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Xiao W, Chen M, Wang B, Huang Y, Zhao Z, Deng Z, Xie H, Li J, Tang Y. Efficacy and safety of antibiotic agents in the treatment of rosacea: a systemic network meta-analysis. Front Pharmacol 2023; 14:1169916. [PMID: 37251342 PMCID: PMC10210163 DOI: 10.3389/fphar.2023.1169916] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Background: Antibiotics are considered the backbone of rosacea management, especially for controlling inflammatory papules and pustules. We aim to evaluate the efficacy and safety of varied prescriptions and doses of antibiotics in treating rosacea by network meta-analysis. Methods: In this study, we compared all available randomized controlled trials (RCTs) that have studied systemic and topical antibiotics and placebo in rosacea therapy. We searched databases such as the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, Web of Science, and LILACS for published and unpublished RCTs on ClinicalTrials.gov before April 2023. The primary outcome was the improvement of the Investigator's Global Assessment (IGA) scores, and the secondary outcomes consisted of the improvement of the Patient's Global Assessment (PaGA) scores, Clinician's Erythema Assessment (CEA) scores, and adverse events (AEs). We used Bayesian random effects models for multiple treatment comparisons. Results: We identified 1,703 results through these databases. Thirty-one randomized trials with 8,226 patients were included. The heterogeneity and inconsistency between the trials were low, with a low risk of bias of all trials. Oral doxycycline 40 mg, minocycline 100 mg, and minocycline 40 mg, as well as topical ivermectin and metronidazole 0.75%, were effective in treating papules and pustules, thereby decreasing IGA in rosacea. Among these, minocycline 100 mg ranked top in efficacy. As for improving the PaGA scores, topical ivermectin, metronidazole 1%, and systemic oxytetracycline were effective, of which oxytetracycline worked the best. Both doxycycline 40 mg and metronidazole 0.75% presented no therapeutic effect for erythema. Considering the safety of the agents, systemic application of azithromycin and doxycycline 100 mg significantly increase the risk of AEs. Conclusion: Our review suggests that a high dosage of systemic minocycline is the most effective in treating rosacea phenotypes with papules and pustules with a low risk of AEs. However, there were no sufficient evidence-based data in exploring the influence of antibiotics on erythema. The phenotype of rosacea should be taken into consideration along with benefit and safety when making prescriptions due to AEs. Clinical Trial Registration: NCT(2016): http://cochranelibrary-wiley.com/o/cochrane/clcentral/articles/962/CN-01506962/frame.html NCT(2017): http://cochranelibrary-wiley.com/o/cochrane/clcentral/articles/764/CN-01565764/frame.html.
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Affiliation(s)
- Wenqin Xiao
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mengting Chen
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ben Wang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yingxue Huang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhixiang Zhao
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhili Deng
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongfu Xie
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ji Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Tang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Schaller M, Almeida LMC, Bewley A, Cribier B, Del Rosso J, Dlova NC, Gallo RL, Granstein RD, Kautz G, Mannis MJ, Micali G, Oon HH, Rajagopalan M, Steinhoff M, Tanghetti E, Thiboutot D, Troielli P, Webster G, Zierhut M, van Zuuren EJ, Tan J. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. Br J Dermatol 2019; 182:1269-1276. [PMID: 31392722 PMCID: PMC7317217 DOI: 10.1111/bjd.18420] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 01/02/2023]
Abstract
Background A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups. Objectives To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development. Methods Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded. Results Delphi statements on which the panel achieved consensus of ≥ 75% voting ‘Agree’ or ‘Strongly agree’ are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements. Conclusions The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management. What's already known about this topic? A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups. New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations.
What does this study add? We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea. We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.
Linked Comment: Elewski. Br J Dermatol 2020; 182:1090–1091. Plain language summary available online
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Affiliation(s)
- M Schaller
- Department of Dermatology, Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
| | - L M C Almeida
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
| | - A Bewley
- Department of Dermatology, Barts Health (Royal London and Whipps Cross University Hospitals), London, U.K
| | - B Cribier
- Department of Dermatology, Hopitaux Universitaires de Strasbourg, Strasbourg, Alsace, France
| | - J Del Rosso
- JDR Dermatology Research and Thomas Dermatology, Las Vegas, NV, U.S.A
| | - N C Dlova
- Department of Dermatology, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
| | - R L Gallo
- Department of Dermatology, University of California San Diego, La Jolla, CA, U.S.A
| | - R D Granstein
- Department of Dermatology, Weill Cornell Medical College, New York, NY, U.S.A
| | - G Kautz
- Haut- und Laserklinik, Konz, Germany
| | - M J Mannis
- Department of Ophthalmology & Vision Science, University of California Davis, Davis, CA, U.S.A
| | - G Micali
- Dermatology Clinic, University of Catania, Catania, Italy
| | - H H Oon
- National Skin Centre, Singapore
| | - M Rajagopalan
- Apollo Hospitals Enterprise, Chennai, Tamil Nadu, India
| | - M Steinhoff
- Department of Dermatology and Venereology and Translational Research Institute, Weill Cornell Medicine-Qatar, Hamad Medical Corporation, Qatar University, Doha, Qatar.,Department of Dermatology, Weill Cornell University, New York, NY, U.S.A
| | - E Tanghetti
- Center for Dermatology and Laser Surgery, Sacramento, CA, U.S.A
| | - D Thiboutot
- Department of Dermatology, Pennsylvania State University College of Medicine, Hershey, PA, U.S.A
| | - P Troielli
- Faculty of Dermatology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - G Webster
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - M Zierhut
- Centre for Ophthalmology, University Tübingen, Tübingen, Germany
| | - E J van Zuuren
- Department of Dermatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Tan
- Windsor Clinical Research Inc and Department of Medicine, University of Western Ontario, Windsor, ON, Canada
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van Zuuren E, Fedorowicz Z, Tan J, van der Linden M, Arents B, Carter B, Charland L. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. Br J Dermatol 2019; 181:65-79. [PMID: 30585305 PMCID: PMC6850438 DOI: 10.1111/bjd.17590] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping. OBJECTIVES To update our systematic review on interventions for rosacea. METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk-of-bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence. RESULTS We included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light-based treatment. We present the most current evidence for rosacea management based on a phenotype-led approach. CONCLUSIONS For reducing temporarily persistent erythema there was high-certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low-to-moderate-certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high-certainty evidence for topical azelaic acid and topical ivermectin; moderate-to-high-certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate-certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low-certainty evidence for tetracycline and low-dose minocycline. For ocular rosacea, there was moderate-certainty evidence that oral omega-3 fatty acids were effective and low-certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.
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Affiliation(s)
- E.J. van Zuuren
- Dermatology DepartmentLeiden University Medical CentreLeiden2333 ZAthe Netherlands
| | - Z. Fedorowicz
- DynaMed PlusEBSCO Health10 Estes StreetIpswichMA01938U.S.A.
| | - J. Tan
- Department of MedicineUniversity of Western OntarioLondonCanada
| | - M.M.D. van der Linden
- Department of DermatologyAmsterdam University Medical CentreAmsterdamthe Netherlands
| | - B.W.M. Arents
- Skin Patients Netherlands (Huidpatiënten Nederland)Nieuwegeinthe Netherlands
| | - B. Carter
- Biostatistics and Health InformaticsKing's College LondonLondonU.K
- Institute of Psychiatry, Psychology and NeuroscienceLondonU.K
| | - L. Charland
- Independent Researcher and Consumer RefereeQuebecCanada
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective. OBJECTIVES To assess the efficacy and safety of treatments for rosacea. SEARCH METHODS We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea. DATA COLLECTION AND ANALYSIS Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors. MAIN RESULTS We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence). AUTHORS' CONCLUSIONS There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.
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Affiliation(s)
- Esther J van Zuuren
- Leiden University Medical CenterDepartment of DermatologyPO Box 9600B1‐QLeidenNetherlands2300 RC
| | | | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & NeuroscienceBiostatistics and Health InformaticsDenmark HillLondonUK
| | | | - Lyn Charland
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
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Xiong T, Parekh-Bhurke S, Loke YK, Abdelhamid A, Sutton AJ, Eastwood AJ, Holland R, Chen YF, Walsh T, Glenny AM, Song F. Overall similarity and consistency assessment scores are not sufficiently accurate for predicting discrepancy between direct and indirect comparison estimates. J Clin Epidemiol 2012. [PMID: 23186991 PMCID: PMC3537077 DOI: 10.1016/j.jclinepi.2012.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objectives Indirect comparison methods have been increasingly used to assess the effectiveness of different interventions comparatively. This study evaluated a Trial Similarity and Evidence Consistency Assessment (TSECA) framework for assessing key assumptions underlying the validity of indirect comparisons. Study Design and Setting We applied the TSECA framework to 94 Cochrane Systematic Reviews that provided data to compare two interventions by both direct and indirect comparisons. Using the TSECA framework, two reviewers independently assessed and scored trial similarity and evidence consistency. A detailed case study provided further insight into the usefulness and limitations of the framework proposed. Results Trial similarity and evidence consistency scores obtained using the assessment framework were not associated with statistically significant inconsistency between direct and indirect estimates. The case study illustrated that the assessment framework could be used to identify potentially important differences in participants, interventions, and outcome measures between different sets of trials in the indirect comparison. Conclusion Although the overall trial similarity and evidence consistency scores are unlikely to be sufficiently accurate for predicting inconsistency between direct and indirect estimates, the assessment framework proposed in this study can be a useful tool for identifying between-trial differences that may threaten the validity of indirect treatment comparisons.
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Affiliation(s)
- Tengbin Xiong
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, UK
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Cuevas P, Angulo J, Giménez-Gallego G. Long-term effectiveness of dobesilate in the treatment of papulopustular rosacea. BMJ Case Rep 2011; 2011:bcr.08.2011.4579. [PMID: 22675033 DOI: 10.1136/bcr.08.2011.4579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case report is a representative example from a study directed to assess the long-term clinical benefit of dobesilate in rosacea in five enrolled papulopustular rosacea patients with several years of disease, treated topically with 5% potassium dobesilate cream for 3 weeks. The patient suffered papulopustular rosacea for more than 10 years, during which she received topical metronidazole and azelaic acid, and systemic doxycycline therapies without satisfactory improvement. Dobesilate treatment promoted improvement of rosacea symptoms and signs. Two years after treatment the patient still shows a good facial cosmesis.
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Affiliation(s)
- Pedro Cuevas
- Research Department, Hospital Ramon y Cajal, Madrid, Spain.
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Song F, Xiong T, Parekh-Bhurke S, Loke YK, Sutton AJ, Eastwood AJ, Holland R, Chen YF, Glenny AM, Deeks JJ, Altman DG. Inconsistency between direct and indirect comparisons of competing interventions: meta-epidemiological study. BMJ 2011; 343:d4909. [PMID: 21846695 PMCID: PMC3156578 DOI: 10.1136/bmj.d4909] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the agreement between direct and indirect comparisons of competing healthcare interventions. DESIGN Meta-epidemiological study based on sample of meta-analyses of randomised controlled trials. Data sources Cochrane Database of Systematic Reviews and PubMed. Inclusion criteria Systematic reviews that provided sufficient data for both direct comparison and independent indirect comparisons of two interventions on the basis of a common comparator and in which the odds ratio could be used as the outcome statistic. MAIN OUTCOME MEASURE Inconsistency measured by the difference in the log odds ratio between the direct and indirect methods. RESULTS The study included 112 independent trial networks (including 1552 trials with 478,775 patients in total) that allowed both direct and indirect comparison of two interventions. Indirect comparison had already been explicitly done in only 13 of the 85 Cochrane reviews included. The inconsistency between the direct and indirect comparison was statistically significant in 16 cases (14%, 95% confidence interval 9% to 22%). The statistically significant inconsistency was associated with fewer trials, subjectively assessed outcomes, and statistically significant effects of treatment in either direct or indirect comparisons. Owing to considerable inconsistency, many (14/39) of the statistically significant effects by direct comparison became non-significant when the direct and indirect estimates were combined. CONCLUSIONS Significant inconsistency between direct and indirect comparisons may be more prevalent than previously observed. Direct and indirect estimates should be combined in mixed treatment comparisons only after adequate assessment of the consistency of the evidence.
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Affiliation(s)
- Fujian Song
- Faculty of Medicine and Health Science, Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK.
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some patients. A range of treatment options are available but it is unclear which are the most effective. OBJECTIVES To assess the evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY In February 2011 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea. DATA COLLECTION AND ANALYSIS Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors. MAIN RESULTS Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. Only two studies assessed our primary outcome 'quality of life'.Pooled data from physician assessments in three trials provided some evidence that metronidazole was more effective compared to placebo (RR 1.95, 95% CI 1.48 to 2.56). Three trials provided data, based on participants' assessments, illustrating azelaic acid was more effective than placebo (RR 1.52, 95% CI 1.32 to 1.76).Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doses of doxycycline, but there was evidence of less adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54).One study reported that cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes). AUTHORS' CONCLUSIONS Although the majority of included studies were assessed as being at high or unclear risk of bias there was some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately-powered randomised controlled trials are required.
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Affiliation(s)
- Esther J van Zuuren
- Department of Dermatology, Leiden University Medical Center, PO Box 9600, B1-Q, Leiden, Netherlands, 2300 RC
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Elewski BE, Draelos Z, Dréno B, Jansen T, Layton A, Picardo M. Rosacea - global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group. J Eur Acad Dermatol Venereol 2010; 25:188-200. [PMID: 20586834 DOI: 10.1111/j.1468-3083.2010.03751.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The absence of specific histological or serological markers, the gaps in understanding the aetiology and pathophysiology of rosacea, and the broad diversity in its clinical manifestations has made it difficult to reach international consensus on therapy guidelines. OBJECTIVES The main objective was to highlight the global diversity in current thinking about rosacea pathophysiology, classification and medical features, under particular consideration of the relevance of the findings to optimization of therapy. METHODS The article presents findings, proposals and conclusions reached by the ROSacea International Expert group (ROSIE), comprising European and US rosacea experts. RESULTS New findings on pathogenesis provide a rationale for the development of novel therapies. Thus, recent findings suggest a central role of the antimicrobial peptide cathelicidin and its activator kallikrein-5 by eliciting an exacerbated response of the innate immune system. Cathelicidin/kallikrein-5 also provide a rationale for the effect of tetracyclines and azelaic acid against rosacea. Clinically, the ROSIE group emphasized the need for a comprehensive therapy strategy - the triad of rosacea care - that integrates patient education including psychological and social aspects, skin care with dermo-cosmetics as well as drug- and physical therapies. Classification of rosacea into stages or subgroups, with or without progression, remained controversial. However, the ROSIE group proposed that therapy decision making should be in accordance with a treatment algorithm based on the signs and symptoms of rosacea rather than on a prior classification. CONCLUSION The ROSIE group reviewed rosacea pathophysiology and medical features and the impact on patients and treatment options. The group suggested a rational, evidence-based approach to treatment for the various symptoms of the condition. In daily practice this approach might be more easily handled than prior subtype classification, in particular since patients often may show clinical features of more than one subtype at the same time.
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Affiliation(s)
- B E Elewski
- Department of Dermatology, University of Alabama, Birmingham, AL, USA
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Smith JR, Lanier VB, Braziel RM, Falkenhagen KM, White C, Rosenbaum JT. Expression of vascular endothelial growth factor and its receptors in rosacea. Br J Ophthalmol 2007; 91:226-9. [PMID: 17244661 PMCID: PMC1857639 DOI: 10.1136/bjo.2006.101121] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Justine R Smith
- Casey Eye Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Biomedical Research Building, Mail Code L467AD, Portland, OR 97239, USA.
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Goodman KJ, Joyce SL, Ismond KP. Extragastric diseases associated with Helicobacter pylori infection. Curr Gastroenterol Rep 2007; 8:458-64. [PMID: 17105683 DOI: 10.1007/s11894-006-0035-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper critically reviews the current literature on extragastric diseases associated with Helicobacter pylori infection, with an emphasis on methodologic issues that complicate interpretation of study findings. This review reveals common study limitations and overall uncertainty that H. pylori infection plays a role in extragastric diseases, although such a role has not been clearly ruled out for specific diseases of relevance. Evidence suggests that anti-H. pylori therapy may lead to improvement of a few extragastric diseases, in particular, idiopathic thrombocytopenic purpura, iron deficiency anemia, and chronic idiopathic urticaria, but the data from randomized controlled trials are insufficient to confirm this beneficial effect; if the benefit of anti-H. pylori therapy for specific diseases is real, it is not clear if it results from removing H. pylori-specific injurious effects, eliminating some other infectious pathogen, or reducing the total infectious burden.
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Affiliation(s)
- Karen J Goodman
- Division of Gastroenterology, Zeidler Ledcor Centre, University Campus 130, University of Alberta, Edmonton, AB, Canada, T6G 2X8.
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van Zuuren EJ, Gupta AK, Gover MD, Graber M, Hollis S. Systematic review of rosacea treatments. J Am Acad Dermatol 2007; 56:107-15. [PMID: 17190628 DOI: 10.1016/j.jaad.2006.04.084] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 04/13/2006] [Accepted: 04/15/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rosacea is a common chronic skin and ocular condition. It is unclear which treatments are most effective. We have conducted a Cochrane review of rosacea therapies. This article is a distillation of that work. OBJECTIVE We sought to assess the evidence for the efficacy and safety of rosacea therapies. METHODS Multiple databases were systematically searched. Randomized controlled trials in people with moderate to severe rosacea were included. Study selection, assessment of methodologic quality, data extraction, and analysis were carried out by two independent researchers. RESULTS In all, 29 studies met inclusion criteria. Topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95-12.06). Azelaic acid is more effective than placebo (odds ratio 2.45, 95% confidence interval 1.82-3.28). Firm conclusions could not be drawn about other therapies. LIMITATIONS The quality of the studies was generally poor. CONCLUSIONS There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. More well-designed, randomized controlled trials are required to provide better evidence of the efficacy and safety of other rosacea therapies.
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Affiliation(s)
- Esther J van Zuuren
- Department of Dermatology B1-Q, Leiden University Medical Center, The Netherlands.
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