 1.49 on day 2 compared with 2.24 in the 38 infected subjects receiving PSS (p = 0.04). On day 3, the mean titers were 1.45 and 2.08, respectively. Median length of viral shedding was 3.3 days (OMZ) and 3.4 (PSS). Duration of clinical illness was 6.1 days in both groups.

CONCLUSION

Topical OMZ decreased viral titer on day 2 during experimental rhinovirus infection in normal volunteers.

Oxymetazoline inhibits and resolves inflammatory reactions in human neutrophils

The nasal decongestant oxymetazoline (OMZ) exhibits anti-oxidative and anti-inflammatory properties (I. Beck-Speier et al., J Pharmacol Exp Ther. 2006;316:842-851). In a follow up study, we hypothesized that OMZ generates pro-resolving lipoxins being paralleled by production of immune-modulating prostaglandin E(2) (PGE(2)) and anti-inflammatory 15(S)-hydroxy-eicosatetraenoic acid [15(S)-HETE] and depletion of pro-inflammatory leukotriene B(4) (LTB(4)). Human neutrophils (PMN) were chosen as the cellular system. The effect of OMZ on these parameters as well as on respiratory burst activity and oxidative stress marker 8-isprostane was analyzed in unstimulated and co-stimulated PMN by ultrafine carbon particles (UCP) or opsonized zymosan (OZ), respectively. In unstimulated cells, OMZ induced formation of PGE(2), 15(S)-HETE, and LXA(4). The levels of LTB(4) and 8-isoprostane were not affected, whereas respiratory burst activity was drastically inhibited. In UCP- and OZ-stimulated control cells, all parameters were elevated. Here, OMZ maintained the increased levels of PGE(2), 15(S)-HETE, and LXA(4), but substantially suppressed levels of LTB(4) and 8-isoprostane and inhibited the respiratory burst activity. These findings suggest a switch from the pro-inflammatory eicosanoid class LTB(4) to the pro-resolving LXA(4). Since LXA(4) is most relevant in returning inflamed tissue to homeostasis, OMZ is postulated to terminate rhinitis-related inflammation, thus contributing to shortening of disease duration.

Oxymetazoline modulates proinflammatory cytokines and the T-cell stimulatory capacity of dendritic cells

Abstract:  The nasal decongestant oxymetazoline (OMZ) is frequently used in the topical treatment of rhinitis/sinusitis. As proinflammatory cytokines play a critical role in the development and maintenance of local inflammation, the aim of this study was to investigate the influence of OMZ on immune cells in order to diminish the mucosal infiltration of the nose. Peripheral blood mononuclear cells (PBMC) from buffy coats of healthy volunteers were isolated and stimulated in the presence or absence of OMZ. In addition, monocyte‐derived dendritic cells (DC) were generated and different concentrations of OMZ were added. DC phenotype and their T‐cell stimulatory properties were analysed. The vasoactive substance OMZ showed a concentration dependent inhibitory effect on T‐cell activation as well as a dominant effect on T‐cell stimulatory properties of DC. Low concentrations of OMZ inhibited the proliferation of polyclonally activated T cells. In addition, secretion of proinflammatory mediators such as the cytokines interleukin‐1β (IL‐1β), tumor necrosis factor‐α (TNF α), IL‐6 and IL‐8 were inhibited in the presence of physiological doses of OMZ. Interestingly, the addition of IL‐6 to DC‐T‐cell co‐culture was able to completely restore T‐cell proliferation. In conclusion, these findings indicate that the anti‐inflammatory properties of OMZ are partially mediated by the inhibition of proinflammatory cytokines as well as reduced T‐cell stimulatory capacity of DC resulting in a repressed stimulation of T cells. Therefore, the therapeutic benefit of OMZ can be explained in part by its immunomodulating effects in the topical treatment of nasal inflammation.