Azelaic acid 15% gel: in the treatment of papulopustular rosacea

Rosacea: Practical Guidance and Challenges for Clinical Management

Rosacea is a common chronic dermatosis. Clinically, rosacea can present with flushing, erythema, papules, pustules, telangiectasias, phymatous changes, pruritus, burning, and stinging. In 2017, the National Rosacea Society Expert Committee recommended a phenotype-based classification for therapy. In this review, we identify monotherapies and multimodal treatment approaches for the clinical management of rosacea including topical, systemic, laser and light, alternative, and combination therapies.

Rosacea Management: A Comprehensive Review

Rosacea is a chronic cutaneous disorder affecting primarily the face, characterized by erythema, transient or persistent, telangiectasia, and inflammatory lesions including papulo-pustules and swelling. The essential component of the disease is the persistent erythema of facial skin. Episodes of flushing (acute-subacute intermittent vasodilation) are common. Swelling and erythema of the nose along with dilatation of the pilosebaceous poral orifices, known as rhinophyma, can be noted in chronic cases. Rosacea affects up to 10% of the world population and is especially noted in fair skinned individuals aged 35 to 50. Women are affected more often than men. Several treatment modalities including topical medications, systemic drugs, lasers and light-based therapies have been used for the management of rosacea with variable results. Topical medications such as azelaic acid, metronidazole, and sulfacetamide/sulphur, oral antibiotics such as tetracyclines, and oral retinoids alone or, most commonly, in combination form the mainstay of treatment. Light therapies such as intense pulsed light and pulsed dye laser are best used for the eythemato-telangiectatic type. Topical brimonidine, oxymetazoline, ivermectin, tacrolimus, pimercrolimus, low-dose modified release tetracyclines and botulinum toxin are the new additions to the therapeutic armamentarium. This article provides a comprehensive review of the various therapies used for rosacea.

Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acne

BACKGROUND

Acne is an inflammatory disorder with a high global burden. It is common in adolescents and primarily affects sebaceous gland-rich areas. The clinical benefit of the topical acne treatments azelaic acid, salicylic acid, nicotinamide, sulphur, zinc, and alpha-hydroxy acid is unclear.

OBJECTIVES

To assess the effects of topical treatments (azelaic acid, salicylic acid, nicotinamide, zinc, alpha-hydroxy acid, and sulphur) for acne.

SEARCH METHODS

We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers.

SELECTION CRITERIA

Clinical randomised controlled trials of the six topical treatments compared with other topical treatments, placebo, or no treatment in people with acne.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Key outcomes included participants' global self-assessment of acne improvement (PGA), withdrawal for any reason, minor adverse events (assessed as total number of participants who experienced at least one minor adverse event), and quality of life.

MAIN RESULTS

We included 49 trials (3880 reported participants) set in clinics, hospitals, research centres, and university settings in Europe, Asia, and the USA. The vast majority of participants had mild to moderate acne, were aged between 12 to 30 years (range: 10 to 45 years), and were female. Treatment lasted over eight weeks in 59% of the studies. Study duration ranged from three months to three years. We assessed 26 studies as being at high risk of bias in at least one domain, but most domains were at low or unclear risk of bias. We grouped outcome assessment into short-term (less than or equal to 4 weeks), medium-term (from 5 to 8 weeks), and long-term treatment (more than 8 weeks). The following results were measured at the end of treatment, which was mainly long-term for the PGA outcome and mixed length (medium-term mainly) for minor adverse events. Azelaic acid In terms of treatment response (PGA), azelaic acid is probably less effective than benzoyl peroxide (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.72 to 0.95; 1 study, 351 participants), but there is probably little or no difference when comparing azelaic acid to tretinoin (RR 0.94, 95% CI 0.78 to 1.14; 1 study, 289 participants) (both moderate-quality evidence). There may be little or no difference in PGA when comparing azelaic acid to clindamycin (RR 1.13, 95% CI 0.92 to 1.38; 1 study, 229 participants; low-quality evidence), but we are uncertain whether there is a difference between azelaic acid and adapalene (1 study, 55 participants; very low-quality evidence). Low-quality evidence indicates there may be no differences in rates of withdrawal for any reason when comparing azelaic acid with benzoyl peroxide (RR 0.88, 95% CI 0.60 to 1.29; 1 study, 351 participants), clindamycin (RR 1.30, 95% CI 0.48 to 3.56; 2 studies, 329 participants), or tretinoin (RR 0.66, 95% CI 0.29 to 1.47; 2 studies, 309 participants), but we are uncertain whether there is a difference between azelaic acid and adapalene (1 study, 55 participants; very low-quality evidence). In terms of total minor adverse events, we are uncertain if there is a difference between azelaic acid compared to adapalene (1 study; 55 participants) or benzoyl peroxide (1 study, 30 participants) (both very low-quality evidence). There may be no difference when comparing azelaic acid to clindamycin (RR 1.50, 95% CI 0.67 to 3.35; 1 study, 100 participants; low-quality evidence). Total minor adverse events were not reported in the comparison of azelaic acid versus tretinoin, but individual application site reactions were reported, such as scaling. Salicylic acid For PGA, there may be little or no difference between salicylic acid and tretinoin (RR 1.00, 95% CI 0.92 to 1.09; 1 study, 46 participants; low-quality evidence); we are not certain whether there is a difference between salicylic acid and pyruvic acid (1 study, 86 participants; very low-quality evidence); and PGA was not measured in the comparison of salicylic acid versus benzoyl peroxide. There may be no difference between groups in withdrawals when comparing salicylic acid and pyruvic acid (RR 0.89, 95% CI 0.53 to 1.50; 1 study, 86 participants); when salicylic acid was compared to tretinoin, neither group had withdrawals (both based on low-quality evidence (2 studies, 74 participants)). We are uncertain whether there is a difference in withdrawals between salicylic acid and benzoyl peroxide (1 study, 41 participants; very low-quality evidence). For total minor adverse events, we are uncertain if there is any difference between salicylic acid and benzoyl peroxide (1 study, 41 participants) or tretinoin (2 studies, 74 participants) (both very low-quality evidence). This outcome was not reported for salicylic acid versus pyruvic acid, but individual application site reactions were reported, such as scaling and redness. Nicotinamide Four studies evaluated nicotinamide against clindamycin or erythromycin, but none measured PGA. Low-quality evidence showed there may be no difference in withdrawals between nicotinamide and clindamycin (RR 1.12, 95% CI 0.49 to 2.60; 3 studies, 216 participants) or erythromycin (RR 1.40, 95% CI 0.46 to 4.22; 1 study, 158 participants), or in total minor adverse events between nicotinamide and clindamycin (RR 1.20, 95% CI 0.73 to 1.99; 3 studies, 216 participants; low-quality evidence). Total minor adverse events were not reported in the nicotinamide versus erythromycin comparison. Alpha-hydroxy (fruit) acid There may be no difference in PGA when comparing glycolic acid peel to salicylic-mandelic acid peel (RR 1.06, 95% CI 0.88 to 1.26; 1 study, 40 participants; low-quality evidence), and we are uncertain if there is a difference in total minor adverse events due to very low-quality evidence (1 study, 44 participants). Neither group had withdrawals (2 studies, 84 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

Compared to benzoyl peroxide, azelaic acid probably leads to a worse treatment response, measured using PGA. When compared to tretinoin, azelaic acid probably makes little or no difference to treatment response. For other comparisons and outcomes the quality of evidence was low or very low. Risk of bias and imprecision limit our confidence in the evidence. We encourage the comparison of more methodologically robust head-to-head trials against commonly used active drugs.

A review of diagnosis and treatment of acne in adult female patients

This review focuses on the treatment options for adult female patients with acne. Acne in adult female patients may start during adolescence and persist or have an onset in adulthood. Acne has various psychosocial effects that impact patients’ quality of life. Treatment of acne in adult women specifically has its challenges due to the considerations of patient preferences, pregnancy, and lactation. Treatments vary widely and treatment should be tailored specifically for each individual woman. We review conventional therapies with high levels of evidence, additional treatments with support from cohort studies and case reports, complementary and/or alternative therapies, and new agents under development for the treatment of patients with acne.

Oral Administration of the Japanese Traditional Medicine Keishibukuryogan-ka-yokuinin Decreases Reactive Oxygen Metabolites in Rat Plasma: Identification of Chemical Constituents Contributing to Antioxidant Activity

Insufficient detoxification and/or overproduction of reactive oxygen species (ROS) induce cellular and tissue damage, and generated reactive oxygen metabolites become exacerbating factors of dermatitis. Keishibukuryogan-ka-yokuinin (KBGY) is a traditional Japanese medicine prescribed to treat dermatitis such as acne vulgaris. Our aim was to verify the antioxidant properties of KBGY, and identify its active constituents by blood pharmacokinetic techniques. Chemical constituents were quantified in extracts of KBGY, crude components, and the plasma of rats treated with a single oral administration of KBGY. Twenty-three KBGY compounds were detected in plasma, including gallic acid, prunasin, paeoniflorin, and azelaic acid, which have been reported to be effective for inflammation. KBGY decreased level of the diacron-reactive oxygen metabolites (d-ROMs) in plasma. ROS-scavenging and lipid hydroperoxide (LPO) generation assays revealed that gallic acid, 3-O-methylgallic acid, (+)-catechin, and lariciresinol possess strong antioxidant activities. Gallic acid was active at a similar concentration to the maximum plasma concentration, therefore, our findings indicate that gallic acid is an important active constituent contributing to the antioxidant effects of KBGY. KBGY and its active constituents may improve redox imbalances induced by oxidative stress as an optional treatment for skin diseases.

A prodrug approach to enhance azelaic acid percutaneous availability

Azelaic acid is a dicarboxylic acid compound used in treatment of acne vulgaris. However, high concentration (ca 20%) is needed to guarantee the drug availability in the skin. The latter increases the incidence of side effects such as local irritation. The prodrug strategy to enhance azelaic acid diffusion through skin was not reported before. Thus, a lipophilic prodrug of azelaic acid (diethyl azelate [DEA]) was synthesized and investigated to improve percutaneous availability of azelaic acid, with a subsequent full physical, chemical, and biological characterization. Expectedly, DEA exhibited a significant increase in diffusion compared to azelaic acid through silicone membrane. In contrast, the diffusion results through human stratum corneum (SC) displayed weaker permeation for DEA with expected retention in the SC. Therefore, a desorption study of DEA from SC was conducted to examine the reservoir behavior in SC. Results showed an evidence of sustained release behavior of DEA from SC. Consequently, enhancement of keratolytic effect is expected due to azelaic acid produced from enzymatic conversion of DEA released from SC.

The management of acne vulgaris in pregnancy

Acne vulgaris is a common condition in adolescence and also for many women of childbearing age. The management of acne in pregnancy is complicated by the lack of clinical studies and pharmacokinetic data in this patient population and safety concerns regarding retinoid use in pregnancy. Of primary concern to both patients and clinicians is the safety profile of medications used during pregnancy. This review seeks to clarify what management options are available to treat acne during pregnancy and what data are available to guide decision making. Topical treatments are considered the safest option during pregnancy. They have the best safety profile and minimize the levels of systemic absorption, and therefore the least risk of fetal exposure. If these are applied properly with a strong emphasis on adherence, excellent results can be achieved.

Overview of the Pharmacologic Options for Rosacea

Objective:

To review available therapies for rosacea.

Data Sources:

A PubMed literature search (1985-July 2009) was conducted. Search terms included rosacea, antibiotics, and treatment.

Study Selection and Data Extraction:

English-language reviews, comparative clinical trials, and guidelines for treatment of rosacea were reviewed. Seven comparative trials were identified.

Data Synthesis:

Rosacea is a common dermatologic disease that affects about 10% of the adult population, usually before age 50. The etiology of the disease is unknown. There are 4 subtypes of rosacea: erythematotel-angiectatic (frequent flushing and redness), papulopustular (early telangiectasias, classic rosacea), phymatous (thickened skin with prominent pores), and ocular. Severity of each subtype is classified as mild, moderate, or severe. The goal of therapy is symptomatic control versus cure. For papulopustular rosacea, topical metronidazole is the first line of therapy. Azelaic acid is a newer preparation that patients have preferred over topical metronidazole in head-to-head trials. Topical sodium sulfacetamide/sulfur is another alternative. Systemic agents may be needed for nonresponders or patients with severe disease. Oral alternatives include a 40–mg dose of doxycycline, which costs significantly more than generic doxycycline 100 mg. The lowest effective oral dose should be used to reduce the possibility of bacterial resistance. Telangiectasias may require laser surgery.

Conclusions:

Several alternatives are available for the treatment of rosacea, depending on the subtype, severity of disease, and patient response. In addition to pharmacologic therapy, patients with rosacea need to be counseled about identification and avoidance of triggers that can exacerbate their symptoms, the use of broad-spectrum sunscreens, and the use of mild cleansers.

Skin tolerance, efficacy, and quality of life of patients with red facial skin using a skin care regimen containing Licochalcone A

BACKGROUND

Patients with rosacea and red facial skin often show sensitivity to skin care products which can exacerbate inflammation and subjective irritation. Besides pharmacologic management, special skin care is prudent to avoid cosmetically induced irritation and address cosmetic concerns. Appropriate skin care should provide gentle cleansing, UVA/UVB protection, effective moisturization, and concealing pigments to neutralize the appearance of redness.

AIMS

To evaluate skin compatibility and efficacy of a skin care regimen containing licochalcone A (Lic A), an anti-irritant from the licorice plant Glycyrrhiza inflata, for subjects with mild to moderate facial redness.

PATIENTS/METHODS

Sixty-two patients with mild to moderate red facial skin used a four-product skin care regimen for 8 weeks. Clinical assessments of erythema and subjective irritation, cross-polarized photography, and self-assessment questionnaires were completed at baseline, and after 4 and 8 weeks of use. A quality of life questionnaire was given at baseline and week 8.

RESULTS

Clinical evaluations, subject response, and photography confirmed very good tolerability of the regimen and effective neutralization of redness by the pigmented products. Significant improvements in average erythema scores were observed at 4 and 8 weeks (P < 0.05), and an improvement in quality of life was confirmed by the patient questionnaires.

DISCUSSION

The skin care regimen containing Lic A was found to be compatible with the sensitive facial skin of patients with rosacea and improved the appearance of persistent facial redness. The products were also observed to be compatible with daily metronidazole treatment.

Rosacea: the battle goes on

Rosacea presents an enigma to patients and physicians alike. Although new insights and a plethora of therapies provide hope, the underlying etiology remains unknown. This assures a certain amount of frustration as available treatments temporize rather than cure the disease. This article examines the current state of knowledge regarding this fascinating entity.

Photodynamic Therapy in the Treatment of Rosacea

BACKGROUND

Rosacea is a common disease, with an estimated prevalence of 5-10%. Established systemic and topical treatment is often effective but requires continuous medication.

AIM

We report the outcome of photodynamic therapy (PDT) in 4 patients with rosacea.

METHODS

Prior treatment consisted of standard treatment with tetracycline and metronidazole. The treatment was however either ineffective or the patients were dissatisfied with the need for continuous treatment. The patients all received standard treatment with PDT.

RESULTS

The treated skin cleared in 3 of the 4 patients. Treatment with light alone did not appear to have any effect. In one of the patients there has been no relapse during a 9-month follow-up. In 2 patients, remissions lasted 3 months, during which time no additional or supplementary treatment was used.

CONCLUSION

Our observation suggests that PDT may play a role in the future treatment of selected cases of rosacea.

Rosacea: An Update

Rosacea is a common chronic cutaneous disorder of unknown etiology which occurs most commonly in middle-aged individuals. Cutaneous manifestations include transient or persistent facial erythema, telangiectasia, edema, papules and pustules that are usually confined to the central portion of the face. The National Rosacea Society's Expert Committee on the Classification and Staging of Rosacea identified four subtypes of rosacea: erythematotelangiectatic, papulopustular, phymatous and ocular. Recently, a standard grading system for assessing gradations of the severity of rosacea has been reported. Little is known about the cause of rosacea. Genetic, environmental, vascular, inflammatory factors and microorganisms such as Demodex folliculorum and Helicobacter pylori have been considered. Topical metronidazole and azelaic acid have been demonstrated to be effective treatments for rosacea. Severer or persistent cases may be treated with oral metronidazole, tetracyclines or isotretinoin.

Comparison of azelaic acid and anthralin for the therapy of patchy alopecia areata: a pilot study

BACKGROUND

Although topical azelaic acid has been previously used for the treatment of alopecia, no controlled trials of azelaic acid for this condition have been conducted to date.

OBJECTIVE

The goal of this study was to determine the efficacy, tolerability, and safety of azelaic acid treatment in patients with patchy alopecia areata (AA) in comparison with anthralin (dithranol) treatment.

SUBJECTS AND METHODS

This study included 31 subjects with patchy AA who did not receive any treatment for at least 1 month prior to the study. Demographic and clinical characteristics of these subjects were recorded at baseline. Subjects were randomized to apply either 20% azelaic acid (15 subjects) or 0.5% anthralin (16 subjects) for 12 consecutive weeks. In a subsequent 8-week follow-up period no cream was applied. Two independent investigators performed an efficacy evaluation with clinical examination using a terminal hair regrowth score (RGS) with a scale ranging from 0 (inadequate response) to 2 (complete response) at week 20. Partial response was accepted as score 1.

RESULTS

Both groups were well matched for the relevant demographic and clinical indicators affecting treatment response at baseline. All subjects completed the trial. At week 20 the RGS was 1.27 +/- 0.9 in the azelaic acid group versus 1.37 +/- 0.8 in the anthralin group (p > 0.05). A complete response was observed in 53.3% of cases in the azelaic acid group (8 of 15) compared with 56.2% (9 of 16) in the anthralin group (p > 0.05). No serious adverse events were observed in either group during the study.

CONCLUSION

The present pilot study showed that the use of azelaic acid gave similar results to anthralin with regard to hair regrowth, and that it can be an effective topical therapy for patchy AA. More extensive trials are necessary, however, to reach a definitive conclusion.