Standard management options for rosacea, part 2: options according to subtype

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss the standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) management options according to subtype. The menu of options is considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanisms of action of therapies are more definitively established.

A topical azithromycin preparation for the treatment of acne vulgaris and rosacea

BACKGROUND

Erythromycin is a common therapy for acne and rosacea. A newer macrolide, azithromycin, offers superior tissue distribution and cellular concentration and is an effective oral anti-acne agent. Topical formulations such as erythromycin have been a major clinical therapy for acne. To date, no topical solution of azithromycin is available for the treatment of acne.

OBJECTIVE

To prepare a stable topical 2% azithromycin formulation that could be used in an acne clinical trial to determine the efficacy of topical azithromycin in treating subjects with acne vulgaris and acne rosacea.

METHODS

The study was divided into two phases. In phase I, azithromycin was prepared over a range of ethanol/water concentrations to determine solubility. The stability of a 2% azithromycin in 60% ethanol/water preparation was assessed by high-pressure liquid chromatography. The temperature, light, and pH dependence of the stability was also assessed. In phase II, a single center, randomized, double-blind, treatment-controlled study compared once-nightly application of topical 2% azithromycin versus 2% erythromycin. A total of 20 subjects with moderate inflammatory acne and 20 with rosacea were examined clinically at 0, 2, 4, 8, and 12 weeks for a 12-week period. Efficacy was evaluated with the Physician's Visual Analog Scale evaluation (PVAS), the papulopustule count, and acne severity rating (in subjects with acne).

RESULTS

In phase I, azithromycin was soluble in 60% ethanol/water. A 2% azithromycin in 60% ethanol/water solution maintained stability at room temperature for up to 26 weeks but at 37 degrees C there was some decay (16%) at 26 weeks. The stability was greatest at pH 6.8 and was unaffected by ambient light exposure. In phase II, the number of inflammatory lesions decreased in both acne and rosacea subjects treated with 2% erythromycin (7.56, p=0.03 and 4.4, p=0.01, respectively). Azithromycin was not as effective for the treatment of rosacea. Both azithromycin (p=0.01) and erythromycin (p=0.03) treatment significantly reduced the inflammatory lesion count in acne vulgaris. No significant adverse events were identified in the acne group. In patients with rosacea, transient irritation occurred in five patients.

CONCLUSIONS

A 2% azithromycin in 60% ethanol/water solution can be prepared and is stable for at least 6 months at room temperature. The methodology and power of the study were adequate to identify improvement in acne vulgaris and rosacea. Though it appears the formulation of topical azithromycin was at least comparable with topical erythromycin, larger studies would be needed to determine whether topical azithromycin has any significant advantage over topical erythromycin.

Beneficial use of Cetaphil® Moisturizing Cream as part of a daily skin care regimen for individuals with rosacea

INTRODUCTION

Rosacea is a common and chronic disorder characterized by flushing, erythema, papules, pustules, and telangiectasia on the central part of the face. Because the facial skin of individuals with rosacea is particularly sensitive, irritants can trigger a worsening of the signs and symptoms of the disease. This enhanced sensitivity is thought to be linked to a deficient stratum corneum barrier function.

MATERIALS AND METHODS

In the present study, 20 individuals receiving twice-daily applications of metronidazole 0.75% gel for at least 15 days applied a gentle non-irritating moisturizing cream (Cetaphil Moisturizing Cream) twice daily for 15 days on one half of the face; the other side remained treated with metronidazole only and served as the control.

RESULTS

Clinical assessments, confirmed by biophysical measurements (electrical capacitance, transepidermal water loss (TEWL), and lactic acid stinging test), provided evidence that the moisturizer contributed to the restoration of the skin barrier: skin dryness, roughness and desquamation were much improved and skin sensitivity was significantly reduced. Skin properties and skin discomfort were also greatly enhanced and the patients were very satisfied with the product.

CONCLUSIONS

It can thus be concluded that in the management of rosacea, basic skin care regimens, including daily use of a therapeutic moisturizer, offer optimal benefits.

Treatment of papulopustular rosacea with sodium sulfacetamide 10%/sulfur 5% emollient foam

Acne rosacea is a chronic cutaneous disorder affecting as many as 14 million Americans. Papulopustular rosacea is the classic form of rosacea characterized by papules, pustules, and erythema. The skin barrier deficiency and vascular hyperactivity characteristic of papulopustular rosacea increase skin dryness and irritation, which can be further exacerbated by medications commonly used to treat rosacea. Sodium sulfacetamide 10%/sulfur 5% emollient foam (SSSE foam) is formulated for topical administration and is fragrance free and alcohol free. This nonrandomized, noncontrolled, open-label, prospective case series was designed to evaluate the efficacy and safety of a SSSE foam for the treatment of papulopustular rosacea in 8 patients. Patients experienced clinically significant improvements in the severity of rosacea with a favorable safety profile, and reported of an improved quality of life. The high patient satisfaction ratings for SSSE foam suggest that the product may improve long-term compliance rates, with the potential to yield more favorable clinical outcomes.

Moisturizers for the treatment of inflammatory skin conditions

The maintenance of normal hydration is an important function of the skin. The stratum corneum provides an antimicrobial, antioxidant, and UV barrier and plays an integral role in maintaining skin hydration. Environmental factors and disease states may compromise the barrier function of the stratum corneum, leading to excessively dry skin. Evidence supports the use of moisturizers in the treatment of various skin conditions, and a wide variety of these products are currently available. The presence of moisturizing agents in a compound, however, may not guarantee optimal moisturization effects. Pharmacologic and physiologic (eg, concentration, bioavailability, and proper determination of moisturization effects), as well as patient-based considerations, can potentially influence the effects of moisturizer ingredients. While moisturizers as adjunctive therapy have proven benefits in enhancing the management of certain dermatologic conditions, the incorporation of moisturizing ingredients into topical treatments may not translate into clinical benefit, particularly in the enhancement of skin barrier function.

A study of the pathogenesis of rosacea: how angiogenesis and mast cells may participate in a complex multifactorial process

In the present study we evaluated, in involved and clinically uninvolved skin of Rosacea, microvessels density (MVD) and total vascular area (TVA) in addition to multiple morphologic characteristics of microvessels and also mast cells (MCs) number. We examined also the relationship between angiogenesis, MCs number and disease clinicopathological data. The study included 69 patients with Rosacea. A skin biopsy with a 4-mm punch was performed from clinically involved skin in each case. In nine randomly selected patients, facial biopsy specimens were obtained from both involved and clinically uninvolved skin. Histological sections, immunostained for factor VIII, were evaluated by image analysis for the quantification of MVD, TVA and several morphometric parameters related to the vessel size or shape. MCs detection in the dermis was carried out using the chloracetate esterase method (Fast Blue RR) in parafin sections. Serum antibodies against H.pylori were detected. Statistically important differences concerning the factors of angiogenesis between lesional and clinically non-lesional skin were demonstrated. A statistical important correlation was found also between high vascular density, PPR clinical type and the presence of ocular manifestations. MVD or TVA showed no correlation with the degree of solar elastosis or inflammation and with the Demodex density as well. However, high MVD values were found to correlate with granuloma formation in the dermis. MCs number were significantly greater in lesional compared to clinically non-lesional skin. Statistical significance was shown between MCs density and disease duration. However, no correlation between MCs number and blood vessel density was found. Angiogenesis seems to play an important role in the pathogenesis especially of the more severe clinical form of Rosacea. MCs seem to participate in evolution to disease chronicity by contributing to inflammation, angiogenesis and tissue fibrosis.

Topical kinetin 0.1% lotion for improving the signs and symptoms of rosacea

Many patients with rosacea are unable to tolerate extended treatment periods with topical agents because of the unusually high skin sensitivity that often accompanies rosacea. Kinetin (N(6)-furfuryladenine) is a plant cytokinin that reportedly helps restore skin barrier function and may be useful to ameliorate the signs and symptoms of rosacea. The purpose of this open-label study was to determine the tolerance and efficacy of twice-daily application of kinetin 0.1% lotion for improving the signs and symptoms of mild to moderate facial rosacea. Subjects applied kinetin 0.1% lotion twice daily to the face, with daily use of a sunscreen of sun protection factor 30. Subjects were evaluated at baseline and at 4-week intervals for 12 weeks to assess efficacy and tolerance. Results of this study suggest that kinetin 0.1% lotion is a well-tolerated moisturizing lotion option for subjects with mild to moderate inflammatory rosacea.

Lymphangiogenesis and angiogenesis in non-phymatous rosacea

BACKGROUND

Our study evaluated the expression of vascular endothelial growth factor (VEGF), CD31 and D2-40 in involved and uninvolved skin of 18 patients with rosacea.

METHODS

Immunostaining of facial skin specimens with VEGF, CD31 and D2-40 was compared between the lesional and the non-lesional skin of patients with erythemotelangiectatic and papulopustular rosacea.

RESULTS

Significantly increased dermal expression of VEGF in lesional vs. non-lesional skin (88.9% and 55.6%) was observed. Dermal expression of CD31 and D2-40 was also increased in lesional vs. non-lesional skin. There was no statistically significant difference in cutaneous expression of VEGF, CD31 and D2-40 between patients with papulopustular and erythemotelangiectatic rosacea, and no correlation was found between disease duration and immunoreactivity of VEGF, CD31or D2-40.

CONCLUSIONS

Our study showed marked immunostaining of lesional skin with VEGF, CD31 and D2-40 compared with non-lesional skin. Increased immunoreactivity of D2-40 in lesional skin is interesting, given that none of the patients had facial edema. There are no published data regarding the role of lymphangiogenesis in patients with non-phymatous rosacea; thus, our study represents a new understanding of its pathogenesis. Lack of correlation between D2-40 expression and disease duration suggests that lymphatics are involved early in the pathogenesis of rosacea and do not constitute a late event.

Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea

Acne rosacea is an inflammatory skin disease that affects 3% of the US population over 30 years of age and is characterized by erythema, papulopustules and telangiectasia. The etiology of this disorder is unknown, although symptoms are exacerbated by factors that trigger innate immune responses, such as the release of cathelicidin antimicrobial peptides. Here we show that individuals with rosacea express abnormally high levels of cathelicidin in their facial skin and that the proteolytically processed forms of cathelicidin peptides found in rosacea are different from those present in normal individuals. These cathelicidin peptides are a result of a post-translational processing abnormality associated with an increase in stratum corneum tryptic enzyme (SCTE) in the epidermis. In mice, injection of the cathelicidin peptides found in rosacea, addition of SCTE, and increasing protease activity by targeted deletion of the serine protease inhibitor gene Spink5 each increases inflammation in mouse skin. The role of cathelicidin in enabling SCTE-mediated inflammation is verified in mice with a targeted deletion of Camp, the gene encoding cathelicidin. These findings confirm the role of cathelicidin in skin inflammatory responses and suggest an explanation for the pathogenesis of rosacea by demonstrating that an exacerbated innate immune response can reproduce elements of this disease.

Recalcitrant rosacea successfully treated with multiplexed pulsed dye laser

There are few treatments that address both papulopustular and telangiectatic components of rosacea. We present a case of rosacea that was unresponsive to treatment with antibiotics. We report the novel use of a new laser technology, the multiplexed laser, for treatment of both papular and telangiectatic rosacea.

Ocular rosacea and treatment of symptomatic Helicobacter pylori infection: a case series

Rosacea is a chronic inflammatory skin disease characterized by recurrent episodes of facial flushing, erythema, papules, pustules, and telangiectasia. More than half of all rosacea patients may have ocular symptoms. Rosacea is associated with certain digestive diseases, such as gastritis, hypochlorhydria, or a number of jejunal mucosal abnormalities, and many patients have Helicobacter pylori infection. The role of Helicobacter pylori has often been a subject of investigation; these studies show conflicting results. Here we present results of the effects of treatment given for H. pylori eradication in seven patients with ocular rosacea that, at the same time, had clinical and serological evidence of H. pylori infection. Six weeks after completion of the treatment, all patients experienced improvement of their rosacea symptoms. Ocular disease responded better than cutaneous rosacea.

Objective evaluation of the effect of intense pulsed light on rosacea and solar lentigines by spectrophotometric analysis of skin color

BACKGROUND

To date, intense pulsed light (IPL) has been applied to various skin diseases, but there have been few objective evaluations of its efficacy.

OBJECTIVE

The aim of this study was to perform objective evaluations of the effect of the IPL system on rosacea and solar lentigines.

METHODS

Twelve patients with rosacea were treated with IPL at the wavelength of 550 to 670 nm, three times every 4 weeks, and the skin color was determined with L(*)a(*)b(*) color space using a spectrophotometer. In addition, 18 patients with solar lentigines were treated once, and the lightness L(*) was determined. RESULTS In all of 6 erythematotelangiectatic rosacea patients and in 5 of 6 papulopustular rosacea patients, each of the L(*)a(*)b(*) values of the posttreated lesions approached those of normal skin areas (efficacy rate, 91.6%). The mean level of the L(*)a(*)b(*) values improved significantly after treatment and particularly in the erythematotelangiectatic rosacea patients. In 12 of 18 patients with solar lentigines, the lightness L(*) was elevated after treatment (efficacy rate, 66.6%).

CONCLUSION

As demonstrated by spectrophotometric analysis of skin color, IPL at the wavelength of 550 to 670 nm is effective for rosacea and solar lentigines, particularly most useful for erythematotelangiectatic rosacea.

[Bowen's disease and squamous cell carcinoma in Haber's syndrome: two cases]

BACKGROUND

Haber's syndrome is a rare form of autosomal dominant genodermatosis. Clinically, it is associated with rosaceiform dermatosis of the face that begins in childhood, and profuse keratotic lesions resembling seborrheic keratoses, seen predominantly on the trunk, the tops of the limbs and the scalp. We report two cases of Bowen's disease and cutaneous epidermoid carcinoma in Haber's syndrome patients.

OBSERVATIONS

A 67 year-old woman with Haber's syndrome and with a familial history consulted for a budding lesion on the abdomen, histological examination of which confirmed epidermoid carcinoma. A 77 year-old woman presented a clinical picture consistent with Haber's syndrome, with three infiltrated erythematosquamous abdominal lesions. Histological examination of a biopsy sample confirmed the clinical diagnosis of Bowen's disease. The patient was successfully treated with imiquimod.

DISCUSSION

These two cases appear to indicate the existence of an association between Haber's syndrome and the presence of cutaneous carcinomatous lesions. We propose the hypothesis of transformation of the keratoses seen in seborrheic keratosis. These lesions may be considered as pre-cancerous. Association with skin carcinomas requires regular monitoring of these patients. The use of imiquimod to treat lesions in patients with Bowen's disease resulted in complete cure.

Expression of vascular endothelial growth factor and its receptors in rosacea

BACKGROUND

Rosacea is a common chronic disease of unclear pathogenesis, characterised by inflammation and vascular abnormalities of the facial skin and ocular surface. Recognising that vascular endothelial growth factor (VEGF) is vasoactive and has inflammatory activities, the expression of this molecule and its receptors, VEGF-R1 and VEGF-R2, in rosacea was investigated.

METHODS

Formalin-fixed, paraffin wax-embedded sections of skin obtained from 20 patients with rosacea were immunostained to detect expression of VEGF, VEGF-R1 and VEGF-R2, using an indirect methodology incorporating antigen retrieval. Adjacent sections were stained with haematoxylin and eosin.

RESULTS

Biopsy specimens were characterised by perivascular and perifollicular lymphohistiocytic infiltration and dilated vascular channels. In addition to keratinocyte and epithelial staining, which was also noted in normal skin, vascular endothelium frequently stained positive for VEGF-R1 (14/20, 70%) and VEGF-R2 (20/20, 100%), but infrequently for VEGF (2/20, 10%). In most specimens, infiltrating leucocytes, including lymphocytes, macrophages and plasma cells, expressed VEGF (17/20, 85%), VEGF-R1 (20/20, 100%) and VEGF-R2 (20/20, 100%).

CONCLUSION

Expression of VEGF receptors, both by vascular endothelium and infiltrating mononuclear cells, is observed in rosacea. Although not expressed by endothelium, VEGF is present in epidermis and epithelium, and is expressed by infiltrating cells. VEGF receptor-ligand binding may contribute to the vascular changes and cellular infiltration that occurs in rosacea.

Papulopustular drug eruption due to an epidermal growth factor receptor inhibitors, erlotinib and cetuximab

Two patients receiving epidermal growth factor receptor inhibitors for cancer treatment developed papulopustular eruptions a few days after starting treatment. One patient is a 56-year-old man with metastatic lung cancer treated with erlotinib. Bacterial cultures of the nares and a pustule showed no growth. The eruption improved with a lowered dose of erlotinib and the application of topical clindamycin solution and triamcinolone cream. The other patient is a 53-year-old man with metastatic rectal cancer treated with cetuximab. Bacterial culture of a pustule grew Staphylococcus aureus, and a skin biopsy specimen showed a suppurative folliculitis. The eruption improved with a two-week course of oral antibiotics and the application of topical clindamycin solution and triamcinolone cream. A papulopustular eruption occurs in up to 90% of patients treated with epidermal growth factor receptor blocking agents and may correlate with a positive response to chemotherapy. Treatment options are based on anecdotal evidence and may include topical antibiotics, topical glucocorticoids, and oral antibiotics for secondary infection.

Surgical management of extensive gnathophyma

Rhinophyma is an uncommon disease of the nose characterized by irregular skin thickening and nodular deformation. The extensive growth causing 'whisky nose' is due to hyperplasia of the sebaceous glands and the surrounding connective tissue. Other facial regions may concomitantly be affected. We present a case of extensive gnathophyma accompanying minor lesions of the nose. Surgical treatment led to an excellent cosmetic result.

The CLEAR trial: results of a large community-based study of metronidazole gel in rosacea

A phase 4, open-label, multicenter, community-based study was conducted in subjects with mild to moderately severe papulopustular rosacea of various etiologies and locations to identify subgroups particularly responsive to twice-daily application of metronidazole topical gel 0.75% to the affected areas of the face. A total of 582 subjects were randomized. Evaluations were conducted at baseline and at weeks 4, 8, and 12. At each evaluation, investigator global assessment (IGA) scores, mean papule and pustule counts, erythema scores, and telangiectasia scores improved significantly (P < .0001), with consistent results across sex and age subgroups. The mean erythema severity score decreased significantly (P < .0001) from baseline by week 4 and continued to decline at all study visits, with a nearly 50% reduction by week 12. At study end, subjects indicated a 25% improvement in itching, pain, soreness, or stinging; a 53% improvement in embarrassment or self-consciousness; and a 31% improvement in rosacea's effect on social or leisure activities. Metronidazole topical gel 0.75% was associated with a very low incidence of side effects in this trial, similar to previous clinical trials. The most common treatment-related adverse event (AE) reported in this study was mild application-site discomfort. The gel formulation was well-tolerated and effective in all subject subgroups and in a variety of climates. The findings of this study expand the collected data on the efficacy and safety of metronidazole topical gel 0.75% beyond that demonstrated in controlled clinical trials and confirm the utility of this therapy in the community setting.

The ocular manifestations of atopic dermatitis and rosacea

Atopic dermatitis and rosacea are chronic diseases that have both dermatologic and ocular manifestations. The occurrence of ocular disease is often proportionately higher than that of dermatologic disease. Even if the skin abnormalities appear well controlled, these patients require ophthalmic evaluation as well. Optimal management usually requires a team approach that includes internists, dermatologists, and ophthalmologists. Both disorders are characterized by acute exacerbations and require maintenance therapy for control. Exacerbations need aggressive treatment to limit ocular signs and symptoms and to reduce ocular inflammation that can lead to permanent visual loss. Topical corticosteroid use, although at times needed, should be minimized for both disorders. Future research will continue to emphasize the use of steroid-sparing and immune-modulating agents that have the potential to provide long-lasting anti-inflammatory control with a more favorable side-effect profile.

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.

Wolf's isotopic response: Rosacea appearing at the site of healed herpes zoster

A 40-year-old man developed an erythematous rash on the right side of his face 3 weeks after a herpes zoster infection at the same location. Examination revealed an erythematous papular eruption and telangiectasias along the ophthalmic and maxillary divisions of the right trigeminal nerve, exactly at the site of the consistent with previous herpes zoster infection, Wolf's isotopic response. Histological examination showed vascular ectatic dilatation and perivascular and perifollicular infiltration of lymphocytes and histiocytes consistent with rosacea. The rash was resistant to oral doxycycline and topical metronidazole 1% cream and resolved with oral isotretinoin therapy.

Azelaic Acid in the Treatment of Papulopustular Rosacea

OBJECTIVE

To evaluate the clinical efficacy of topical 20% azelaic acid cream and 15% azelaic acid gel compared with their respective vehicles and metronidazole gel in the treatment of papulopustular rosacea.

DATA SOURCES

Electronic searches of MEDLINE, EMBASE, BIOSIS, and SciSearch through July or August 2004 and the Cochrane Central Register of Controlled Trials through 2004 (issue 3). We performed hand searches of reference lists, conference proceedings, and clinical trial databases. Experts in rosacea and azelaic acid were contacted.

STUDY SELECTION

Randomized controlled trials involving topical azelaic acid (cream or gel) for the treatment of rosacea compared with placebo or other topical treatments. Two authors independently examined the studies identified by the searches. Ten studies were identified, of which 5 were included (873 patients).

DATA EXTRACTION

Two authors independently extracted data from the included studies, then jointly assessed methodological quality using a quality assessment scale.

DATA SYNTHESIS

Because standard deviation data were not available for 4 of the 5 studies, a meta-analysis could not be conducted. Four of the 5 studies demonstrated significant decreases in mean inflammatory lesion count and erythema severity after treatment with azelaic acid compared with vehicle. None of the studies showed any significant decrease in telangiectasia severity.

CONCLUSIONS

Azelaic acid in 20% cream and 15% gel formulations appears to be effective in the treatment of papulopustular rosacea, particularly in regard to decreases in mean inflammatory lesion count and erythema severity. Compared with metronidazole, azelaic acid appears to be an equally effective, if not better, treatment option.

A novel aqueous metronidazole 1% gel with hydrosolubilizing agents (HSA-3)

Rosacea is a common chronic dermatosis that often is characterized by the presence of facial erythema, visible blood vessels, papules, and pustules. Because the face is the predominant site of involvement, rosacea may cause serious psychologic trauma and can significantly affect the quality of life of individuals with the condition. The first topical therapy approved for rosacea by the US Food and Drug Administration was metronidazole for the treatment of inflammatory lesions and erythema. A stable aqueous gel formulation of 1% metronidazole has been developed with the novel combination of hydrosolubilizing agents. Metronidazole 1% gel is a clear gel that exhibits advantageous qualities. Some features of the new product include being highly spreadable, easy to use, cosmetically friendly, ultramild, nondrying, and moisturizing. Data are presented from a 21-day cumulative irritation study, an assessment of skin barrier function, an in vitro skin penetration study, an absorption following maximal topical exposure study, and a skin hydration study.

Dermatologic Problems of Older Women

Women are living longer today, composing the majority of persons aged 65 and over. Their dermatologic needs are unique and cross ethnic and cultural lines. With this increased life expectancy comes an increased occurrence of skin disorders. The identification and treatment of these conditions is important for the practicing clinician. This article reviews some of the more common dermatologic disorders of older women, and discusses the latest treatments and issues facing this geriatric population.

Efficacy and safety of once-daily metronidazole 1% gel compared with twice-daily azelaic acid 15% gel in the treatment of rosacea

Rosacea is an inflammatory dermatologic disorder characterized by the presence of facial erythema, visible blood vessels, papules, and pustules. The National Rosacea Society has established a classification system that identifies 4 distinct rosacea subtypes based on clinical presentation: erythematotelangiectatic, papulopustular, phymatous, and ocular. The goal of topical therapy for rosacea is to reduce inflammatory lesion counts; decrease intensity of erythema; and reduce symptoms such as stinging, burning, and pruritus. Metronidazole and azelaic acid are thought to reduce the inflammation associated with rosacea by inhibiting the production of reactive oxygen species produced by neutrophils. Both metronidazole 1% gel and azelaic acid 15% gel recently have been approved for the treatment of rosacea. The current study was conducted to compare the once-daily application of metronidazole 1% gel with twice-daily applications of azelaic acid 15% gel for the treatment of patients with moderate rosacea (N=160). Both treatments showed similar reductions in inflammatory lesion counts (77% for metronidazole 1% gel and 80% for azelaic acid 15% gel) and high success rates in both global severity (53.7% vs 56.4% for metronidazole 1% gel and azelaic acid 15% gel, respectively) and erythema (42.7% vs 42.3% for metronidazole 1% gel and azelaic acid 15% gel, respectively). On average, the efficacy (including reduction in erythema) of the once-daily application of metronidazole 1% gel and twice-daily applications of azelaic acid 15% gel were similar.

A look at the safety of metronidazole 1% gel: cumulative irritation, contact sensitization, phototoxicity, and photoallergy potential

Rosacea is a common, recurrent, inflammatory dermatologic disorder characterized by the presence of facial erythema, visible blood vessels, papules, and pustules. The condition may cause serious psychologic morbidity and may significantly affect quality of life. The first topical rosacea therapy approved by the US Food and Drug Administration was metronidazole for the treatment of inflammatory lesions and erythema. Previously, metronidazole was available as a 0.75% gel. Improved solubility was achieved in a new, stable, aqueous gel that permitted the formulation of metronidazole 1.0%. This new formulation is highly spreadable, easy to use, cosmetically friendly, mild to the skin, nondrying, and moisturizing. The safety of metronidazole 1% gel was determined by the evaluation of its cumulative irritation, contact sensitization, phototoxicity, and photoallergy potential in healthy male and female patients. In this formulation, metronidazole was not irritating under occlusive application. Additionally, metronidazole 1% gel had a low potential for causing sensitization reactions, and no evidence suggested phototoxic or photoallergic reactions.

An update on the role of topical metronidazole in rosacea

Topical metronidazole (Noritate 1% Cream, Dermik; MetroCream 0.75% Cream, MetroLotion 0.75% Lotion, Metrogel 0.75% and 1% Topical Gel, Galderma) has been used for the treatment of rosacea for over 30 years. Several placebo-controlled trials have demonstrated its effectiveness in the treatment of moderate-to-severe rosacea. It is also effective in preventing relapses of disease and is well tolerated by most patients. A growing number of formulations are available.

A clinical overview of azelaic acid

Azelaic acid (AzA) initially was released in a 20% cream formulation, which has been shown to be effective in the treatment of mild to moderate rosacea. Recently, a 15% gel formulation was developed that vastly improved the delivery of AzA and has been proven by multiple studies to be effective in the treatment of rosacea. We present studies that examine both of these formulations, first in comparison with their vehicles and then in contrast with other well-accepted topical treatments of rosacea, such as metronidazole cream and gel.

The use of topical azelaic acid for common skin disorders other than inflammatory rosacea

Topical azelaic acid (AzA) is approved for the treatment of acne vulgaris and inflammatory (papulopustular) rosacea. Because of diverse mechanisms of action that correlate with potential therapeutic benefit, AzA has been used to treat several common dermatoses including acne vulgaris, inflammatory rosacea, erythematotelangiectatic rosacea, perioral dermatitis, melasma, and postinflammatory hyperpigmentation. This article reviews the therapeutic use of topical AzA for the treatment of common skin disorders other than the US Food and Drug Administration (FDA)-approved indications of acne vulgaris and inflammatory rosacea.

Optical treatments for acne

Light-based treatments for acne are becoming increasingly commonplace in dermatology. This article reviews various light approaches in acne therapy. Methods are discussed from an anatomical and a functional perspective. The emphasis is on the practicality of treatment as well as the pros and cons of various devices. Also, a review of the recent literature is presented. The article is intended to give the reader a panoramic view of this still-young and developing area. Most likely, light-based acne treatment will receive more popularity as dermatologists learn how to integrate this type of therapy within the context of more established drug agents.

Rosacea fulminans in pregnancy: case report and review of the literature

Rosacea fulminans is a rare disease of unknown cause which occurs exclusively in women years after adolescence. Although the etiology is unknown, immunologic, hormonal, and vascular factors have been suggested. When rosacea fulminans occurs during pregnancy and in women taking oral contraceptive pills, hormonal factors may be a trigger. Rosacea fulminans is localized specifically to the face, with the chin, cheeks, and forehead bearing the brunt of the attack. A dull red, cyanotic erythema of all involved facial areas, extending beyond the inflammatory nodules, is typical. We present the case of a 31-year-old pregnant woman who had rosacea fulminans during the first trimester of her second pregnancy. She had multiple erythematous papules, pustules, nodules, and purulent discharging cysts on the face. Conventional therapeutic approaches with systemic corticosteroids were associated with clear improvement within 2 months, and subsequently only 0.75% metronidazole topical cream was used during the second trimester.

Videocapillaroscopic alterations in erythematotelangiectatic rosacea

BACKGROUND

Rosacea is a common chronic dermatosis that involves the cutaneous microvasculature of the face. There are no objective measures for assessing the severity of erythematotelangiectatic rosacea.

OBJECTIVE

Our purpose was to characterize and provide objective measures of vessel changes in erythematotelangiectatic rosacea by videocapillaroscopy.

METHODS

We compared 30 patients with erythematotelangiectatic rosacea with 30 age- and sex-matched patients with facial seborrheic dermatitis and 30 healthy control subjects. Videocapillaroscopy was performed both on the cheeks and on the nailfold region. The analyzed parameters of the face were morphological (background color, vessel irregularities) and quantitative (polygonal net perimeter, telangiectasia, and vessel diameters).

RESULTS

Characteristic alterations of skin vessels were observed in facial rosacea, with a pattern distinct from that of facial seborrheic dermatitis. In particular, rosacea showed neoangiogenesis and significantly larger polygons (13.21 +/- 3 vs 7.8 +/- 3 mm; mean +/- standard deviation, P < .001), more prominent telangiectases (267.8 +/- 108 vs 118.2 +/- 35 microm; P < .001) and larger mean vessel diameter (46.71 +/- 9 vs 24 +/- 10 microm; P < .001) compared with seborrheic dermatitis. Seborrheic dermatitis displayed more polygon irregularities and vessel tortuosity. In contrast, no differences were found in the nailfold region.

LIMITATIONS

Vessel irregularities and overall erythema may be difficult to quantify.

CONCLUSIONS

Videocapillaroscopy may represent a valid adjunctive method in the early diagnosis and measurement of erythematotelangiectatic rosacea.

Therapeutic response of rosacea to dobesilate

Despite an incomplete understanding of the pathogenesis of rosacea, therapeutic modalities continue to expand. The principal subtype of rosacea includes erythematotelangiestatic rosacea, which is characterized by uncontrolled angiogenesis. Angiogenic growth factors such as fibroblast growth factors (FGF) and vascular endothelial growth factor (VEGF) are currently targets of intense effort to inhibit deregulated blood vessel formation in diseases such as cancer. Here we report a 33-years-old woman with erythematotelangestatic rosacea who responds to a daily treatment of topically applied dobesilate, an inhibitor of FGF, with an improvement in erythema and telangectasia after two weeks. Thus, dobesilate might be useful in the treatment of rosacea and other diseases that depend on pathologic angiogenesis.

A basal cell carcinoma mimicking a sign of rosacea

A 55-year-old Caucasian man presented to a plastic surgeon for the treatment of two lesions on his nose, first a chronic indented area with some telangiectasia on the proximal nasal bridge (Figure 1) and second a hyperkeratotic nodule with central crusting on the ala nasi that developed rapidly over several weeks (Figure 2). The surgeon appropriately diagnosed the ala nasi nodule as a squamous cell carcinoma, keratoacanthoma type, but requested an opinion from dermatology for the proximal nasal bridge indentation that he suspected to be a morpheaform or erosive basal cell carcinoma possibly requiring Mohs micrographic surgery. Upon further questioning, the patient revealed that he has had persistent erythema and problems with facial flushing for many years, particularly with alcohol, coffee, and moderate exercise. He infrequently develops papulopustular lesions. Closer clinical inspection revealed a mild erythema, telangiectases, and a hypertrophied nose. He noted that he wore an old heavy pair of glasses every day. He was notified of a coexisting diagnosis of rosacea, and various treatment options were discussed. He was pleased that he would not need any further surgery to his nose.