Rosacea Research Digest - November 29, 2024
The latest rosacea research in your inbox.
The Rosacea Research Digest from the National Rosacea Society keeps you up to date on recently published basic and clinical research on rosacea, as well as news, reviews, and presentations. It goes out on the last weekday of each month.
Subscriptions are included as part of professional membership in the NRS, and are also available — free through the end of the year — to all healthcare professionals, patients and others interested in this common but often misunderstood disorder affecting more than 16 million Americans.
We appreciate your feedback as we develop this new resource. Please email us at digest@rosacea.org with your comments and suggestions.
Research
Topical ivermectin treatment of rosacea changes the bacterial microbiome of the skin.
Nakatsuji T, Cheng JY, Butcher A, et al. J Invest Dermatol. 2024 Oct 29:S0022-202X(24)02869-0. Epub ahead of print. doi:10.1016/j.jid.2024.10.592
Rosacea is a chronic skin condition frequently associated with the Demodex mite which is felt to be a significant contributor to the inflammation in rosacea. Lack of correlation, however, between clinical severity and mite density in multiple studies has put the role of Demodex as the sole driver of the cutaneous manifestations of rosacea into question. Topical ivermectin is an effective treatment for rosacea and its anthelmintic effect against Demodex is believed to be substantial. Demodex frequently co-infects the skin with various bacterial pathogens. Thus, an imbalanced microbiome, known as dysbiosis, has been observed on the skin of patients with rosacea. However, the pathogenesis of microbial dysbiosis in this disease is still largely unknown. This study reports an association between clinical improvement in rosacea with changes in density of Demodex as well as changes in the bacterial microbiome following the use of topical ivermectin.
Incidence of rosacea associated with hormonal intrauterine devices: A comparative study with nonhormonal intrauterine devices.
Arza A, Stitzlein E, Gupta M, Ilyas EN. J Am Acad Dermatol. 2024 Oct 22:S0190-9622(24)03042-1. Epub ahead of print. doi:10.1016/j.jaad.2024.10.029
Hormonal contraceptives alter hormone levels by manipulating progesterone and estrogen. These include oral contraceptive pills, intrauterine devices (IUDs), and other non-pill methods. Concerns about their effects on androgen and estrogen receptors have linked them to potential side effects, including rosacea, a chronic skin condition characterized by facial erythema and inflammatory lesions. This study compares the incidence of rosacea among hormonal and nonhormonal IUD users, examining the potential dermatologic implications of each method.
From CO2 to Er:YAG: a comprehensive review of laser treatments for rhinophyma.
Kamrani P, Boen M, Fabi SG, Goldman MP. J Drugs Dermatol. 2024 Nov 1;23(11):932-936. doi:10.36849/JDD.8199
Background: Rhinophyma, a benign condition resulting in nasal sebaceous tissue hypertrophy, predominantly affects Caucasian males. There are numerous surgical and medical treatments for rhinophyma with varying degrees of success. This review aims to provide a comprehensive overview of ablative therapies, highlighting our preferred treatment approach. Methods: This review analyzes the evidence behind ablative lasers in treating rhinophyma, with a focus on the 10600 nm carbon dioxide (CO2) and 2940 nm erbium: yttrium-aluminum-garnet (Er:YAG). Results: Both CO2 and Er:YAG have demonstrated efficacy in treating rhinophyma. CO2 laser ablation results in a higher incidence of scarring and hypopigmentation. Er:YAG has high water absorption, which results in less thermal damage, allowing for quicker healing and fewer complications. Conclusion: Management of rhinophyma can remain challenging; however, ablative lasers are an effective treatment. Both laser types have promising outcomes, each with different advantages and complications. In particular, Er:YAG presents fewer complications compared to CO2 lasers.
Effect of combined probiotics and doxycycline therapy on the gut-skin axis in rosacea.
Yu J, Duan Y, Zhang M, et al. mSystems. 2024 Oct 30:e0120124. Epub ahead of print. doi:10.1128/msystems.01201-24
Rosacea is a chronic inflammatory skin condition marked by facial erythema, telangiectasia, and acne-like eruptions, affecting millions worldwide. While antibiotics remain a common treatment, prolonged use has significant adverse effects and can lead to antibiotic resistance. This study evaluated the impact of combined probiotics and doxycycline treatment on rosacea, emphasizing the gut–skin axis. Sixty rosacea patients were randomly assigned to the probiotic, placebo, or control groups. After a 2-week doxycycline treatment, participants underwent a 3-month intervention with either a placebo, probiotic, or no further treatment. Clinical outcomes were assessed at baseline and after the 14-week intervention. Our results showed that probiotic administration improved facial skin conditions, alleviated inflammation, and reduced facial skin microbiota diversity while enhancing gut microbiota heterogeneity. Multivariate analysis identified microbial markers distinguishing the probiotic group from the control and placebo groups, and some markers were associated with skin health parameters. After the probiotic intervention, some facial skin-associated taxa, such as Aquabacterium sp., UBA4096 sp. 1, UBA4096 sp. 2, and Yimella indica, decreased in abundance. Additionally, the fecal microbiota of the probiotic group was enriched in specific gut microbes, including Streptococcus parasanguinis, Erysipelatoclostridium ramosum, and Coprobacillus cateniformis, while showing a reduced abundance of Bacteroides vulgatus. These changes were associated with reduced facial sebum levels and a lower physician’s global assessment score. Finally, fewer antibiotic resistance genes, particularly tetracycline resistance genes, were detected in the probiotic group compared with the control and placebo groups. Our study supports the existence of a gut–skin axis and the application of probiotics in managing rosacea.
Efficacy of treatments in reducing facial erythema in rosacea: a systematic review.
Hua NJ, Chen J, Geng RSQ, et al. J Cutan Med Surg. 2024 Oct 31:12034754241287546. Epub ahead of print. doi:10.1177/12034754241287546
Rosacea is a chronic inflammatory skin condition that affects over 5% of individuals worldwide. Its clinical presentation is characterized by an array of features, including erythema, papules and pustules, phymatous changes, telangiectasia, and ocular manifestations. Specifically, the multifaceted manifestation of erythema varies widely in intensity and distribution. Factors contributing to pathogenesis include neurovascular dysregulation, increased levels of pro-inflammatory mediators, and aberrant vasodilation. Erythema management plays an important role in reducing the psychosocial burden associated with rosacea and improving overall quality of life. Cochrane CENTRAL, Medline, and Embase databases were searched from inception to September 2023 and included 33 clinical trials reporting on a total of 7411 rosacea patients (74.1% female) and 21 different topical or systemic treatments. The mean age was 48.8 years (range, 18-83 years), and the mean time to outcome assessment was 8.1 weeks (standard deviation, 4.1 weeks). Treatment efficacy was assessed by outcome measures including percent improvement from baseline on 4- and 5-point scales, clinician erythema assessment (CEA) success (improvement ≥1 point), and CEA and patient self-assessment success (improvement ≥1 point). Pooled effect sizes for each treatment were calculated as a weighted average based on the number of patients in each study. The most effective topical treatments for reducing erythema include sodium sulphacetamide and sulphur, praziquantel, metronidazole, and B244 spray (Nitrosomonas eutropha). The most effective systemic treatment was paroxetine. Our findings highlight the varying efficacy of treatments in addressing the erythema in rosacea, recognizing the nuances of clinical presentations.
The treatment efficacy of 7.5% dapsone gel in papulopustular rosacea: a prospective study.
Özkoca D, Caf N. Cutan Ocul Toxicol. 2024 Nov 12:1-5. Epub ahead of print. doi:10.1080/15569527.2024.2424932
Introduction: Topical dapsone has a level A recommendation for the treatment of papulopustular rosacea; however, its treatment efficacy has not been studied previously. The aim of this study is to evaluate the safety and efficacy of topical 7.5% dapsone gel applied once daily at night in the treatment of papulopustular rosacea. Patients and methods: This is a prospective study including female papulopustular rosacea patients with a minimum IGA score of 2. The patients were recruited at two different outpatient clinics by two independent dermatologists. The patients were prescribed 7.5% dapsone gel (same brand) for once-daily use at night. No other topical or systemic treatment modalities were allowed to be used during the study except for a sun protection factor 50 sunscreen and an emollient face cream. The patients were evaluated with the total lesion counts and IGA scores at weeks 0, 4 and 8 by two independent dermatologists. The side effects of burning, stinging, pain, erythema, and exfoliation were questioned during the follow-up visits. Results: All 32 recruited patients (18-70) completed the study. The mean lesion counts of the patients were 22.10 ± 8.95 on the initial visit, 11.90 ± 6.49 on the 4th week follow-up and 3.87 ± 3.76 on the 8th week follow up. The mean IGA scores of the patients were 3.06 ± 0.81 on the initial visit, 2.10 ± 0.87 on week 4 and 0.74 ± 0.73 on week 8. The decrease in the mean lesion count and IGA score of the patients in weeks 4 and 8 were statistically significant (p = 0.000 for all). This decrease was independent of the patient's age (p > 0.005). No side effects were reported. Conclusions: The 7.5% topical formulation of dapsone is effective for papulopustular rosacea both on the first and second months of the treatment regardless of the age of the patient. Its safe side effect profile suits for a comfortable use in rosacea patients with a decreased skin tolerance.
Toll-like receptor-4 expression and oxidative stress in ocular rosacea.
Yesilirmak N, Bukan N, Kurt B, et al. Mol Vis. 2024 Mar 30;30:211-218. PMID:39563674; PMCID:PMC11575841.
Purpose: To investigate systemic and ocular toll-like receptor (TLR)-4 expression and its association with oxidative stress markers in ocular rosacea (OR). Methods: This prospective study included 40 patients with rosacea with ocular involvement and 20 healthy volunteers. Tear break-up time (TBUT), Schirmer test, meibomoscore, and ocular surface disease index (OSDI) scores were estimated for all participants. TLR-4 expression in conjunctival epithelium and peripheral blood mononuclear cells was quantified using real-time polymerase chain reaction (RT-PCR). In the tears and serum samples of all participants, antioxidant status (TAS), total oxidant status (TOS), and arylesterase (ARE) activation levels were measured using a fully automated spectrophotometric method, and the oxidative stress index (OSI) was calculated. Results: TLR-4 expression levels and oxidative stress status (TOS and OSI values) were significantly higher (p < 0.01), and antioxidant status (TAS and ARE values) were significantly lower (p < 0.01) in both ocular and blood samples of patients with OR compared with those in controls. A significant positive correlation was found between the ocular and blood values in all parameters (p < 0.05). According to the clinical associations of these results, we found negative correlations between TLR-4, OSI, and TBUT and between TLR-4 and Schirmer, whereas a positive correlation was observed between TLR-4, OSI, and meiboscore and between TLR-4, OSI, and OSDI (p < 0.05). No correlation was found between the OSI and Schirmer results (p = 0.92). Conclusions: TLR-4 and oxidative stress both play important roles in OR pathophysiology and are closely related to clinical findings.
Validation of a photonumeric scale for evaluation of telangiectasia in rosacea.
Nguyen L, Seeber N, Baron JM, et al. J Cosmet Dermatol. 2024 Oct 27. Epub ahead of print. doi:10.1111/jocd.16593
Background: Telangiectasia is a prominent feature of rosacea leading to a high demand for effective treatment. To ensure consistent clinical and scientific evaluations and assess treatment response accurately, standardized assessment tools are necessary for grading the severity of telangiectasia. However, no validated grading scales for this condition are currently available. Aim: To develop and validate a photonumeric scale for assessing the severity of telangiectasia in rosacea patients. Methods: The five-point photonumeric Telangiectasia in Rosacea Severity Assessment (TRoSA) scale was developed for the severity of telangiectasia in rosacea. Sixteen experts participated in the validation process, evaluating 50 images of rosacea patients in two rounds. Interrater and intrarater reliability were analyzed using the intraclass correlation coefficient (ICC) and weighted kappa, respectively. Results: Interrater reliability was found to be "almost perfect" in both validation rounds (Round 1: ICC 0.847; Round 2: ICC 0.828). The mean weighted kappa indicated "substantial" intrarater reliability between the two rounds with a weighted kappa of 0.719. A bubble plot of the two rounds illustrated a diagonal order, confirming the consistency of the intrarater agreement. Conclusions: The TRoSA scale demonstrated high interrater and intrarater reliability indicating that it is a consistent and reproducible tool for grading the severity of telangiectasia in rosacea. This scale can standardize clinical assessments, assisting in diagnosis, treatment planning, and evaluation of therapeutic efficacy.
Photodynamic therapy: past, current, and future.
Aebisher D, Czech S, Dynarowicz K, et al. Int. J. Mol. Sci. 2024; 25(20):11325. doi:10.3390/ijms252011325
The Greek roots of the word “photodynamic” are as follows: “phos” (φω~ς) means “light” and “dynamis” (δύναμις) means “force” or “power”. Photodynamic therapy (PDT) is an innovative treatment method based on the ability of photosensitizers to produce reactive oxygen species after the exposure to light that corresponds to an absorbance wavelength of the photosensitizer, either in the visible or near-infrared range. This process results in damage to pathological cancer cells, while minimizing the impact on healthy tissues. PDT is a promising direction in the treatment of many diseases, with particular emphasis on the fight against cancer and other diseases associated with excessive cell growth. The power of light contributed to the creation of phototherapy, whose history dates back to ancient times. It was then noticed that some substances exposed to the sun have a negative effect on the body, while others have a therapeutic effect. This work provides a detailed review of photodynamic therapy, from its origins to the present day. It is surprising how a seemingly simple beam of light can have such a powerful healing effect, which is used not only in dermatology, but also in oncology, surgery, microbiology, virology, and even dentistry. However, despite promising results, photodynamic therapy still faces many challenges. Moreover, photodynamic therapy requires further research and improvement.
Case Reports
Management of 10 children with inflammatory rosacea with topical ivermectin.
Dall'Oglio F, Nasca MR, Tedeschi A, et al. Pediatr Dermatol. 2024 Oct 30. Epub ahead of print. doi:10.1111/pde.15783
Rosacea diagnosis and treatment in children are challenging, due to its rarity and to the lack of approved pharmacological agents for its treatment in this age group. In this case series, response to treatment with once daily applications of ivermectin (IVM) 1% cream for 12 weeks in 10 children affected by mild to severe inflammatory rosacea was evaluated clinically by Investigator Erythema Severity Assessment (IESA), Investigator Global Assessment of Severity (IGA-S), Investigator Global Assessment score of Global Efficacy (IGA-GE), and instrumentally by dermoscopy and Erythema-Directed Digital Photography (EDDP). Clinical improvement was achieved at the end of treatment compared to baseline (IESA: 2.3 vs. 0.5; IGA-S: 2.1 vs. 0.3) and confirmed by IGA-GE (0 = 55%, 1 = 33%, 3 = 11%) and instrumental monitoring (EDDP: 2.7 vs. 0.6). Once daily IVM application may be an effective therapeutic option for children with rosacea.
Rosacea fulminans following initiation of deucravacitinib.
Thomas M, Paranjape M, Sinclair R. Clin Exp Dermatol. 2024 Nov 15:llae495. Epub ahead of print. doi:10.1093/ced/llae495
Rosacea fulminans developed in a middle-aged caucasian man 10 days after initiating Deucravacitinib for chronic plaque psoriasis. The painful papulopustular eruption resolved without scarring after discontinuation of deucravacitinib, and treatment with a short-course of oral prednisolone. This case is notable as it is the first reported instance of rosacea fulminans linked to the use of a JAK inhibitor.
News
‘Another arrow to the quiver for physicians’: FDA approves Emrosi for rosacea
Healio Dermatology
The FDA has approved Emrosi for the treatment of rosacea in adults, Journey Medical Corporation announced in a press release.
Topical Ivermectin Among Treatment Options for Ocular Rosacea
Medscape
In the clinical experience of Julie C. Harper, MD, patients with ocular rosacea don’t always present with telltale signs like red or bloodshot eyes.
Advances and Challenges in Rosacea Treatment: Insights From Hilary Baldwin, MD
Dermatology Times
“We talked again about the importance of the newer, branded medications like ivermectin, minocycline foam, and the new microencapsulated benzoyl peroxide, as being vastly superior to the other older topical medications that we had for treating the papules and pustules of rosacea. And lastly, we talked about isotretinoin. Don't forget isotretinoin for the treatment of recalcitrant rosacea. It works extremely well,” said Hilary Baldwin, MD, in an interview with Dermatology Times at the 2024 Society of Dermatology Physician Associates (SDPA) Fall Conference in Las Vegas, Nevada.
Beginning with our January issue, the full issue of Rosacea Research Digest will only be accessible to those with a paid subscription. (Professional members of the NRS will continue to receive a complementary as part of their annual membership. Learn more here.) Subscriptions are $5 per month or $50 per year.