A randomized, controlled, split‐face study of Botulinum toxin and broadband light for the treatment of Erythemato telangiectatic rosacea

Intradermal injection of botulinum toxin for erythema in rosacea: A scoping review and meta-analysis

Background Rosacea is a skin condition characterised by persistent facial erythema, flushing, papules, pustules, and telangiectasia. Botulinum toxin A (BoNT-A) has been used to treat a variety of conditions, but its effectiveness in improving facial erythema in rosacea patients is uncertain. Objectives The aim of the study is to evaluate the effectiveness and determine the optimal dose of BoNT-A treatment for rosacea. Methods An online database search (Pubmed, Cochrane Library and Embase) was conducted on 30th June 2023 to identify studies that used intradermal injection of BoNT-A to treat facial erythema in rosacea patients and excluded studies in which BoNT-A was used for facial erythema due to other known medical condition such as menopause, drug or pregnancy. The primary outcome measure for this study was the improvement in erythema score as objectively assessed. A random effect model was used in the meta-analysis. Results Seven studies involving a total of 167 rosacea patients were included in the meta-analysis. Meta-analysis of two randomised controlled trials showed improvement of erythema on the third month after treatment standardized mean difference (SMD): 1.676, 95% confidence interval (CI): 2.278-1.074, I2: 35.76%). A separate analysis of seven single-armed treatment studies found significant improvement in erythema with intradermal injection of BoNT-A at one, two and three months after treatment (first month: SMD: 2.712, 95% CI: 4.1182-1.243; second month: SMD:2.213, 95% CI: 3.702-0.725; third month: SMD: 1.912, 95% CI: 2.882-0.941). Adverse events, including mild facial paralysis and injectional purpura, were reported in some studies. Limitation The limitations of this study include heterogeneity in study design and a small sample size. Conclusion Intradermal injection of BoNT-A may be an effective treatment for facial erythema in rosacea. Unwanted facial muscle paralysis was seen in different BoNT-A concentration but not noted when the dose was less than 0.02ml per site. Future studies particularly randomised trials are required to identify the volume of injection required to reduce the erythema.

Using Neuromodulators to Improve Scar Formation, Keloids, Rosacea, and Antiaging

BACKGROUND

Botulinum toxin A (BoNT-A) treatment has many uses in dermatology. Its mechanism of action and long-term effects for scar formation, rosacea, and antiaging are still being investigated.

OBJECTIVE

To conduct a literature review on BoNT-A to further investigate its use in scar formation, rosacea, and antiaging.

METHODS

A literature review was conducted using PubMed on botulinum toxin treatment for scar formation, rosacea, and antiaging. Studies discussing the toxin mechanism of action and treatment algorithm were included. The authors also provided their personal experience in BoNT-A use for these 3 conditions.

RESULTS

The mechanism of action of Botulinum toxin A in improving scar formation, rosacea, and antiaging is now better understood. While it is effective in the short term, little is still known about how frequently treatment needs to be repeated and if there are any long-term effects.

CONCLUSION

While in vitro studies have supporting evidence on the mechanism of action of BoNT-A on scar formation, rosacea, and antiaging, further studies are needed to identify long-term treatment effects.

Therapeutic strategies focusing on immune dysregulation and neuroinflammation in rosacea

Rosacea is a complex inflammatory condition characterized by papulopustular lesions and erythema on the central face for which there is no cure. The development of rosacea is influenced by both external triggers and genetics, but the common pathophysiology is overactivation of the immune system. Here, we review the current data on proinflammatory cytokines and dysregulation of the neurovascular system as targetable components of rosacea. Amelioration of cutaneous and gastrointestinal dysbiosis and other external factors impacts the immune state and has been observed to improve rosacea. While multiple treatments exist, many patients do not achieve their goals for rosacea control and highlights an unmet need for dermatologic care. Current interventions encompass topical/oral drugs, light devices, and avoidance of triggers management. Additional understanding of the underlying pathogenesis may help us develop novel targeted therapeutic strategies to improve rosacea.

Five-blade scratcher for treating severe rhinophyma: A retrospective study

BACKGROUND

Rhinophyma, a late-stage subtype of rosacea, is characterized by excessive sebaceous glands and connective tissue proliferation. Patients may experience respiratory disturbances and psychological distress that significantly affect their quality of life when excessive nasal hyperplasia obstructs the external nasal valves. Surgery is the treatment of choice for rhinophyma. However, excessive bleeding, scarring, pigmentation, and high recurrence rates frequently characterize current surgical methods.

AIM

To evaluate the clinical effectiveness and recurrence rates after treating severe rhinophyma with the five-blade scratcher.

METHODS

This study retrospectively analyzed the clinical records of 28 patients with severe rhinophyma rosacea. The Global Flushing Severity Score (GFSS), Clinician Erythema Assessment (CEA), Rhinophyma Severity Index (RHISI), Glasgow Benefit Inventory (GBI), and satisfaction scores were used to assess the recovery of patients at 6 months and 5 years, with the recurrence rate calculated at 5 years postoperatively. In addition, the levels of pro-inflammatory factors (TNF-α, IL-1β, and IL-6) in the serum of patients before and after surgery were detected by ELISA.

RESULTS

The GFSS, CEA, and RHISI scores at 6 months and 5 years postoperatively were significantly lower than those preoperatively (P < 0.001 for both periods). Five-blade scratcher treatment greatly benefits patients as demonstrated by the GBI and patient satisfaction. A small number of patients (7/28, 25%) reported recurrence after surgical treatment for rhinophyma in our department that was not more serious than before treatment. The expression of pro-inflammatory factors (TNF-α, IL-1β, and IL-6) in the patient's serum was significantly reduced after surgery of five-blade scratcher.

CONCLUSION

The five-blade scratcher treatment demonstrates notable advantages, including simplicity, safety, efficacy, and cost-effectiveness, coupled with reduced bleeding, minimized scarring, lower recurrence rates, reduced the level of pro-inflammatory factors and improved patient satisfaction. Consequently, this therapeutic modality exhibits a viable option for individuals afflicted with severe rhinophyma.

Treating rosacea with botulism toxin: Protocol for a systematic review and meta-analysis

BACKGROUND

Rosacea is a chronic inflammatory disease usually associated with persistent erythema and periodic flushing. This disease is difficult to treat, and the outcomes are often unsatisfactory and prone to recurrence. In recent years, botulinum toxin has been used as a new treatment for rosacea; however, its efficacy and safety remain under discussion. Although a systematic review of the effectiveness and safety of botulinum toxin has been previously conducted by other researchers, our systematic review and meta-analysis evaluate the efficacy of botulinum toxin from a more comprehensive and detailed perspective to provide evidence for clinicians.

METHODS

Any study using botulinum toxin for the treatment of rosacea was considered for the analysis.

RESULTS

A total of 22 studies were included, 9 of which were randomized controlled trials involving 720 subjects. After treatment, all studies showed varying degrees of improvement in patient signs and symptoms along with reduced Clinician's Erythema Assessment (CEA) scores. The improvement was maintained for several months, and the adverse effects were mild and self-limiting.

CONCLUSION

Botulinum toxin may be an effective treatment for patients with rosacea; however, further clinical evidence is needed to confirm its long-term efficacy and side effects. The study was preregistered with Prospero (CRD42022358911).

Long-term maintenance treatment of rosacea: experts' opinion

BACKGROUND

Rosacea is a chronic inflammatory dermatosis characterized by remissions and flares. Although the rosacea active treatment phase is well established, the long-term maintenance phase is still challenging.

OBJECTIVE

To discuss and make recommendations on how to treat patients during the long-term maintenance phase for the main rosacea phenotypes.

METHODS

A panel of six board-certified Brazilian dermatologists and one American dermatologist gathered to compose a consensus based upon an initial statement on how to treat rosacea during the long-term maintenance phase based on the methodology Nominal Group Technique. The experts discussed each factor based upon an initial statement on how to treat rosacea patients in the long-term maintenance phase. A sequence of comprehensive narrative reviews was performed; a questionnaire preparation about the definition of the maintenance phase and its management was presented; an interpersonal discussion and ranking of the ideas were conducted. Recommendations were made if the specialists had 75% agreement.

RESULTS

The maintenance treatment phase, which starts by achieving IGA 0 or 1 grades at the active phase, should be considered at least during the 9-month period after remission. The recommendations of all treatments target this period. Daily skincare regimen and sunscreen are crucial. Active treatment phase should be recommended if signs or symptoms reappear or worsen.

CONCLUSION

Maintenance phase success depends on patient's adherence to daily skin care, appropriate treatments, continued follow-up with dermatologist, and self-assessment to identify new signs and symptoms indicating disease relapse.

Decoding the role of m6A Regulators in identifying and characterizing molecular subtypes of rosacea

Rosacea is a common skin disease that predominantly affects individuals aged between 30 and 50 years. While the exact cause of the disease remains unclear, various factors have been shown to trigger or exacerbate its symptoms. N6-methyladenosine (m6A) modification is one of the most abundant epigenetic methylation modification in messenger RNA (mRNA) and non-coding RNA (ncRNA), plays a crucial role in RNA splicing, export, stability, and translation. In this study, we aimed to characterize m6A genes in rosacea, identify molecular subtypes based on m6A gene expression, characterize the immune features among subtypes, explore key molecules based on co-expression analysis, and identify potential targets and drugs. To achieve our objectives, we first compared the expression pattern and immune regulation of m6A genes between healthy and diseased groups. Then, we performed clustering to stratify disease samples into different subtypes and analyzed immune regulation and functional enrichment among the subtypes. Then, we conducted differential analysis between subtypes and applied weighted gene co-expression network analysis (WGCNA) in three subtypes. We found hub differential expression analysis (DEG) genes and their potential drug based on the WGCNA results and the drug-gene interaction database (DGIdb). Finally, in vivo and in vitro studies showed significant differences in m6A methyltransferase METTL3 levels in rosacea mice and control mice, as well as in the skin of rosacea patients and healthy people, while reducing METTL3 significantly inhibited the inflammatory response of human fibroblasts (HDFs) stimulated by LL37, suggesting that METTL3 may be associated with changes in overall m6A levels in rosacea. Taken together, our findings provide valuable insights into therapeutic targets and drug predictions for rosacea.

5-aminolevulinic acid photodynamic therapy using 560-1200 nm followed by 420-1200 nm broadband light in the treatment of moderate-to-severe acne

BACKGROUND

Moderate-to-severe acne vulgaris, which is a chronic inflammatory skin disease, seriously impacts millions of people. However, traditional therapies may cause severe adverse reactions that are unacceptable to many patients, thus limiting the further application of these therapies. Novel therapeutic approaches to effectively treat moderate-to-severe acne vulgaris with minimal adverse reactions are urgently needed. In this retrospective study, we investigated the efficacy and adverse reactions of photodynamic therapy (PDT) using 560-1200 nm followed by 420-1200 nm broadband light (BBL).

METHODS

Twenty-four patients with moderate-to-severe acne vulgaris were included in the study and all patients expressed a strong desire for beauty. After aminolevulinic acid (ALA) gel applied, the entire face was sequentially irradiated by using BBL with a 560 nm cut-off filter (560-1200 nm), followed by BBL with a 420 nm cut-off filter (420-1200 nm). The clinical efficacy was evaluated by the proportion of patients achieving cured response and excellent response (effective rate), based on the percentage of lesions reduction (treatment rate). The fluorescent images and photographs of acne vulgaris were recorded. Pain and other common local adverse reactions during the treatment were also recorded and evaluated.

RESULTS

In patients with moderate acne, the mean treatment rates were 57.74 ± 16.40 (%) and 87.40 ± 8.521 (%) at the 6th week and 12th week of treatment, respectively. In patients with severe acne, the mean treatment rates were 60.95 ± 12.06 (%) and 85.04 ± 9.115 (%) at the 6th week and 12th week of treatment, respectively. At the 6th and 12th weeks of treatment, the effective rates of patients were 20.00 % and 93.33 % in patients with moderate acne, and 0.000 % and 88.89 % in patients with severe acne, respectively. Pain scores were significantly higher in patients with severe acne compared to patients with moderate acne when receiving 560-1200 nm BBL-PDT. Additionally, patients when receiving 420-1200 nm BBL-PDT exhibited significantly higher pain scores than those when receiving 560-1200 nm BBL-PDT. The degree of erythema was more severe in patients with severe acne than in those with moderate acne. The pigmentation was observed in one patient with moderate acne and one patient with severe acne.

CONCLUSION

The 560-1200 nm and 420-1200 nm BBL-PDT therapy can effectively treat moderate-to-severe acne vulgaris with tolerable adverse reactions, providing a new option for patients with higher esthetic requirements.

The Efficacy and Safety of Botulinum Toxin A for the Treatment of Rosacea: A Systematic Review

The off-label use of botulinum toxin type-A (BoNT-A) in treating rosacea seems encouraging, but the evidence is still lacking regarding its efficacy and safety. This study was conducted to summarize the evidence regarding the efficacy and safety of BoNT-A in the treatment of rosacea patients. A comprehensive literature search was conducted in several databases, and 17 studies were included. Before-after and split-face comparisons showed that BoNT-A significantly alleviated the symptoms of facial erythema and flushing and improved the patient's quality of life/satisfaction. However, the symptoms recurred three to six months post-injection, requiring repeated treatments in some patients. The pooled rates of post-injection localized erythema, ecchymosis, and facial muscle affection represented 24.6%, 5.1%, and 4.3%, respectively. BoNT-A seems to be effective in alleviating the symptoms of rosacea with a low rate of adverse events. However, the recurrence of the symptoms a few months after the injection requires repeated sessions, which may raise cost-effectiveness issues. Large-scale clinical trials are required to confirm the effectiveness and define the optimal dosing regimen and the rate of recurrence. Future studies should allow for an adequate follow-up after the treatment, with repeated measurements of the outcomes.

Treatment of periorbital aging with negative pressure fractional microneedle radiofrequency: A self-controlled clinical trial

BACKGROUND

Several treatment modalities are used for the treatment of periorbital rejuvenation with variable results. Recent studies showed that fractional radiofrequency may be an effective treatment modality for periorbital aging. This study aims to determine the efficacy and safety of negative pressure fractional microneedle radiofrequency (NPFMR) as a treatment for periorbital aging.

METHODS

Twenty-five patients with periorbital aging were involved in this study. They were treated two times with an interval of 1 month. The patients were evaluated before treatment and 1, 3, and 6 months after the final treatment.

RESULTS

The research findings suggest that periorbital wrinkles of the patients were significantly improved by VISIA system (p < 0.05). Physiological indicators detected by MPA10 system showed that compared with before treatment, the hydration increased (p < 0.05) and trans epidermal water loss (TEWL) decreased (p < 0.05) at 3 and 6 months after treatment. The glossiness increased at 1 month after treatment compared to pre-treatment (p < 0.05) and returned to the baseline level at 3 and 6 months after treatment. There was no significant change in melanin content (p > 0.05). Periorbital dermal thickness of the patients significantly increased at 1, 3, and 6 months after treatment according to skin ultrasound (p < 0.05). A periorbital skin biopsy revealed that the collagen fibers in the dermis were significantly thicker and more orderly after treatment, and the expression of type I collagen fibers and elastic fibers was increased compared with that before treatment. One patient developed post-inflammatory hyperpigmentation (PIH) at 1 month after the first treatment, which improved after active treatment. No other adverse reactions were observed.

CONCLUSIONS

NPMFR could be an effective and safe treatment modality for the treatment of periorbital aging.

Exploring the Pathogenesis and Mechanism-Targeted Treatments of Rosacea: Previous Understanding and Updates

Rosacea is a chronic inflammatory skin disease characterized by recurrent erythema, flushing, telangiectasia, papules, pustules, and phymatous changes in the central area of the face. Patients with this condition often experience a significant negative impact on their quality of life, self-esteem, and overall well-being. Despite its prevalence, the pathogenesis of rosacea is not yet fully understood. Recent research advances are reshaping our understanding of the underlying mechanisms of rosacea, and treatment options based on the pathophysiological perspective hold promise to improve patient outcomes and reduce incidence. In this comprehensive review, we investigate the pathogenesis of rosacea in depth, with a focus on emerging and novel mechanisms, and provide an up-to-date overview of therapeutic strategies that target the diverse pathogenic mechanisms of rosacea. Lastly, we discuss potential future research directions aimed at enhancing our understanding of the condition and developing effective treatments.

Off-Label Use of Botulinum Toxin in Dermatology—Current State of the Art

Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacteria. Among seven different isoforms, only BoNT-A and BoNT-B are commercially used. Currently, botulinum toxin has been indicated by the U.S. Food and Drug Administration in several disorders, among others: chronic migraine, hyperhidrosis, urinary incontinence from detrusor overactivity, or cosmetics. However, there are numerous promising reports based on off-label BTX usage, indicating its potential effectiveness in other diseases, which remains unknown to many. Among them, dermatological conditions, such as rosacea, annal fissure, Raynaud phenomenon, hypertrophic scars and keloids, and also hidradenitis suppurativa, are currently being investigated. This article aims to provide a comprehensive update on the off-label use of botulinum toxin in dermatology, based on an analysis and summary of the published literature.