Update on the management of rosacea

Treatment of Metophyma with Isotretinoin

Abstract is missing (Short communication)

Rosacea Topical Treatment and Care: From Traditional to New Drug Delivery Systems

Rosacea is a multifactorial chronic inflammatory dermatosis characterized by flushing, nontransient erythema, papules and pustules, telangiectasia, and phymatous alterations accompanied by itching, burning, or stinging, the pathophysiology of which is not yet fully understood. Conventional topical treatments usually show limited efficacy due to the physical barrier property of the skin that hinders skin penetration of the active ingredients, thereby hampering proper drug skin delivery and the respective therapeutic or cosmetic effects. New advances regarding the physiopathological understanding of the disease and the underlying mechanisms suggest the potential of new active ingredients as promising therapeutic and cosmetic approaches to this dermatosis. Additionally, the development of new drug delivery systems for skin delivery, particularly the potential of nanoparticles for the topical treatment and care of rosacea, has been described. Emphasis has been placed on their reduced nanometric size, which contributes to a significant improvement in the attainment of targeted skin drug delivery. In addition to the exposition of the known pathophysiology, epidemiology, diagnosis, and preventive measures, this Review covers the topical approaches used in the control of rosacea, including skin care, cosmetics, and topical therapies, as well as the future perspectives on these strategies.

Development of a Specific Variant of Patient Benefit Index (PBI) Assessing Patient Needs, Goals and Benefits in Rosacea Treatment

Introduction

Evaluation of patient-reported outcomes including health-related quality of life (HRQoL) and perceived benefits from treatment has become a fundamental component of medical decision-making. Standardized evaluation of treatment benefits in rosacea based on patient preferences is still lacking.

Objective

Development and validation of an instrument for recording patient-defined benefits in rosacea therapy based on the Patient Benefit Index (PBI) methodology.

Patients and Methods

In an open survey of n = 50 patients, potential benefits of therapy from the patient's perspective were examined. The generated item pool was combined with pre-existing PBI items for other skin conditions and reviewed by an expert panel of dermatologists, psychologists and patients. Items were condensed to n = 25 and converted into a Likert-scaled questionnaire. The validity and feasibility of the resulting Patient Benefit Index for rosacea (PBI-RO) were tested on individuals with rosacea recruited from a German rosacea patient organization.

Results

N = 446 patients with rosacea completed the PBI-RO. The internal consistencies measured by Cronbach's alpha were high (Patient Needs Questionnaire [PNQ] 0.94). Mean PBI-RO was 1.9 ± 1.2 (scale from 0 = no benefit to 4 = maximum benefit), 23.5% of the patients experienced a PBI-RO < 1 (no clinically relevant benefit). The PBI-RO correlated with HRQoL, health state, current extent of rosacea lesions and treatment satisfaction. The highest correlation was found between PBI-RO and satisfaction with previous treatment (r = -0.59, p < 0.001); correlation with the extent of rosacea lesions was low (r = 0.16, p < 0.001).

Conclusion

The PBI-RO shows satisfying internal consistency and construct validity. It offers the option of a patient-weighted evaluation of the therapeutic benefit of rosacea therapy and may add to more stringent goal orientation in therapy.

Successful Treatment of Minocycline-Induced Facial Hyperpigmentation with a Combination of Chemical Peels and Intense Pulsed Light

Minocycline is a tetracycline derivative antibiotic commonly used to treat acne, rosacea, and other inflammatory skin conditions. Taking minocycline risks inducing skin pigmentation. If minocycline-induced hyperpigmentation is not treated, it may take months to years for the symptoms to subside after discontinuation of the drug, or the hyperpigmentation may never disappear completely, which can lead to cosmetic anxiety and affect people's quality of life. Previous treatment options for hyperpigmentation were mainly q-switched nd: YAG, ruby, and alexandrite lasers. This article reports a case of facial hyperpigmentation caused by minocycline using a combination of chemical peel and intense pulsed light in a patient with eosinophilic cellulitis (Wells syndrome) who was taking oral minocycline. This case suggests combining chemical peel and intense pulsed light is an effective treatment option for minocycline-induced hyperpigmentation.

Laser and light-based therapies in the management of rosacea: an updated systematic review

Unlike other rosacea therapies which need daily takings or applications over long periods, the edge of lasers and light-based therapies (LLBT) is the limited number of sessions to achieve improvement. The proper selection of the adequate physical device in accordance with the patients' skin features and rosacea-related signs and symptoms should be considered and the management with physical sources should be updated as new data become available. This article reviews and discusses the current use of lasers and light-based therapies in rosacea with reference to all the available literature.This systematic review demonstrates the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence. Treatments options should be tailored for each specific clinical scenario as it is unlike that single modality results in complete resolution. Platforms that include two or more devices and combined therapies with topical agents are suitable and they warrant further investigations.

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.

Management of severe rhinophyma with electrocautery dermabrasion - A case report

INTRODUCTION

Rhinophyma is benign hypertrophic thickening of the skin and edema of the nasal pyramid. The affected tissue enlarges slowly before reaching its permanent size. The lobulated skin surface with hundreds of pores can become cosmetically embarrassing and cause significant psychosocial stress, anxiety, and depression for patients. In addition, extensive alar thickening can obstruct the external nasal valves making treatment necessary to alleviate respiratory issues. No consensus has been reached regarding management of rhinophyma and many surgeons follow the "to each his own technique" mindset. Our objective was to present a case report to support the use of electrocautery and dermabrasion as the mainstay of treatment.

PRESENTATION OF CASE

Here we describe the case of a 62-year-old Caucasian male with a long-standing history of acne rosacea who developed severe rhinophyma overtime which lead to nasal obstruction and major cosmetic deformity. Electrocautery and dermabrasion in the operating room were utilized to obtain an outstanding cosmetic result and respiratory function improvement. Loop and Colorado cautery tips were used with cutting current to remove the hypertrophic skin and create a smooth contour. The patient tolerated the procedure well without any complications. The patient's skin was scab-free with normal pigmentation by four weeks post-op. He was satisfied with the cosmetic outcome and reported substantial improvement in his breathing.

DISCUSSION

There have been several case reports published which describe using different surgical methods to treat rhinophyma including lasers, electrocautery dermabrasion, surgical blade, cryosurgery, and radio excision. The main limitations of laser therapy are imprecise tissue removal, risk of scarring, dyspigmentation, and bleeding. Other therapies such as surgical excision and skin grafts may require multiple procedures before obtaining a satisfactory cosmetic outcome.

CONCLUSION

This case report supports electrocautery dermabrasion as the mainstay of treatment as it is a management technique which allows for smooth contouring, efficient hemostasis, more control in the operating room, and does not require multiple procedures.

Multitarget Approaches against Multiresistant Superbugs

Despite efforts to develop new antibiotics, antibacterial resistance still develops too fast for drug discovery to keep pace. Often, resistance against a new drug develops even before it reaches the market. This continued resistance crisis has demonstrated that resistance to antibiotics with single protein targets develops too rapidly to be sustainable. Most successful long-established antibiotics target more than one molecule or possess targets, which are encoded by multiple genes. This realization has motivated a change in antibiotic development toward drug candidates with multiple targets. Some mechanisms of action presuppose multiple targets or at least multiple effects, such as targeting the cytoplasmic membrane or the carrier molecule bactoprenol phosphate and are therefore particularly promising. Moreover, combination therapy approaches are being developed to break antibiotic resistance or to sensitize bacteria to antibiotic action. In this Review, we provide an overview of antibacterial multitarget approaches and the mechanisms behind them.

Botulin Toxin Use in Rosacea and Facial Flushing Treatment

Botulinum toxin (BTX) is a neurotoxin derived from the Clostridium botulinum bacterium that inhibits the release of acetylcholine at the neuromuscular junction level whose effects has been used for many years to treat a variety of muscular/neuromuscular conditions and more recently also for cosmetic use.

BTX has experimented in some dermatological conditions, which include Rosacea and facial flushing treatment with good results. The complex mechanism underlying those results is not completely understood but was proposed a release inhibition of acetylcholine from peripheral autonomic nerves of the cutaneous vasodilatory system combined with the blockade substance P and calcitonin gene-related peptide (CGRP) thus modulating blood vessel dilatation.

We analysed the published data on BTX off label applications rosacea and flushing retrieved from PubMed.

Effect of recombinant bovine basic fibroblast growth factor gel on repair of rosacea skin lesions: A randomized, single-blind and vehicle-controlled study

The aim of the present study was to assess the effect of topical use of recombinant bovine basic fibroblast growth factor (rbFGF) gel on the repair of facial skin lesions in patients with rosacea. In the present single-blind study, a total of 1,287 patients with Demodex mite-induced rosacea who received treatment with ornidazole tablets were randomized to rbFGF gel treatment group (n=651) or control group (n=636) without revealing the group identity. Patients in the treatment group were treated with topical application of rbFGF gel over the skin lesions (0.2 g/cm²) for up to 8 weeks, whereas patients in the control group received gel vehicle treatment unless ulceration occurred. Skin lesions of all patients were scored prior to and following treatment with rbFGF gel and subjected to histological analysis. All patients were followed up for 6 months. Significant improvement in the total effective rates for erythema, papules, desquamation and dryness were observed in the rbFGF treatment group. At the end of the 2, 4 and 6 months of follow-up, the total effective rates for patients in the treatment group were significantly higher than those in the control group (81.67 vs. 28.84%; 85.11 vs. 40.81%, and 96.56 vs. 55.82%, respectively). Following treatment for 6 months, none of the patients in the rbFGF group exhibited ulceration or scar formation. In the control group, 61% of patients experienced exacerbation of skin lesions, of which, 12% exhibited ulceration and were treated with rbFGF gel to prevent scar formation. Histological analysis revealed gradual reduction in epidermal hyperplasia and resolution of dermal edema in skin lesions treated with rbFGF gel. In conclusion, rbFGF gel may improve the repair of facial rosacea skin lesions in patients treated with anti-Demodex.

New trends in botulinum toxin use in dermatology

Background

Recent studies have highlighted new botulinum neurotoxin (BoNT) applications in the field of dermatology.

Objective

To review current knowledge of BoNT use in dermatology.

Methods

The literature of the last 5 five years has been reviewed.

Results

We describe interesting protocols of BoNT treatment for hyperhidrosis (HH), hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and periorbital syringomas.

Conclusions

Several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT.

Anti-inflammatory and Immunomodulatory Effects of Antibiotics and Their Use in Dermatology

Antibiotics (antibacterial, antiviral, and antiparasitic) are class of drugs which result in either killing or inhibiting growth and multiplication of infectious organisms. Antibiotics are commonly prescribed by all specialties for treatment of infections. However, antibiotics have hitherto immunomodulatory and anti-inflammatory properties and can be exploited for various noninfectious dermatoses. Dermatologists routinely prescribe antibiotics in treatment of various noninfectious disorders. This study will review anti-inflammatory and immunomodulatory effects of antibiotics and their use in dermatology.

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.

Improving Treatment of Erythematotelangiectatic Rosacea with Laser and/or Topical Therapy Through Enhanced Discrimination of its Clinical Features

Rosacea is a chronic inflammatory disease that can present with a variety of cutaneous symptoms. Erythematotelangiectatic rosacea is a subtype characterized by flushing (transient erythema), persistent central facial erythema (background erythema), and telangiectasias. The severity of individual symptoms differs in each patient, which can complicate the selection of an appropriate treatment strategy. Evaluation of these specific symptoms has been greatly improved by the routine use of diagnostic tools such as (video) dermatoscopy. Following a thorough clinical assessment, treatment decisions should be made based on the proportion of these individual symptoms in individual patients. Brimonidine 0.33% gel is recommended in the symptomatic treatment of facial erythema, and there is evidence for the efficacy of laser/light-based therapies in the treatment of erythema and telangiectasias. In patients presenting with both marked background erythema and telangiectasias, initial treatment with brimonidine 0.33% gel to target the erythema followed by laser/light-based therapy for the telangiectasias has been shown to be an effective combination in clinical practice. This article aims to facilitate treatment decision-making in clinical practice through: 1) better differentiation of the main symptoms of erythematotelangiectatic rosacea and 2) practical advice for the selection of appropriate treatments, based on clinical case examples.

Combination of new multifunctional molecules for erythematotelangiectatic rosacea disorder

Background

Rosacea, a common chronic skin disorder, is currently managed by patient education, pharmacological drugs, medical devices (laser and light therapies), and use of proper skin cares. Unfortunately, none of these actual treatments used alone or in combination is curative, and so we proposed a dermocosmetic active ingredient to mitigate some aspects of the rosacea and particularly for erythematotelangiectatic rosacea.

Methods

Dermocosmetic active ingredient is composed of three glucosylated derivatives of natural plants hydroxybenzoic acid and hydroxycinnamic acids (rosmarinic acid, gallic acid, and caffeic acid). Anti-inflammatory, anti-angiogenesis, and anti-degranulation studies were done on cellular models (keratinocytes, mast cells, and endothelial cells). Efficiency of the active ingredient in comparison to placebo was assessed clinically on human volunteers having erythematotelangiectatic rosacea. The active and placebo were applied topically twice a day for 28 days. Biometrical analyses were done using a siascope tool.

Results

We found that the active ingredient decreases inflammation (inhibition of interleukin-8 and tumor necrosis factor release), decreases degranulation of mast cells (inhibition of histamine release), and controls angiogenesis mechanism (inhibition of the production of vascular endothelial growth factor and neovessel formation) on cellular models. Study on human volunteers confirmed macroscopically the efficiency of this active ingredient, as we observed no neovessel formation and less visible vessels.

Conclusion

Although rosacea is a skin condition disorder that is difficult to heal, the studies have shown that this active ingredient could be a dermocosmetic support, especially for erythematotelangiectatic rosacea armamentarium. The active ingredient was topically applied on the face for 28 days and improved erythematotelangiectatic rosacea symptoms either by decreasing them (vessels are less visible) or by limiting their development (any neovessels). The active ingredient decreases inflammation (inhibition of interleukin-8 and tumor necrosis factor release), decreases degranulation of mast cells (inhibition of histamine release), and limits the angiogenesis process (inhibition of vascular endothelial growth factor production and neovessel formation).