An update on the treatment of rosacea

Knowledge, attitudes and practices among rosacea patients in Chongqing, China: a cross-sectional study

BACKGROUND

This study aimed to investigate the knowledge, attitude and practice (KAP) of rosacea patients towards rosacea.

OBJECTIVE

The objective was to assess the KAP levels among rosacea patients to inform potential educational interventions.

DESIGN

A web-based cross-sectional study was conducted.

PARTICIPANTS/SETTING

The study was conducted from November 2022 to October 2023 among rosacea patients attending the Dermatology Department of Southwest Hospital, Chongqing, using a self-administered questionnaire.

INTERVENTION

No specific intervention was applied; the focus was on understanding existing KAP.

MAIN OUTCOME MEASURES

The primary outcome measures included KAP scores regarding rosacea.

STATISTICAL ANALYSES PERFORMED

Multivariate logistic regression analysis and structural equation modelling were employed to analyse the associations between KAP scores and demographic factors.

RESULTS

A total of 514 valid questionnaires were collected, with 458 (89.11%) respondents being women. The mean KAP scores were 7.14±2.98 (possible range: 0-12) for knowledge, 52.57±7.07 (possible range: 13-65) for attitude and 62.77±13.24 (possible range: 18-90) for practice. Multivariate analysis indicated that knowledge, attitude, being male, aged 25-30 years and having health insurance were independently associated with proactive practice. Additionally, structural equation modelling revealed that knowledge directly influenced both attitude and practice, while attitude also directly impacted practice (all p<0.001).

CONCLUSIONS

The study found that rosacea patients had inadequate knowledge, a positive attitude and suboptimal practices regarding their condition. It is recommended that comprehensive patient education and support programmes be developed to enhance knowledge, foster positive attitudes and improve practice behaviours among rosacea patients.

Efficacy and safety of topical minocycline preparations for papulopustular rosacea: a systematic review and meta-analysis

Background

Rosacea is a chronic inflammatory skin condition. Papulopustular rosacea (PPR), one of the subtypes of rosacea, presents with papules and pustules (Pelle, 2008). Topical minocycline allow the delivery of high concentrations of the medication to the skin while decreasing systemic exposure thereby evading side effects (Jones et al., 2021, Webster et al., 2020). This study aims to review the literature to delineate the efficacy and safety of topical preparations of minocycline in the treatment of moderate to severe papulopustular rosacea.

Methods

This systematic review included randomized clinical trials (RCT) only that compared the efficacy and safety of 1.5% minocycline foam and 1%, 3% minocycline gel versus placebo in patients with moderate to severe papulopustular rosacea. We performed a systematic search in Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and ClinicalTrials.gov. Efficacy outcomes included the absolute change in inflammatory lesion counts, the percentage change in the inflammatory lesion count, the percentage of participants achieving Investigator Global Assessment (IGA) with improvement of at least two grades, and the proportion of individuals that achieved an IGA 0/1 score ("clear" or "almost clear"). This paper was conducted in adherence to PRISMA guidelines. Also, we have registered our protocol in PROSPERO (CRD42023447486). Quality assessment of the included studies was conducted using ROB-2 tool. Additionally, we have assessed the level of evidence using GRADE too. The analysis was performed using RevMan.

Results

Five randomized controlled trials with low risk of bias were included in the quantitative synthesis with a total of 2,453 enrolled participants. Minocycline (FMX103) 1.5% foam yielded statistically significant results in terms of IGA score indicating treatment success [Risk Ratio (RR) = 1.31, 95% confidence interval (CI) = 1.04-1.66, P = 0.02]. FMX103 and minocycline gel 1% and 3% had significant results in absolute change in inflammatory lesion count (RR = 3.49, 95% CI = 2.61-4.36, P < 0.00001). Change in inflammatory lesion count from baseline with minocycline 1.5% foam was significantly reduced (RR = 9.45, 95% CI = 5.84-13.06, P < 0.00001). Other indicators of symptom reduction were not significant for both foam and gel preparations.

Conclusion

Our findings suggest that topical preparations of minocycline provide statistically significant results in reducing absolute inflammatory lesion count and having IGA treatment success among patients with moderate to severe papulopustular rosacea. Further studies, however, should assess the efficacy of different concentrations and combinations of minocycline to better delineate the effect of this drug in the clinical aspect.

Systematic review registration

PROSPERO, identifier CRD42023447486, https://www.crd.york.ac.uk/PROSPERO/view/CRD42023447486.

A Review of the Diagnostic and Therapeutic Gaps in Rosacea Management: Consensus Opinion

Rosacea is a common, chronic inflammatory disease characterized by both fluctuating and fixed heterogeneous signs such as facial erythema, papules/pustules, telangiectasia, acute vasodilation (flushing), and phymatous changes, and symptoms such as cutaneous stinging and burning. The shift to a phenotype-based approach to rosacea management has improved the consistency of recommendations across recent published guidelines. Consistent and thorough guidance for the classification, diagnosis, and management of the disease is difficult, as the mechanisms underlying the development of rosacea are still not completely understood nor universally accepted. Here, we provide a critical review of current published guidance, and gaps in the knowledge and management of rosacea. We present the recently approved microencapsulated benzoyl peroxide as an effective topical treatment option for papulopustular rosacea. Benzoyl peroxide (BPO) has been used in acne management for many years; however, many clinicians perceive treatment of rosacea with any BPO formulation to be counterintuitive because of concerns of potential skin irritation, while the lack of an accepted mechanism of action on rosacea pathophysiology means that others may be hesitant to use BPO as a treatment. Minocycline foam 1.5% is also an option for the treatment of inflammatory lesions in rosacea, with a decreased risk of systemic adverse events compared with oral minocycline.

Review of laser and energy-based devices to treat rosacea in skin of color

The prevalence of rosacea in skin of color (SOC) populations is estimated to be as high as 10% in some countries. Traditionally, intense pulsed light (IPL) and pulsed dye laser (PDL) have been the laser and energy-based devices (EBDs) used to treat rosacea. However, not all laser and EBDs are safe for SOC (Fitzpatrick skin types IV-VI) due to increased absorption of energy in pigmented skin and increased risk of post-inflammatory hyperpigmentation and scarring. This review summarizes the use of the top seven laser and EBDs for treating rosacea in SOC.

The role of macrophages in rosacea: implications for targeted therapies

Introduction

Rosacea, a widespread chronic skin condition, may be influenced by macrophages, key immune cells in the skin, although their exact role is not yet fully understood. This review delves into the function of macrophages, their potential contribution to rosacea pathogenesis, current treatments, and promising macrophage-targeted therapies. It concludes by identifying knowledge gaps and potential areas for future rosacea research.

Method

Leveraging systematic and narrative literature review techniques, we conducted a comprehensive search of databases such as PubMed, Embase, and Web of Science. Utilizing keywords like "rosacea" and "macrophages", we targeted English articles from the last 5 years (2018-2023). We manually checked reference lists of relevant articles for additional studies. We included only articles emphasizing macrophages' role in rosacea and/or the development of related therapies and published within the specified timeframe.

Results

The systematic search of electronic databases yielded a total of 4,263 articles. After applying the inclusion and exclusion criteria, 156 articles were selected for inclusion in this review. These articles included original research studies, review articles, and clinical trials that focused on the role of macrophages in rosacea and/or the development of macrophage-targeted therapies for the disease. The selected articles provided a comprehensive and up-to-date overview of the current state of research on macrophages in rosacea, including their function in the skin, the potential mechanisms through which they may contribute to rosacea pathogenesis, and the current treatments and therapies available for the disease. Additionally, the articles identified gaps in knowledge regarding the role of macrophages in rosacea and suggested potential areas for future research.

Conclusion

This literature review emphasizes the important role that macrophages, vital immune cells in the skin, may play in the pathogenesis of rosacea, a common chronic inflammatory skin disorder. The selected studies suggest potential mechanisms by which these cells might contribute to rosacea progression, although these mechanisms are not yet fully understood. The studies also spotlight current rosacea treatments and illuminate the promising potential of new macrophage-focused therapies. Despite these insights, significant gaps persist in our understanding of the precise role of macrophages in rosacea. Future research in this area could provide further insights into the pathogenesis of rosacea and contribute to the development of more effective, targeted therapeutic strategies.

Demodicosis in Different Age Groups and Alternative Treatment Options-A Review

Infestation with Demodex mites is a common occurrence, especially in adults and the elderly. More recent attention has been paid to the presence of Demodex spp. mites in children, even ones without comorbidities. It causes both dermatological and ophthalmological problems. The presence of Demodex spp. is often asymptomatic, thus it is suggested to include parasitological investigation tests in dermatological diagnostics, in addition to bacteriological analysis. Literature reports show that Demodex spp. are related to the pathogenesis of numerous dermatoses, including rosacea or demodicosis gravis, and common eye pathologies reported by patients such as dry eye syndrome or ocular surface inflammatory conditions, such as blepharitis, chalazia, Meibomian gland dysfunction, and keratitis. Treatment of patients is a challenge and is usually prolonged, therefore it is important to carefully diagnose and properly select the therapy regimen for the treatment to be successful, and with minimal side effects, especially for young patients. Apart from the use of essential oils, research is ongoing for new alternative preparations active against Demodex sp. Our review was focused on the analysis of the current literature data on the available agents in the treatment of demodicosis in adults and children.

Solubility of Foreign Molecules in Stratum Corneum Brick and Mortar Structure

The barrier function of the skin is mainly assured by its outermost layer, stratum corneum (SC). One key aspect in predicting dermal drug delivery and in safety assessment of skin exposure to chemicals is the need to determine the amount of chemical that is taken up into the SC. We here present a strategy that allows for direct measures of the amount of various solid chemicals that can be dissolved in the SC in any environmental relative humidity (RH). A main advantage of the presented method is that it distinguishes between molecules that are dissolved within the SC and molecules that are not dissolved but might be present at, for example, the skin surface. In addition, the method allows for studies of uptake of hydrophobic chemicals without the need to use organic solvents. The strategy relies on the differences in the molecular properties of the added molecules in the dissolved and the excess states, employing detection methods that act as a dynamic filter to spot only one of the fractions, either the dissolved molecules or the excess solid molecules. By measuring the solubility in SC and delipidized SC at the same RHs, the same method can be used to estimate the distribution of the added chemical between the extracellular lipids and corneocytes at different hydration conditions. The solubility in porcine SC is shown to vary with hydration, which has implications for the molecular uptake and transport across the skin. The findings highlight the importance of assessing the chemical uptake at hydration conditions relevant to the specific applications. The methodology presented in this study can also be generalized to study the solubility and partitioning of chemicals in other heterogeneous materials with complex composition and structure.

Treatment strategies, including antibiotics, to target the immune component of rosacea

INTRODUCTION

Recent advances in the understanding of the pathophysiology of rosacea have led to increased focus on the disease's immunologic etiology and to the development of immunologically based treatments. With many patients suffering from incomplete control, addressing the immune components of the disease process may provide a more effective treatment option for rosacea patients that may improve quality of life.

AREAS COVERED

This review will provide a brief overview of the pathophysiology of rosacea, as well as specific immunologic contributions to the disease state. Current standard-of-care treatments will be described, including anti-parasitic, anti-inflammatory agents, and antibiotics. Emphasis will be placed on treatments that target the immune components of the disease process.

EXPERT OPINION

Rosacea remains a difficult dermatologic disease to treat, partially due to an incomplete understanding of the disease pathophysiology. The immune pathophysiology of rosacea, particularly the key role of inflammation, has been clarified over the past decade. Identification of specific molecules, including cytokines and nuclear transcription factors, may allow for the development of targeted rosacea-specific biologic and topical treatments. However, medication nonadherence is a limiting factor to achieving symptomatic control among rosacea patients. Focusing on the development of oral or injectable forms of therapy may circumvent poor adherence.

A comprehensive insight into the anti-inflammatory properties of dapsone

The 4,4'-diaminodiphenyl sulfone (DDS), also known as dapsone, is traditionally used as a potent anti-bacterial agent in clinical management of leprosy. For decades, dapsone has been among the first-line medications used in multidrug treatment of leprosy recommended by the World Health Organization (WHO). Shortly after dapsone's discovery as an antibiotic in 1937, the dual function of dapsone (anti-microbial and anti-inflammatory) was elucidated. Dapsone exerts its anti-bacterial effects by inhibiting dihydrofolic acid synthesis, leading to inhibition of bacterial growth, while its anti-inflammatory properties are triggered by inhibiting reactive oxygen species (ROS) production, reducing the effect of eosinophil peroxidase on mast cells and downregulating neutrophil-mediated inflammatory responses. Among the leading mechanisms associated with its anti-microbial/anti-protozoal effects, dapsone clearly has multiple antioxidant, anti-inflammatory, and anti-apoptotic functions. In this regard, it has been described in treating a wide variety of inflammatory and infectious skin conditions. Previous reports have explored different molecular targets for dapsone and provided insight into the anti-inflammatory mechanism of dapsone. This article reviews several basic, experimental, and clinical approaches on anti-inflammatory effect of dapsone.

Perspectives on rosacea patient characteristics and quality of life using baseline data from a phase 3 clinical study conducted in Japan

There is a lack of contemporary data on rosacea originating in Japan. Using baseline data from a randomized, phase 3 study of 130 Japanese patients with rosacea treated with metronidazole gel (0.75%) or vehicle, the authors evaluated demographic and clinical characteristics, pretreatment quality of life, and exacerbating factors. In line with global data, most patients were women (82.3%; 107/130) and aged between 30 and 50 years (60.7%; 79/130). Patient-reported quality of life scores indicated that rosacea had an impact similar to that of other debilitating and disfiguring skin conditions (such as psoriasis), particularly in terms of the emotional burden. Anxiety or depression was reported by 30% of patients (39/130), with 6.9% (9/130) reporting moderate levels and 0.8% (1/130) reporting severe levels. The top five exacerbating factors reported to trigger worsening of rosacea were temperature changes, sun exposure, hot weather, seasonal variation, and heavy exercise. In addition, pollen exposure and menstruation were noted as triggers of rosacea symptoms; these are novel findings that require further investigation to fully understand the implications for patients and treatment. Rosacea is likely to be underdiagnosed and undertreated in Japan because of the current lack of consensus guidelines and standardized therapy. The authors anticipate that the results of this analysis will provide much needed information to help improve diagnosis and facilitate the management of rosacea in patients.

Compatibility of Personalized Formulations in Cleoderm™, A Skin Rebalancing Cream Base for Oily and Sensitive Skin

Inflammatory skin conditions are prevalent in the general population and are a source of much concern for those who suffer from them. Acne is an extremely common condition and can significantly impact the quality of life of affected patients. Rosacea is another common dermatological disorder that often affects the face and can present with flushing, irritated skin, and pimples. In addition to being key for acne and rosacea, inflammation can also play a role in prematurely aging skin and contributes to the formation of wrinkles. Given the prevalence and patient impact of dermatological conditions on the face, such as those previously described, there is a demand for personalized medicines to manage these conditions when commercially available options are unsuitable, unavailable, or insufficient to fully resolve the condition. When designing an appropriate personalized therapy for a patient, both the vehicle and the active pharmaceutical ingredient choices are key to the success of the treatment. Cleoderm™ is a topical cream designed for use as a vehicle for the preparation of dermatological treatments by compounding pharmacies. Its ingredient profile was specifically curated to be gentle on the skin, allowing its use as a vehicle for compounded preparations that may be applied to sensitive and affected skin. In this bracketed study, benzoyl peroxide, cyproterone acetate, estriol, metronidazole, niacinamide, progesterone, retinoic acid, spironolactone, and tranexamic acid were selected, due to their known applications for dermatological skin conditions. To evaluate the compatibility and stability of Cleoderm™ in these formulations, high-performance liquid chromatography, followed by antimicrobial effectiveness testing, were performed for 180 days. For most formulations, a beyond-use date of 180 days was observed when stored at room temperature, except for retinoic acid, which had a beyond-use date of 30 days. Through the outcomes of this study, we concluded that Cleoderm™ presents increased convenience for both the compounding pharmacist and the patient, suggesting that it is an adequate candidate vehicle for compounding different dermatological formulations with adequate stability, presenting itself as a good alternative to commercially available treatments that cannot be personalized.

Assessment of the Efficacy and Safety of 30% Supramolecular Salicylic Acid Peeling for Papulopustular Rosacea Treatment

Background

Thirty per cent supramolecular salicylic acid (SSA) is a water-soluble, sustained release salicylic acid (SA) modality, which is well tolerated by sensitive skin. Anti-inflammatory therapy plays an important role in papulopustular rosacea (PPR) treatment. SSA at a 30% concentration has a natural antiinflammatory property.

Aims

This study aims to investigate the efficacy and safety of 30% SSA peeling for PPR treatment.

Methods

Sixty PPR patients were randomly divided into two groups: SSA group (30 cases) and control group (30 cases). Patients of the SSA group were treated with 30% SSA peeling three times every 3 weeks. Patients in both groups were instructed to topically apply 0.75% metronidazole gel twice daily. Transdermal water loss (TEWL), skin hydration and erythema index were assessed after 9 weeks.

Results

Fifty-eight patients completed the study. The improvement of erythema index in the SSA group was significantly better than that in the control group. No significant difference was found in terms of TEWL between the two groups. The content of skin hydration in both the groups increased, but there was no statistical significance. No severe adverse events were observed in both the groups.

Conclusion

SSA can significantly improve the erythema index and overall appearance of skin in rosacea patients. It has a good therapeutic effect, good tolerance and high safety.

Protective Effects of Dapsone on Scopolamine-Induced Memory Impairment in Mice: Involvement of Nitric Oxide Pathway

Introduction

The leading cause of memory impairment is dementia-related disorders. Since current treatments for memory impairment target the neuroinflammatory pathways, we selected dapsone, an anti-inflammatory agent, to evaluate its effects on scopolamine-induced memory impairment in mice and the underlying role of nitric oxide (NO).

Methods

Scopolamine (1 mg/kg, intraperitoneal [i.p.]) was used for induction of memory impairment. The animals received various doses of dapsone (0.1, 0.3, 1, 5, and 10 mg/kg, i.p.). Duration and number of arms visits in the Y-maze and step-through latency in the passive-avoidance were documented. To evaluate the underlying signaling pathway, N(ω)-nitro-L-arginine methyl ester (a nonspecific NO synthase [NOS] inhibitor), aminoguanidine (a specific inducible NOS inhibitor), and 7-nitroindazole (a specific neuronal NOS inhibitor) were administered 30 min after dapsone administration.

Results

Dapsone (5 mg/kg) substantially improved memory acquisition in scopolamine-induced memory impairment. Additionally, NOS inhibitors considerably reversed the observed neuroprotective effects of dapsone, accompanied by the elevation of NO levels.

Conclusion

Dapsone revealed a neuroprotective effect against scopolamine-induced memory impairment in mice, possibly through the nitrergic pathway.

The effect of presence of Helicobacter pylori on the severity and clinical course of Rosacea

Introduction: Rosacea is manifested by erythema and telangiectasias limited to the regions of cheeks, nose, chin and forehead. Data from the literature indicate a possible causal relationship between Helicobacter pylori infection in the gastrointestinal tract and rosacea, which is confirmed by the improvement of symptoms and clinical picture of rosacea after administered Helicobacter pylori eradication therapy. The aim of the paper was to determine the frequency of Helicobacter pylori infection in patients with rosacea and to examine the effect of the therapy for eradication of infection of this microorganism on the clinical course of rosacea. Methods: Sixty patients with a diagnosis of rosacea who were treated in 2018 at the Clinic for Skin and Venereal Diseases of the University Clinical Centre of Republic of Srpska were analysed. Patients were examined during their visit to a dermatologist (first week) and after applied therapy (sixth week). Subjects were divided into two groups-group I consisted of subjects in which, in addition to rosacea, the presence of Helicobacter pylori was registered and for whom the topical therapy and triple therapy for eradication of Helicobacter pylori were administered, and group II, which included subjects in which, in addition to rosacea, the presence of Helicobacter pylori was not registered and for whom only topical therapy was administered. Statistical processing was performed in the IBM SPSS Statistics 21 software package. Results: Helicobacter pylori infection was registered in 45 % of patients. Statistical significance was determined between the presence of Helicobacter pylori infection and the presence of pustules in patients with rosacea (p = 0.027), with an occurrence of pustules significantly more frequent in patients belonging to group I (55.6 %) than in patients belonging to group II (24.2 %). Conclusion: Therapy for eradicating Helicobacter pylori infection improves the clinical course of rosacea, especially in the stage of papules and pustules.

Foray into Concepts of Design and Evaluation of Microemulsions as a Modern Approach for Topical Applications in Acne Pathology

With a fascinating complexity, governed by multiple physiological processes, the skin is considered a mantle with protective functions which during lifetime are frequently impaired, triggering dermatologic disorders. As one of the most prevalent dermatologic conditions worldwide, characterized by a complex pathogenesis and a high recurrence, acne can affect the patient's quality of life. Smart topical vehicles represent a good option in the treatment of a versatile skin condition. By surpassing the stratum corneum known for diffusional resistance, a superior topical bioavailability can be obtained at the affected place. In this direction, the literature study presents microemulsions as a part of a condensed group of modern formulations. Microemulsions are appreciated for their superior profile in matters of drug delivery, especially for challenging substances with hydrophilic or lipophilic structures. Formulated as transparent and thermodynamically stable systems, using simplified methods of preparation, microemulsions have a simple and clear appearance. Their unique structures can be explained as a function of the formulation parameters which were found to be the mainstay of a targeted therapy.

Update on the Management of Rosacea from the American Acne & Rosacea Society (AARS)

Importance: Previous consensus articles on rosacea from the American Acne and Rosacea Society (AARS) have focused on pathophysiology, clinical assessment based on phenotypic expressions of rosacea, management guidelines, discussions of individual medical therapies, and reviews of physical modalities. Pathophysiologic mechanisms believed to be operative in rosacea have been covered extensively in the literature. Objective: This article updates the previously published consensus recommendations from the AARS on the management of rosacea, including systematic literature and evidence-based reviews of available therapeutic agents and physical modalities. Observations: This article includes discussions of available published data on topical ivermectin, topical oxymetazoline, combination therapy approaches, and physical devices for the management of rosacea. Consistent with what many publications on rosacea currently emphasize, clinicians are encouraged to define the clinical manifestations present in the patient and to select therapies that correlate with the optimal treatment of those manifestations. There are less data available on how to optimally integrate therapies; however, it appears that rationally selected medical therapies can be utilized concurrently. Conclusion: Due to the multifactorial pathogenesis of rosacea, its clinical presentation is heterogeneous. Rosacea is a chronic and recurrent inflammatory disorder, and clinical manifestations often vary in nature and severity over time, which might necessitate an adjustment in treatment. As new data become available, rosacea management approaches should be updated.

Mesenchymal Stem/Stromal Cell-Derived Exosomes for Immunomodulatory Therapeutics and Skin Regeneration

Exosomes are nano-sized vesicles that serve as mediators for cell-to-cell communication. With their unique nucleic acids, proteins, and lipids cargo compositions that reflect the characteristics of producer cells, exosomes can be utilized as cell-free therapeutics. Among exosomes derived from various cellular origins, mesenchymal stem cell-derived exosomes (MSC-exosomes) have gained great attention due to their immunomodulatory and regenerative functions. Indeed, many studies have shown anti-inflammatory, anti-aging and wound healing effects of MSC-exosomes in various in vitro and in vivo models. In addition, recent advances in the field of exosome biology have enabled development of specific guidelines and quality control methods, which will ultimately lead to clinical application of exosomes. This review highlights recent studies that investigate therapeutic potential of MSC-exosomes and relevant mode of actions for skin diseases, as well as quality control measures required for development of exosome-derived therapeutics.

Update on the use of dapsone in dermatology

Dapsone (4,4'-diaminodiphenylsulfone) is the only remaining sulfone used in anthropoid therapeutics and is commercially available as an oral formulation, an inhaled preparation, and a 5% or 7.5% cream. Dapsone has antimicrobial effects stemming from its sulfonamide-like ability to inhibit the synthesis of dihydrofolic acid. It also has anti-inflammatory properties such as inhibiting the production of reactive oxygen species, reducing the effect of eosinophil peroxidase on mast cells and down-regulating neutrophil-mediated inflammatory responses. This allows for its use in the treatment of a wide variety of inflammatory and infectious skin conditions. Currently in dermatology, the US Food and Drug Administration (FDA)-approved indications for dapsone are leprosy, dermatitis herpetiformis, and acne vulgaris. However, it proved itself as an adjunctive therapeutic agent to many other skin disorders. In this review, we discuss existing evidence on the mechanisms of action of dapsone, its FDA-approved indications, off-label uses, and side effects.

The Role of IL-17 in Papulopustular Rosacea and Future Directions

Rosacea is a chronic, progressive, inflammatory condition phenotypically subtyped into diagnostic features, major features, and minor/secondary features. There is currently no cure for rosacea, and it carries a significant negative psychosocial burden for afflicted patients. While there are a number of treatment modalities at the disposal of the clinician, clinical experience has suggested a need for updated treatments. The pathogenesis of rosacea is multifactorial; however, this paper will focus on the pivotal role of interleukin 17 (IL-17) in the development and progression of the disease. Furthermore, this paper will explore the mechanism of action of standard rosacea treatments and their effect on different stages of the IL-17 pathway. The standard treatments for rosacea are usually effective in controlling the symptoms of the disease in its mild-to-moderate form; however, their efficacy is diminished in the setting of severe and treatment-resistant rosacea. We hypothesize that IL-17 inhibitors, currently used successfully in psoriasis and psoriatic arthritis, could perhaps be used to treat severe and treatment-resistant papulopustular rosacea in the future; however, clinical trials and case reports will be needed to dictate expanded indications of IL-17 inhibitors. Furthermore, the high cost of IL-17 inhibitors presently prevents their use in disease states other than psoriasis or psoriatic arthritis.

Update on the Management of Rosacea from the American Acne & Rosacea Society (AARS)

Importance: Previous consensus articles on rosacea from the American Acne and Rosacea Society (AARS) have focused on pathophysiology, clinical assessment based on phenotypic expressions of rosacea, management guidelines, discussions of individual medical therapies, and reviews of physical modalities. Pathophysiologic mechanisms believed to be operative in rosacea have been covered extensively in the literature. Objective: This article updates the previously published consensus recommendations from the AARS on the management of rosacea, including systematic literature and evidence-based reviews of available therapeutic agents and physical modalities. Observations: This article includes discussions of available published data on topical ivermectin, topical oxymetazoline, combination therapy approaches, and physical devices for the management of rosacea. Consistent with what many publications on rosacea currently emphasize, clinicians are encouraged to define the clinical manifestations present in the patient and to select therapies that correlate with the optimal treatment of those manifestations. There are less data available on how to optimally integrate therapies; however, it appears that rationally selected medical therapies can be utilized concurrently. Conclusion: Due to the multifactorial pathogenesis of rosacea, its clinical presentation is heterogeneous. Rosacea is a chronic and recurrent inflammatory disorder, and clinical manifestations often vary in nature and severity over time, which might necessitate an adjustment in treatment. As new data become available, rosacea management approaches should be updated.

Effects of dextran sulfate, 4-t-butylcyclohexanol, pongamia oil and hesperidin methyl chalcone on inflammatory and vascular responses implicated in rosacea

Background

Rosacea is a chronic facial skin disorder characterized by inflammation and vascular abnormalities. The pathophysiology of rosacea involves increased activation of the capsaicin receptor, TRPV1, the vascular endothelial growth factor (VEGF) pathway, and cathelicidin LL-37, MMP-9, and KLKs. We evaluated the activity of four compounds (dextran sulfate, 4-t-butylcyclohexanol [BCH; TRP-regulin^®], pongamia oil, and hesperidin methyl chalcone [HMC]) on inflammatory and vascular responses implicated in rosacea.

Materials and methods

The anti-inflammatory activity of dextran sulfate was evaluated on PGE2 production after PMA stimulation of NCTC-2544 keratinocytes, and on normal human epidermal keratinocytes (NHEKs) after proinflammatory stimulation to mimic a rosacea environment. The anti-angiogenic activity of dextran sulfate was measured by analyzing pseudotube formation in co-cultured human microvascular endothelial cells/normal human dermal fibroblasts. HMC modulation of vascular responses and IL-8 cytokine production after SP stimulation was evaluated in human skin explants. We also assessed the effect of BCH on TRPV1 activation, and the effect of combined BCH and pongamia oil on the inflammatory response of NHEKs.

Results

Dextran sulfate strongly and significantly inhibited PMA-induced PGE2 production, inhibited KLK5 and MMP-9 mRNA expression, and IL-8, IL-1α and VEGF production, and displayed a highly significant inhibitory effect on VEGF-induced pseudotube formation. In SP-stimulated human skin explants, HMC significantly decreased the proportion of dilated vessels, total vessel area, and IL-8 production. BCH significantly and dose-dependently inhibited TRPV1 activation, and BCH and pongamia oil inhibited CXCL1 and CXCL6 mRNA expression and IL-8 production in NHEKs. Combined BCH/pongamia oil inhibited IL-8 production synergistically.

Conclusion

These in vitro results showed that dextran sulfate, BCH, pongamia oil and HMC, possess complementary soothing and anti-redness properties, supporting their combination in Avène redness-relief cosmetic products for sensitive skin prone to redness, and for topical adjunctive rosacea treatment.