Medical treatment of rosacea with emphasis on topical therapies

Rhinophyma Successfully Treated with Ultra Plus CO2 Laser: Report of a Case and Literature Review

Rhinophyma (Greek "nose growth") benign skin deformity characterized by tumorous growth leading to a large, bulbous, and erythematous appearing nose. It is a rare subtype of phymatous rosacea. The exact pathogenesis is still not known. It can lead to considerable cosmetic impairment with psychosocial implications and poses a risk of developing an occult malignancy. Early diagnosis and treatment is imperative to avoid these complications. Herein, we report a case of a 47-year-old man presenting with rhinophyma who was treated with ultra plus CO2 laser.

Recent advances in understanding and managing rosacea

Rosacea is a common chronic inflammatory skin disease of the central facial skin and is of unknown origin. Currently, two classifications of rosacea exist that are based on either "preformed" clinical subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) or patient-tailored analysis of the presented rosacea phenotype. Rosacea etiology and pathophysiology are poorly understood. However, recent findings indicate that genetic and environmental components can trigger rosacea initiation and aggravation by dysregulation of the innate and adaptive immune system. Trigger factors also lead to the release of various mediators such as keratinocytes (for example, cathelicidin, vascular endothelial growth factor, and endothelin-1), endothelial cells (nitric oxide), mast cells (cathelicidin and matrix metalloproteinases), macrophages (interferon-gamma, tumor necrosis factor, matrix metalloproteinases, and interleukin-26), and T helper type 1 (T _H1) and T _H17 cells. Additionally, trigger factors can directly communicate to the cutaneous nervous system and, by neurovascular and neuro-immune active neuropeptides, lead to the manifestation of rosacea lesions. Here, we aim to summarize the recent advances that preceded the new rosacea classification and address a symptom-based approach in the management of patients with rosacea.

Analysis of the effect of temperature on protein abundance in Demodex-associated Bacillus oleronius

A potential role for bacteria in the induction of rosacea has been suggested. The aim of this work was to characterise the effect of temperature on the production of immunostimulatory proteins by Bacillus oleronius-a bacterium to which rosacea patients show sera reactivity and which was originally isolated from a Demodex mite from a rosacea patient. The affected skin of rosacea patients is at a higher temperature than unaffected skin, and it was postulated that this might alter the protein expression pattern of B. oleronius. B. oleronius growth was reduced at 37°C compared to 30°C but resulted in increased expression of the immune-reactive 62kDa protein (1.65 fold [P < 0.05]). Proteomic analysis revealed increased abundance of a wide range of proteins involved in the stress response (e.g. stress proteins [21.7-fold increase], phosphocarrier protein HPr [438.5-fold increase], 60 kDa chaperonin [12.6-fold increase]). Proteins decreased in abundance after growth at 37°C included ferredoxin (325-fold decrease) and peptidase (244-fold decrease). This work indicates that the increased skin temperature of rosacea patients may alter the growth and protein production pattern of B. oleronius and lead to the greater production of immuo-stimulatory proteins.

THE MODERN APPROACH TO THE COMPLEX THERAPY OF DEMODICOSIS

Demodicosis is one of the most common diseases of the skin. Despite the large number of scientific publications on this issue the question of the etiology and pathogenesis of this disease still remains unresolved and the development of more effective methods of treatment and prevention has not only medical but also social significance as patients preserving the working ability have actually long enough to be on outpatient and even inpatient treatment. In addition the long existence of the rash on the face that is the "business card" leads to the secondary sometimes severe neurotic disorders that results in reducing abilities, isolation, unwillingness to be in a team, family, etc. We investigated the effect of complex therapy which had been conducted by means of antiparasitic, immunomodulatory, anti-inflammatory and desensitizing drugs in patients with demodicosis, as well as mandatory adjustment of changes in the hepato- panсreato-duodenal system. We examined 109 patients with demodicosis from 18 to 39 years old and 10 healthy individuals of the corresponding age and sex. It was established that the effectiveness of treatment of demodicosis based on the application of albendazole in the complex treatment along with immune-modulating therapy and hepatoprotection increased significantly. There has been a reliable rapid regression of clinical symptoms in most patients with demodicosis.

Management of facial erythema of rosacea: what is the role of topical α-adrenergic receptor agonist therapy?

Several more recent advances have led to a better understanding of the pathophysiologic mechanisms involved in rosacea and therapeutic modalities used for treatment. Although the clinical features may vary among patients, there are some unifying mechanisms that appear to relate to the more common presentations of rosacea. Both neurovascular dysregulation and augmented immune detection and response appear to play central roles that lead to many of the signs and symptoms of rosacea. Diffuse central facial erythema is a very common finding that intensifies during flares and persists to varying degrees between flares. This background of facial redness occurs secondary to vasodilation and fixed vascular changes that develop over time. Physical modalities are commonly used to treat the erythema that persists as a result of fixed changes in superficial cutaneous vasculature that do not remit after treatment with agents whose mechanisms are active primarily against some of the inflammatory processes operative in rosacea (ie metronidazole, azelaic acid, tetracyclines). As enlarged superficial cutaneous vessels that contribute to the fixed background facial redness of rosacea remain vasoactive to sympathetic nervous system innervation, topical α-adrenergic receptor agonists, namely brimonidine and oxymetazoline, are currently under evaluation for the treatment of facial erythema of rosacea. This article focuses on the clinical differentiation of facial erythema of rosacea and its management.

Clinical efficacy of a serum integrating multiple cosmetic ingredients in the management of erythema of the face in aging skin

BACKGROUND

Skin redness is a common cosmetic concern affecting predominantly fair-skin individuals and often leading to rosacea. On the basis of the current scientific knowledge of the physiological mechanisms underlying the problem, a complex and integral skin care serum (100RXED2025) was developed and tested clinically for efficacy.

METHOD

Forty-five healthy men and women volunteers, age 30-65, were recruited. All subjects had fair skin (phototype I, II, or III) and presented some degree of skin redness with telangiectasia on the cheeks, the nose, or the nose sides, at baseline. In the course of this open label study, subjects applied the test product on their face, twice daily for 56 days. For each subject, skin redness was evaluated through colorimetric and visual analysis of photographs taken under cross-polarized light at T = 28 (week 4) and T = 56 (week 8), then compared to baseline measurements obtained at day 0.

RESULTS

Forty-four volunteers completed the study. On visual evaluation, skin redness had decreased in average by 32.2% at T = 28 (P < 0.001) and by 48.0% at T = 56 (P < 0.001). Importantly, 91% of the subjects showed improvement of skin redness at T = 28, reaching 100% at T = 56. Colorimetric analysis gave an average reduction in redness of 11.6% at T = 28 (P < 0.001) and 13.7% at T = 56 (P < 0.001).

CONCLUSION

The anti-redness efficacy of the test product was demonstrated after 28 days with further increase following 56 days of application.

New antibiotic therapies for acne and rosacea

Acne and rosacea compromise a substantial portion of the dermatology clinical practice. Over the past century, many treatment modalities have been introduced with antibiotics playing a major role. Today, both oral and topical antibiotics are used in the management of acne and rosacea, with several novel formulations and/or combination regimens recently introduced. The latest studies suggest anti-inflammatory actions to be the most likely mechanism of antibiotics in acne and rosacea, shifting the focus to subantimicrobial-dose oral antibiotics and/or topical antibiotic regimens as the preferred first-line agents. Here we will discuss the most recent oral and topical antibiotic therapies available for treatment of acne and rosacea, with special focus on efficacy data, indication, dosing, and mechanism of action.

Rosacea and its ocular manifestations

BACKGROUND

Rosacea is a chronic condition affecting the facial and ocular surface tissues. It is historically underdiagnosed and affects people of all ethnicities. The exact pathophysiology of rosacea is poorly understood. A variety of medical therapies are available to treat the various signs and symptoms of rosacea. Currently, there is no cure for the condition.

METHODS

This report is a literature review.

RESULTS

The clinical manifestations of rosacea are diverse, with periods of exacerbation and remission. Many short- and long-term treatments are available to alleviate the symptoms and effects of rosacea. Variations are common in the medications used, dosages, and durations of treatment. Current topical, oral, and surgical treatment options are presented and reviewed. As a chronic condition, rosacea treatment should be tailored toward individuals and adjusted over time.

CONCLUSIONS

Subtle presentations of rosacea may be overlooked by health care providers. When treating the condition, certain individuals may require both systemic and topical therapy to effectively control rosacea outbreaks. Eye care professionals need to be aware of the presence of rosacea to appropriately treat ocular surface disease that is not responding as expected to standard topical therapy. Severe facial and ocular surface damage caused by rosacea may need surgical intervention. Specific treatment protocols are elusive because of the diversity of the disease. Additional research is needed to find the exact cause of rosacea to more effectively manage the dermatologic and ocular manifestations of the disease and to find a cure.

Current topical and systemic approaches to treatment of rosacea

Rosacea is a common, often overlooked, chronic facial dermatosis characterized by intermittent periods of exacerbation and remission. Clinical subtypes and grading of the disease have been defined in the literature. On the basis of a genetic predisposition, there are several intrinsic and extrinsic factors possibly correlating with the phenotypic expression of the disease. Although rosacea cannot be cured, there are several recommended treatment strategies appropriate to control the corresponding symptoms/signs. In addition to adequate skin care, these include topical and systemic medications particularly suitable for the papulopustular subtype of rosacea with moderate to severe intensity. The most commonly used and most established therapeutic regimens are topical metronidazole and topical azelaic acid as well as oral doxycycline. Conventionally, 100-200 mg per day have been used. Today also a controlled release formulation is available, delivering 40 mg per day using non-antibiotic, anti-inflammatory activities of the drug. Anti-inflammatory dose doxycycline in particular allows for a safe and effective short- and long-term therapy of rosacea. Topical metronidazole and topical azelaic acid also appear to be safe and effective for short-term use. There are indications that a combined therapy of anti-inflammatory dose doxycycline and topical metronidazole could possibly have synergy effects. Further interesting therapy options for the short- and long-term therapy of rosacea could be low-dose minocycline and isotretinoin; however, too little data are available with regard to the effectiveness, safety, optimal dosage and appropriate length of treatment for these medications to draw final conclusions.

Prescription refills and healthcare costs associated with topical metronidazole in Medicaid enrolled patients with rosacea

BACKGROUND

Refill adherence to medications and healthcare costs are important factors to consider while making informed decisions regarding the treatment of rosacea patients.

OBJECTIVE

The objective of this study was to examine predictors of number of refills related to topical metronidazole and total healthcare costs in rosacea patients.

METHODS

This study utilized a longitudinal cohort design and followed rosacea patients enrolled in North Carolina Medicaid and who were prescribed at least one study medication (topical metronidazole, adapalene, azelaic acid, permethrin, and sulfacetamide). Patients' demographic characteristics, number of metronidazole refills, and different components of healthcare costs were examined.

RESULTS

Out of the total 2587 rosacea patients, the majority (approximately 69%, n=1771) had one or more prescriptions for topical metronidazole. Most of the patients in this study were white (73%). After controlling for other variables, increasing age was associated with a higher number of metronidazole refills and healthcare costs (both p<0.001). Compared with white patients, African American patients had a significantly lower number of metronidazole refills (p<0.001). Compared with white patients, African American patients and 'other' races were associated with an 8.6% and 10.3% decrease in total healthcare costs respectively (both p<0.001). An increase in the number of metronidazole refills was not associated with an increase in healthcare costs.

CONCLUSION

Patients' race is significantly associated with the number of topical metronidazole refills. Patients' healthcare costs increased with increasing age and charges paid for prescriptions. Topical metronidazole seems to be an economically feasible treatment option for Medicaid-enrolled patients with rosacea.

Scavenging properties of metronidazole on free oxygen radicals in a skin lipid model system

Reactive oxygen species (ROS) play a vital role in the pathophysiology of the skin disease rosacea, a chronic, genetically-determined and UV-triggered disease, leading to facial redness and blemishes and exhibiting a deep impact on a patient's self-esteem and quality of life. ROS can cause oxidative damage to nucleic acids, sugars, proteins and lipids, thereby contributing to adverse effects on the skin. Metronidazole has been the first-line topical agent therapy for many years; nevertheless the mechanism of action is still not well understood. The therapeutic efficacy of metronidazole has been attributed to its antioxidant effects, which can involve two pathways: decreased generation of ROS within tissues or scavenging and inactivation of existing ROS. Previous investigations have shown that metronidazole reduces ROS by decreasing ROS production in cellular in-vitro systems. The aim of the following study was to demonstrate that metronidazole additionally exhibits antioxidative properties in a cell-free system, by acting as an antioxidant scavenger. A simple skin lipid model (oxidative) system and a complex skin adapted lipid system in conjunction with thiobarbituric acid (TBA) test, a quantitative assay for the detection of malondialdehyde (MDA) and therefore lipid peroxidation, were used to determine the antioxidative properties of metronidazole after UV irradiation. Results clearly show that metronidazole has antioxidative properties in a cell-free environment, acting as a free radical scavenger. Simple skin lipid model: in the presence of 10, 100 and 500 microg mL(-1)metronidazole the MDA concentration was reduced by 25, 36 and 49%, respectively. Complex skin lipid system: in the presence of 100 and 500 microg mL(-1)metronidazole the MDA concentration was reduced by 19 and 34%, respectively. The results obtained in this study and from previous publications strongly suggest that metronidazole exhibits antioxidative effects via two mechanisms: decrease in ROS production through modulation of neutrophil activity and decrease in ROS concentration by exhibiting ROS scavenging properties. The remarkable clinical efficacy of metronidazole in the treatment of rosacea is probably due to its ability to decrease ROS via different mechanisms, thereby protecting skin components from induced damage.

Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea

BACKGROUND

Doxycycline monotherapy at antimicrobial doses has been shown to be effective for the treatment of rosacea.

OBJECTIVE

To evaluate the efficacy and safety of once-daily anti-inflammatory dose doxycycline for the treatment of rosacea.

METHODS

In two phase III, parallel-group, multicenter, randomized, double-blind, placebo-controlled studies (studies 301 and 302), patients received 40-mg of controlled-release doxycycline (n = 269) or placebo (n = 268) for 16 weeks. The primary efficacy end point was the mean change from baseline in facial inflammatory lesion count.

RESULTS

The mean lesion count at baseline was approximately 20 in each study arm. At week 16, the mean change from baseline in lesion count in the active-treatment groups was -11.8 in study 301 and -9.5 in study 302 compared with -5.9 and -4.3, respectively, in the placebo groups (P < .001 for both comparisons). Anti-inflammatory dose doxycycline was well tolerated; the most common adverse events were nasopharyngitis (4.8%), diarrhea (4.4%), and headache (4.4%).

LIMITATIONS

In both studies, the reduction of inflammatory lesion counts did not plateau within the 16-week time frame in either treatment group. Rosacea is often treated for a period of months or years. The duration of the studies did not allow for assessment of safety beyond 16 weeks or whether the progressive improvement seen with active treatment would continue beyond 16 weeks. Neither study assessed the effect of treatment in patients with only erythematotelangiectatic (subtype 1) rosacea.

CONCLUSION

Once-daily anti-inflammatory dose doxycycline appears to be effective and safe for the treatment of rosacea.