Recent Scientific Abstracts of Rosacea

Steroid-induced rosacealike dermatitis: case report and review of the literature. Chen AY, Zirwas MJ. Cutis. 2009 Apr;83(4):198-204.

Steroid-induced rosacealike dermatitis (SIRD) is an eruption composed of papules,
pustules, papulovesicles, and sometimes nodules with telangiectatic vessels on a
diffuse erythematous and edematous background. It results from prolonged topical
steroid use or as a rebound phenomenon after discontinuation of topical steroid.
There are 3 types of SIRD that are classified based on the location of the
eruption: perioral, centrofacial, and diffuse. Diagnosis of this disease entity
relies on a thorough patient history and physical examination. Treatment involves
discontinuation of the offending topical steroid and administration of oral
and/or topical antibiotics. Topical calcineurin antagonists should be considered
as alternative or adjunctive therapies for patients who do not respond to
traditional treatments. Dermatologists may need to provide psychological support
during office visits for patients who have difficulty dealing with the
discontinuation of topical steroid and/or the psychological impact of a flare.
Epidemiology, pathogenesis, histopathology, and differential diagnosis of the
entity also are reviewed.

[Inflammation of the conjunctiva] [Article in German] Meyer P, Messerli J. Ther Umsch. 2009 Mar;66(3):153-61.

Inflammations of the conjunctiva represent some of the most frequent eye diseases
in general and ophthalmologic practice. Etiologically multiple diseases can be
identified. A group of infectious conjunctivites contrasts with a very
hereogeneous non-infectious group. Neoplastic processes such as low grade
epithelial dysplasias and lymphomas may mascarade conjunctivitis. The
differentiation of the various clinical pictures may be challenging for the
practitioner. This article reviews the methodology of patient history and
clinical work up as well as the symptomatology and treatment options for the most
important conjunctivites in clinical practice.

Innovations in natural antioxidants and their role in dermatology. Ditre C, Wu J, Baumann LS, Rigel D. Cutis. 2008 Dec;82(6 Suppl):2-16.

The use of natural products for skin care has become more common in the past few
years. Consumers are more aware of unnatural chemicals and other toxins and are
searching for natural products to use on their skin. Fortunately, a large number
of botanical antioxidants exist and are being marketed as either over-the-counter
or prescription skin care products. Antioxidants can have profound effects on the
intracellular signaling pathways involved in skin damage and thus may be
protective against photodamage as well as may prevent wrinkles and inflammation.
This supplement discusses the potent effect that botanical antioxidants may have
in the management of a broad range of skin issues, from photoaging to
inflammatory skin conditions.

Facial seborrheic dermatitis: a report on current status and therapeutic horizons. Bikowski J. J Drugs Dermatol. 2009 Feb;8(2):125-33.

Seborrheic dermatitis, characterized by erythema and/or flaking or scaling in
areas of high sebaceous activity, affects up to 5% of the US population and often
appears in conjunction with other common skin disorders, such as rosacea and
acne. Despite ongoing research, its etiology is puzzling. Increased sebaceous and
hormonal (androgenic) activity is thought to play a part. Recent evidence
suggests an important role for individual susceptibility to irritant metabolites
of the skin commensal Malassezia, most probably M globosa. Current approaches
thus include agents with antifungal as well as antikeratinizing, and
anti-inflammatory activity. Azelaic acid, which has all 3 properties, may be a
useful addition to first-line management, which now comprises of topical
steroids, the immunosuppressant agents tacrolimus and pimecrolimus, azoles and
other antifungals, and keratolytic agents. A recent exploratory study supports
the efficacy and safety of azelaic acid 15% gel in seborrheic dermatitis. Azelaic
acid may be especially valuable in this application because of its efficacy in
treating concomitant rosacea and acne.

[Are there any clinical evaluations confirming higher incidence of skin cancers as a result of pimecrolimus therapy?] [Article in Polish] Barańjska-Rybak W, Nowicki R, Sokołowska-Wojdyło M, Roszkiewicz J. Pol Merkur Lekarski. 2008 Sep;25(147):284-7.

Pimecrolimus (SDZ ASM 981), nonsteroid anty-inflammatory ackomycin-derived drug
has more and more indications in dermatology. It has been recommended in therapy
of atopic and contact dermatitis at the beginning. Nowadays pimecrolimus is used
in the treatment of seborrhoic dermatitis, post-steroidal rosacea, bullous
diseases etc. News reporting higher incidence of skin cancers after pimecrolimus
application has not been proved clinically. The common use of mentioned
medication forced us to detailed analysis of references concerning that problem.

Moisturizers for the treatment of inflammatory skin conditions. Lynde C. J Drugs Dermatol. 2008 Nov;7(11):1038-43.

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

[Cathelicidins: multifunctional defense molecules of the skin] [Article in German] Peric M, Koglin S, Ruzicka T, Schauber J. Dtsch Med Wochenschr. 2009 Jan;134(1-2):35-8. Epub 2008 Dec 17.

The human skin is constantly exposed to microbial pathogens but infections only
rarely occur. Innate cutaneous immunity is a primary system for protection
against infection, and antimicrobial peptides (AMPs) expressed in skin are
essential defence molecules. The AMPs include molecules such as the defensins
that were first characterized for their antimicrobial properties as well as other
peptides and proteins first known for their activity as chemokines, enzymes,
enzyme inhibitors and neuropeptides. Cathelicidins are unique AMPs that act as
defensive and signalling molecules. Two different pathways are involved in this
function: cathelicidins have direct antimicrobial activity and they also initiate
a host of cellular responses in cytokine release, inflammation and angiogenesis.
Several skin diseases are associated with cathelicidin dysfunction. In atopic
eczema, for example, cathelicidin expression is suppressed, whereas in rosacea
cathelicidin peptides are abnormally processed to forms that induce cutaneous
inflammation and a vascular response. In psoriasis cathelicidin peptide converts
self-DNA to a potent stimulus in an autoinflammatory cascade. Current studies
have unexpectedly identified vitamin D3 as a major factor for the regulation of
cathelicidin expression. This finding may provide new strategies in the
management of infectious and inflammatory diseases of the skin by targeting
control of the expression and function of cathelicidin and other AMPs.

Drugs for acne, rosacea and psoriasis. [No authors listed] Treat Guidel Med Lett. 2008 Nov;6(75):75-82.

Antibiotic use in acne vulgaris and rosacea: clinical considerations and resistance issues of significance to dermatologists. Del Rosso JQ, Leyden JJ, Thiboutot D, Webster GF. Cutis. 2008 Aug;82(2 Suppl 2):5-12.

Antibiotics are commonly prescribed in dermatology practice for a variety of
disorders, including acne vulgaris and rosacea. Importantly, they often are used
long-term for these inflammatory dermatoses. Changes in bacterial ecology related
to antibiotic prescribing have led to the decreased sensitivity of some bacterial
organisms, such as Propionibacterium acnes, to antibiotics commonly prescribed by
dermatologists. The potential clinical outcomes of altered bacterial
sensitivities may vary among specific disease states and include decreased
therapeutic response and the need to alter approaches in disease management.
Additionally, changing patterns of antibiotic sensitivity and the emergence of
more virulent pathogens, such as community-acquired methicillin-resistant
Staphylococcus aureus, macrolide-resistant staphylococci and streptococci, and
mupirocin-resistant S aureus, have led to marked changes in how clinicians use
antibiotics in clinical practice. This article reviews antibiotic prescribing in
dermatology practice and provides important clinical perspectives and
recommendations to preserve the therapeutic value of antibiotics based on a
thorough review of current literature and clinical experience.

Vasoactive peptides in the pathogenesis of psoriasis. Reich A, Szepietowski JC. G Ital Dermatol Venereol. 2008 Oct;143(5):289-98.

Psoriasis, a chronic inflammatory skin disease, is believed to be exacerbated by
stress. The exact mechanism of this phenomenon is not fully understood, however,
it has been postulated that different substances released from dermal nerve
endings during stress may take part in initiation or modulation of psoriasis. One
of the most interesting group of mediators are polypeptides, also named as
neuropeptides, that possess vasoactive properties. It was documented that these
polypeptides could not only be released from nerve endings, but may also be
directly synthesised in the skin and liberated from numerous dermal cells.
Moreover, these substances are not only released by different cells, but may
activate various cell types showing a wide spectrum of biological actions. Thus,
this complex system of interactions seems to be important component of psoriatic
pathological reaction. The significant role of these neuromediators has also been
postulated in other chronic skin diseases, like palmoplantar pustulosis, atopic
and irritant eczema, rosacea, lichen sclerosus, vitiligo, pigmented urticaria or
prurigo nodularis. Among different neuropeptides, substance P, calcitonin
gene-related peptide, vasoactive intestinal peptide (VIP) and neuropeptide Y have
been mostly studied in psoriasis.

Azelaic acid 15% gel in the treatment of rosacea. Gollnick H, Layton A. Expert Opin Pharmacother. 2008 Oct;9(15):2699-706.

Rosacea represents a chronic inflammatory dermatosis of uncertain
pathophysiology. There are several associated risk factors and the need for
long-term treatment is well recognized. This diverse disease is frequently
difficult to manage and has a significant impact on quality of life. There are
several topical and oral treatments available, of which azelaic acid 15% gel
(Finacea) is the first new treatment for rosacea in more than a decade. Azelaic
acid per se has multiple modes of action in rosacea, but an anti-inflammatory
effect achieved by reducing reactive oxygen species appears to be the main
pharmacological action. Clinical studies have shown that azelaic acid 15% gel is
an effective and safe first-line topical therapeutic option in patients with
mild-to-moderate papulopustular rosacea. Significant continuous improvement in
the number of inflammatory lesions and in erythema has been shown over a period
of 15 weeks. Adverse effects associated with azelaic acid 15% gel are mostly mild
or transient and do not usually necessitate discontinuation of therapy.

The role of antimicrobial peptides in human skin and in skin infectious diseases. Schittek B, Paulmann M, Senyürek I, Steffen H. Infect Disord Drug Targets. 2008 Sep;8(3):135-43.

Antimicrobial peptides or proteins (AMPs) represent an ancient and efficient
innate defense mechanism which protects interfaces from infection with pathogenic
microorganisms. In human skin AMPs are produced mainly by keratinocytes,
neutrophils, sebocytes or sweat glands and are either expressed constitutively or
after an inflammatory stimulus. In several human skin diseases there is an
inverse correlation between severity of the disease and the level of AMP
production. Skin lesions of patients with atopic dermatitis show a diminished
expression of the beta-defensins and the cathelicidin LL-37. Furthermore, these
patients have a reduced amount of the AMP dermcidin in their sweat which
correlates with an impaired innate defense of human skin in vivo. In addition,
decreased levels of AMPs are associated with burns and chronic wounds. In
contrast, overexpression of AMPs can lead to increased protection against skin
infections as seen in patients with psoriasis and rosacea, inflammatory
skin-diseases which rarely result in superinfection. In other skin diseases, e.g.
in patients with acne vulgaris, increased levels of AMPs are often found in
inflamed or infected skin areas indicating a role of these peptides in the
protection from infection. These data indicate that AMPs have a therapeutical
potential as topical anti-infectives in several skin diseases. The broad spectrum
of antimicrobial activity, the low incidence of bacterial resistance and their
function as immunomodulatory agents are attractive features of AMPs for their
clinical use.

Case report: subacute synovitis of the knee after a rose thorn injury: unusual clinical picture. Duerinckx JF. Clin Orthop Relat Res. 2008 Dec;466(12):3138-42. Epub 2008 Sep 5.

Synovitis secondary to penetrating plant thorn injuries is not frequently
reported. Historically, it is considered aseptic and treated with removal of the
intraarticular foreign body and affected synovial lining. We report a 57-year-old
healthy man who was admitted 2 weeks after being injured by a rose (Rosacea)
thorn with subacute and mild synovitis with effusion of his right knee. No
intraarticular foreign body was retained. Pantoea agglomerans was identified in
the synovial fluid. Contrary to former teaching, effusions from joints violated
by thorns should not be presumed sterile. Bacterial growth is reported
infrequently, but when reported, Pantoea agglomerans is the most common organism
found. We recommend removal of foreign bodies if present, arthroscopic total
synovectomy, and beginning empiric antibiotic treatment with coverage against
gram-negative enteric pathogens in all cases of thorn synovitis until the results
of culture specimens are known. Improved physician awareness can result in more
rapid diagnosis and improved clinical outcome in affected individuals.

The use and safety of doxycycline hyclate and other second-generation tetracyclines. Sloan B, Scheinfeld N. Expert Opin Drug Saf. 2008 Sep;7(5):571-7.

Tetracyclines have long been used to treat a wide variety of medical conditions,
especially in the field of dermatology. Unfortunately, safety concerns,
especially gastrointestinal (GI), have always been present. Other safety concerns
have included tooth development in children, candidiasis, vestibular concerns,
photosensitivity/phototoxicity, and more unusual adverse effects such as
uncontrolled hypertension. This article first discusses the pharmacological
development of the tetracyclines from the first to the second generation versions
with an emphasis on the safety concerns, especially with regards to doxycycline
hyclate (DH). Second, the adverse effects of the tetracyclines are discussed.
Third, the favorable side effect profile of DH delayed release capsules (Doryx)
is compared with DH powder contained in tablets (Vibramycin). Fourth, the
increased use with a continued favorable safety profile is also discussed
concerning the subantimicrobial dosing of DH for acne. Fifth, the safety of
periodontic uses of DH is discussed. Last, the favorable safety profiles of the
2006 approved uses of an anti-inflammatory dose of 40 mg doxycycline for rosacea
and an extended-release minocycline tablet for acne are also discussed.

Rhinophyma: diagnosis and treatment options for a disfiguring tumor of the nose. Sadick H, Goepel B, Bersch C, Goessler U, Hoermann K, Riedel F. Ann Plast Surg. 2008 Jul;61(1):114-20.

Rhinophyma is a benign dermatologic disease of the nose affecting primarily
Caucasian men in their fifth to seventh decades of life. It is characterized by a
slowly progressive enlargement with irregular thickening of the nasal skin and
nodular deformation. It is assumed to be the end stage of chronic acne rosacea.
Main reasons that urge the patients to seek help are plastic cosmetic and
functional impairments such as nasal obstruction. Surgical removal of the
hyperplastic tumor mass is the treatment of choice for rhinophyma. In a
retrospective review, the authors describe the pros and cons of the main
treatment modalities that have been described in literature and present their own
clinical experience.

Publication Types:
Review

PMID: 18580161 [PubMed - indexed for MEDLINE]

16: Exp Dermatol. 2008 Aug;17(8):633-9. Epub 2008 Jun 28.

The vitamin D pathway: a new target for control of the skin’s immune response?

Schauber J, Gallo RL.

Department of Dermatology and Allergology, Ludwig-Maximilians-University, Munich,
Germany. juergen.schauber@med.uni-muenchen.de

The surface of our skin is constantly challenged by a wide variety of microbial
pathogens, still cutaneous infections are relatively rare. Within cutaneous
innate immunity the production of antimicrobial peptides (AMPs) is a primary
system for protection against infection. Many AMPs can be found on the skin, and
these include molecules that were discovered for their antimicrobial properties,
and other peptides and proteins first known for activity as chemokines, enzymes,
enzyme inhibitors and neuropeptides. Cathelicidins were among the first families
of AMPs discovered on the skin. They are now known to have two distinct
functions; they have direct antimicrobial activity and will initiate a host
cellular response resulting in cytokine release, inflammation and angiogenesis.
Dysfunction of cathelicidin is relevant in the pathogenesis of several cutaneous
diseases including atopic dermatitis where cathelicidin induction is suppressed,
rosacea, where cathelicidin peptides are abnormally processed to forms that
induce cutaneous inflammation and a vascular response, and psoriasis, where a
cathelicidin peptide can convert self-DNA to a potent stimulus of an
autoinflammatory cascade. Recent work has unexpectedly identified vitamin D3 as a
major factor involved in the regulation of cathelicidin expression. Therapies
targeting the vitamin D3 pathway and thereby cathelicidin may provide new
treatment modalities in the management of infectious and inflammatory skin
diseases.

Antimicrobial peptides and the skin immune defense system. Schauber J, Gallo RL. J Allergy Clin Immunol. 2008 Aug;122(2):261-6. Epub 2008 Apr 25.

Our skin is constantly challenged by microbes but is rarely infected. Cutaneous
production of antimicrobial peptides (AMPs) is a primary system for protection,
and expression of some AMPs further increases in response to microbial invasion.
Cathelicidins are unique AMPs that protect the skin through 2 distinct pathways:
(1) direct antimicrobial activity and (2) initiation of a host response resulting
in cytokine release, inflammation, angiogenesis, and reepithelialization.
Cathelicidin dysfunction emerges as a central factor in the pathogenesis of
several cutaneous diseases, including atopic dermatitis, in which cathelicidin is
suppressed; rosacea, in which cathelicidin peptides are abnormally processed to
forms that induce inflammation; and psoriasis, in which cathelicidin peptide
converts self-DNA to a potent stimulus in an autoinflammatory cascade. Recent
work identified vitamin D3 as a major factor involved in the regulation of
cathelicidin. Therapies targeting control of cathelicidin and other AMPs might
provide new approaches in the management of infectious and inflammatory skin
diseases.

[Dermatitis and VDU work] [Article in Italian] Pigatto P, Marsili C, Pierini F, Bergamaschi A, Piccoli B. G Ital Med Lav Ergon. 2007 Jul-Sep;29(3 Suppl):454-6.

Skin disorders like rosacea, seborrhoeic dermatitis, non-specific erythema and
acne can be VDU work linked. At present, many environmental and individual causes
are involved in the development of these disorders, but the former appear to be
the issue to investigate more in depth.

[Rosacea] [Article in Spanish] Barco D, Alomar A. Actas Dermosifiliogr. 2008 May;99(4):244-56.

Rosacea is a chronic inflammatory skin disease appearing in the central area of
the face of middle-aged patients. It is characterized by flushing, permanent
erythema, telangiectasia, papules, pustules, and the absence of comedones. Its
underlying pathophysiological mechanisms are not completely understood, although
a number of hypotheses point to vascular abnormalities and infection by
microorganisms such as Demodex folliculorum. Rosacea is classified into 4
subtypes, which determine the therapeutic approach based on skin care, topical
antiinflammatory agents, topical and oral antibiotics and retinoids, and, in some
instances, light-based therapy and surgery.

[Smoking and the skin] [Article in Spanish] Just-Sarobé M. Actas Dermosifiliogr. 2008 Apr;99(3):173-84.

Smoking is the main modifiable cause of disease and death in the developed world.
Tobacco consumption is directly linked to cardiovascular disease, chronic
bronchitis, and many malignant diseases. Tobacco also has many cutaneous effects,
most of which are harmful. Smoking is closely associated with several
dermatologic diseases such as psoriasis, pustulosis palmoplantaris,
hidrosadenitis suppurativa, and systemic and discoid lupus erythematosus, as well
as cancers such as those of the lip, oral cavity, and anogenital region. A more
debatable relationship exists with melanoma, squamous cell carcinoma of the skin,
basal cell carcinoma, and acne. In contrast, smoking seems to protect against
mouth sores, rosacea, labial herpes simplex, pemphigus vulgaris, and dermatitis
herpetiformis. In addition to the influence of smoking on dermatologic diseases,
tobacco consumption is also directly responsible for certain dermatoses such as
nicotine stomatitis, black hairy tongue, periodontal disease, and some types of
urticaria and contact dermatitis. Furthermore, we should not forget that smoking
has cosmetic repercussions such as yellow fingers and fingernails, changes in
tooth color, taste and smell disorders, halitosis and hypersalivation, and early
development of facial wrinkles.

Blepharitis: current strategies for diagnosis and management. Jackson WB. Can J Ophthalmol. 2008 Apr;43(2):170-9.

BACKGROUND: The aim of this article is to present a consensus on the appropriate
identification and management of patients with blepharitis based on expert
clinical recommendations for 4 representative case studies and evidence from
well-designed clinical trials. METHODS: The case study recommendations were
developed at a consensus panel meeting of Canadian ophthalmologists and a guest
ophthalmologist from the U.K., with additional input from family doctors and an
infectious disease/medical microbiologist, which took place in Toronto in June
2006. A MEDLINE search was also conducted of English language articles describing
randomized controlled clinical trials that involved patients with blepharitis.
RESULTS: Blepharitis involving predominantly the skin and lashes tends to be
staphylococcal and (or) seborrheic in nature, whereas involvement of the
meibomian glands may be either seborrheic, obstructive, or a combination (mixed).
The pathophysiology of blepharitis is a complex interaction of various factors,
including abnormal lid-margin secretions, microbial organisms, and abnormalities
of the tear film. Blepharitis can present with a range of signs and symptoms, and
is associated with various dermatological conditions, namely, seborrheic
dermatitis, rosacea, and eczema. The mainstay of treatment is an eyelid hygiene
regimen, which needs to be continued long term. Topical antibiotics are used to
reduce the bacterial load. Topical corticosteroid preparations may be helpful in
patients with marked inflammation. INTERPRETATION: Blepharitis can present with a
range of signs and symptoms, and its management can be complicated by a number of
factors. Expert clinical recommendations and a review of the evidence on
treatment supports the practice of careful lid hygiene, possibly combined with
the use of topical antibiotics, with or without topical steroids. Systemic
antibiotics may be appropriate in some patients.

Tacrolimus: approved and unapproved dermatologic indications/uses-physician’s sequential literature survey: part II. Sehgal VN, Srivastava G, Dogra S. Skinmed. 2008 Mar-Apr;7(2):73-7.

Tacrolimus has been a useful therapeutic tool in dermatology practice ever since
its inception. Accordingly, many “off-label” applications have been reported.
Thus, its local immunosuppressive and steroid-sparing action stands recognized.
Hence, its indications/uses were extended beyond atopic dermatitis to cover
several dermatoses including other types of eczema, papulosquamous disorder of
cornification, rosacea, other inflammatory skin conditions, vesicobullous
disease, connective tissue disease, graft versus host disease, and follicular
disorders. Many such diseases found to respond to tacrolimus therapy have been
briefly recounted. It is worthwhile to conceive, however, that this topical
immunomodulator should be reserved for use only as an alternative, should the
conventional treatment be unresponsive. Hence, guarded use is warranted.

Extragastric manifestations of Helicobacter pylori infection. Prelipcean CC, Mihai C, Gogălniceanu P, Mitrică D, Drug VL, Stanciu C. Rev Med Chir Soc Med Nat Iasi. 2007 Jul-Sep;111(3):575-83.

The role of Helicobacter pylori (HP) in some digestive diseases (gastritis,
ulcer, gastric cancer, MALT lymphoma) is well known. It has been suggested
relatively recently that infection with HP can be involved in various
extra-digestive conditions: respiratory disorders (chronic obstructive pulmonary
disease, bronchiectasis, lung cancer, pulmonary tuberculosis, bronchial asthma);
vascular disorders (ischaemic heart disease, stroke, primary Raynaud phenomena,
primary headache); autoimmune disorders (Sjogren syndrome, Henoch-Schonlein
purpura, autoimmune thrombocytopenia, autoimmune thyroiditis, Parkinson’s
disease, idiopathic chronic urticaria, rosacea, alopecia areata); other disorders
(iron deficiency anaemia, growth retardations, liver cirrhosis). Case studies,
small patient series and non-randomized trials that have shown a beneficial
effect of HP eradication in different conditions are not convincing. According to
Mastricht III the only conditions where HP eradication is indicated are immune
thrombocytopenic purpura and iron deficiency anaemia.

Use of pimecrolimus cream in disorders other than atopic dermatitis. Day I, Lin AN. J Cutan Med Surg. 2008 Jan-Feb;12(1):17-26.

BACKGROUND: Pimecrolimus is indicated for treatment of atopic dermatitis and has
been evaluated in many other disorders. OBJECTIVE: To review the efficacy of
pimecrolimus in treatment of disorders other than atopic dermatitis. METHODS: We
performed a PubMed search of the English-language literature using the key word
“pimecrolimus.” We reviewed articles reporting the use of pimecrolimus in
disorders other than atopic dermatitis and classified them by the type of study
used to evaluate efficacy. RESULTS: Randomized, double-blind studies have shown
that pimecrolimus is superior to vehicle in treatment of seborrheic dermatitis,
hand dermatitis, and asteatotic eczema but have yielded conflicting results
regarding intertriginous psoriasis and vitiligo. Open-label studies involving
four or more patients have shown favorable results in many disorders, including
contact dermatitis, rosacea, lichen sclerosus, and oral and genital lichen
planus. Case reports have shown that topical pimecrolimus may be useful in
cutaneous graft-versus-host disease, lichen striatus, cutaneous lichen planus,
and many other disorders. CONCLUSIONS: Topical pimecrolimus appears to be an
effective treatment for many disorders other than atopic dermatitis, especially
seborrheic dermatitis, hand dermatitis, and asteatoic eczema. It may be effective
in many other disorders, but its role in these disorders remains to be clarified
by additional studies.

Versatility of azelaic acid 15% gel in treatment of inflammatory acne vulgaris. Thiboutot D. J Drugs Dermatol. 2008 Jan;7(1):13-6.

Azelaic acid (AzA) 15% gel is approved for the treatment of rosacea in the US,
but also has approval for the treatment of acne vulgaris in many European
countries where it has demonstrated success. Two randomized, multicenter,
controlled clinical trials compared the effects of AzA 15% gel with those of
topical benzoyl peroxide 5% or topical clindamycin 1%, all using a twice-daily
dosing regimen. The primary endpoint in the intent-to-treat analysis was a
reduction in inflammatory papules and pustules. AzA 15% gel resulted in a 70% to
71% median reduction of facial papules and pustules compared with a 77% reduction
with benzoyl peroxide 5% gel and a 63% reduction with clindamycin. AzA 15% gel
was well-tolerated. In addition, a 1-year European observational study conducted
by dermatologists in private practice evaluated the safety and efficacy of AzA
15% gel used as monotherapy or in combination with other agents in more than 1200
patients with acne. Most physicians (81.9%) described an improvement in patients’
symptoms after an average of 34.6 days, and 93.9% of physicians reported patient
improvement after an average of 73.1 days. Both physicians and patients assessed
AzA 15% gel to be effective with 74% of patients being “very satisfied” at the
end of therapy. AzA 15% gel was considered “well-tolerated” or “very
well-tolerated” by 95.7% of patients. The majority of patients were more
satisfied with AzA than with previous therapies. AzA 15% gel represents a new
therapeutic option for the treatment of acne vulgaris.

Tetracyclines and pulmonary inflammation. Rempe S, Hayden JM, Robbins RA, Hoyt JC. Endocr Metab Immune Disord Drug Targets. 2007 Dec;7(4):232-6.

Tetracycline and its derivatives, such as chlortetracycline, oxytetracycline,
minocycline, doxycycline, methacycline and lymecycline, are naturally occurring
or semi-synthetic polyketide compounds that exhibit a well known broad-spectrum
antibacterial activity that interferes with prokaryotic protein synthesis at the
ribosome level. In addition to this well known antibacterial activity these
compounds also exhibit a variety of additional, less well known properties. Among
them are separate and distinct anti-inflammatory properties. Tetracycline and
related compounds have been shown to be effective chemotherapeutic agents in a
wide variety of chronic inflammatory diseases and conditions. These include
periodontitis, rosacea, acne, auto-immune diseases such as rheumatoid arthritis
and protection of the central nervous system against trauma and neurodegenerative
diseases such as stroke, multiple sclerosis and Parkinson disease. Tetracycline
and related compounds appear to be beneficial for treatment of several chronic
inflammatory airway diseases. Among them are asthma, bronchiectasis, acute
respiratory distress syndrome, chemical induced lung damage and cystic fibrosis.
The clinical use of tetracycline-type drugs in treatment of chronic airway
inflammation is becoming a topic of intense interest. Recent findings in this
area have led to an understanding of the myriad physiological, cellular and
molecular mechanisms of the inflammatory response and how this response may be
controlled to limit damage to host cells and tissues. This review presents a
brief summary of the recent research in the area of tetracycline and its
derivatives in control of pulmonary inflammation.

[Cathelicidin LL-37. A central factor in the pathogenesis of inflammatory dermatoses?] [Article in German] Schauber J, Ruzicka T, Rupec RA. Hautarzt. 2008 Jan;59(1):72-4.

Keratinocytes produce and secrete antimicrobial peptides which function as
endogenous antibiotics and as signaling molecules within the cutaneous innate
immune system. Recent studies demonstrate that the antimicrobial peptide
cathelicidin LL-37 plays an important role in the pathogenesis of atopic eczema,
rosacea and psoriasis. Whereas skin in atopic eczema shows decreased cathelicidin
expression which leads to increased susceptibility to superinfection in those
patients, overabundant expression of cathelicidin peptide fragments causes
inflammation in rosacea. Finally, in psoriasis cathelicidin peptide binds to self
DNA which triggers an autoimmune response. These studies demonstrate the role of
cathelicidin as a central factor in the pathogenesis of cutaneous inflammation.
Therapies targeting cathelicidin expression and function could lead to new
treatments for these diseases.

The enigma of rosacea. Marks R. J Dermatolog Treat. 2007;18(6):326-8.

This short paper reviews the nature of rosacea emphasizing the possibility of a
solar cause. The sites of involvement and the physical signs of rosacea including
the flushing, the erythema and the telangiectasia as well as the intermittent
episodes of inflammation with swelling and papules may all be explained by UVR
induced damage to dermal connective tissue. The dermal damage permits
vaso-dilation and vascular pooling.

[Paediatric rosacea] [Article in French] Léauté-Labrèze C, Chamaillard M. Ann Dermatol Venereol. 2007 Oct;134(10 Pt 1):788-92.

Recently approved systemic therapies for acne vulgaris and rosacea. Del Rosso JQ. Cutis. 2007 Aug;80(2):113-20.

Until recently, with the exception of oral isotretinoin for the treatment of
severe recalcitrant nodular acne, systemic therapy for acne vulgaris and rosacea
has been based on anecdotal support, clinical experience, and small clinical
trials. Tetracycline derivatives are the predominant systemic agents that have
been used for both disease states, prescribed in dose ranges that produce
antibiotic activity. Anti-inflammatory dose doxycycline, a controlled-release
(CR) 40-mg capsule formulation of doxycycline that is devoid of antibiotic
activity when administered once daily, was US Food and Drug Administration
(FDA)-approved for the treatment of inflammatory lesions (papules and pustules)
of rosacea, based on large-scale phase 3 pivotal trials and long-term
microbiologic and safety data. Also, an extended-release (ER) tablet formulation
of minocycline was approved by the FDA for the treatment of inflammatory lesions
of moderate to severe acne vulgaris in patients 12 years and older based on
large-scale phase 3 clinical trials that evaluated efficacy and safety,
dose-response analysis, and long-term data. This article discusses the studies
and clinical applications related to the use of these agents.

[Chronic blepharitis. Pathogenesis, clinical features, and therapy] [Article in German] Auw-Haedrich C, Reinhard T. Ophthalmologe. 2007 Sep;104(9):817-26; quiz 827-8.

Chronic blepharitis is one of the most common diseases of the eyelids, but
surprisingly, it is not often recognized. Frequently, a skin disease such as
seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause
of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase
production, and bacterial lipopolysaccharides are pathogenetically relevant. Only
rarely do genuine bacterial infections play a role. Collarettes occur at the base
of the eye lashes, and the Meibomian glands show either abundant fluid secretion
or inspissated secretion with obstruction of the orifices. Chronic blepharitis
can include sequelae including dry eye and corneal and lid contour changes. The
basic treatment comprises attendance of the underlying dermatological disease and
lid hygiene. In addition, preservative-free tear film substitutes, antibiotics,
immunomodulatory agents, or even surgical intervention may become necessary.

Managing rosacea: a review of the use of metronidazole alone and in combination with oral antibiotics. Conde JF, Yelverton CB, Balkrishnan R, Fleischer AB Jr, Feldman SR. J Drugs Dermatol. 2007 May;6(5):495-8.

BACKGROUND: Rosacea is an extremely common chronic dermatosis affecting an
estimated 14 million Americans. Rosacea is most commonly managed with topical
metronidazole, sometimes in combination with oral antibiotics. PURPOSE: To review
published studies about topical metronidazole therapy for rosacea, both as a
monotherapy and in conjunction with oral antibiotics. METHODS: Medline searches
were conducted for clinical trials using metronidazole, tetracycline, and
doxycycline for rosacea. RESULTS: Topical metronidazole has been well studied as
a rosacea therapy. Twice-daily dosing of metronidazole 1.0% cream is as effective
as 250 mg tetracycline twice daily. Metronidazole 1.0% gel used once daily is as
effective as azelaic acid 15% gel dosed twice daily. When dosed at
subantimicrobial levels, doxycycline 20 mg taken twice daily is effective in
decreasing inflammatory lesions and erythema associated with rosacea.
Metronidazole 0.75% lotion is more effective when used in combination with
doxycycline 20 mg dosed twice daily. DISCUSSION: Metronidazole in 0.75% strength
lotion, cream, and gel and 1.0% metronidazole cream and gel are all efficacious
in treating rosacea. Combination treatment with oral antibiotics at both
antimicrobial and subantimicrobial doses is an efficacious means of treating
rosacea. Maintenance treatment with topical metronidazole decreases relapses and
allows for longer intervals between flares.

Clinical considerations in the treatment of acne vulgaris and other inflammatory skin disorders: focus on antibiotic resistance. Leyden JJ, Del Rosso JQ, Webster GF. Cutis. 2007 Jun;79(6 Suppl):9-25.

Propionibacterium acnes is an anaerobic bacterium that plays an important role in
the pathogenesis of acne. Certain antibiotics that can inhibit P acnes
colonization also have demonstrated anti-inflammatory activities in the treatment
of acne, rosacea, and other noninfectious diseases. Decreased sensitivity of P
acnes to antibiotics, such as erythromycin and tetracycline, has developed and
may be associated with therapeutic failure. Benzoyl peroxide (BPO) is a
nonantibiotic antibacterial agent that is highly effective against P acnes and
for which no resistance against it has been detected to date. Retinoids are
important components in combination therapy for acne, including use with
antibiotics, and can serve as an alternative to these agents in maintenance
therapy. By increasing our understanding of the multifaceted actions of
antibiotics and the known clinical implications of antibiotic resistance,
physicians can improve their decision making in prescribing these agents.

Otophyma: a case report. Daniels K, Haddow K. J Laryngol Otol. 2008 May;122(5):524-6. Epub 2007 May 22.

OBJECTIVE: We report a rare case of otophyma. METHOD: A case report of otophyma
and a review of the current literature concerning otophyma and the more common
rhinophyma, are presented. RESULTS: A 46-year-old male presented with slow
growing fleshy growths on both auricles which were excised. A diagnosis of
otophyma was made. Although rosacea is more common, otophyma and other ‘phymas’
are thought to be the end stage of the rosacea spectrum of skin disease. However,
unlike rhinophyma, otophyma is rarely seen and as a result there is little in the
English language literature regarding it. Consequently, the management of
otophyma is largely based on previous experiences with rhinophyma. CONCLUSION: To
our knowledge this is the first case report of otophyma in the otolaryngology
literature and only the second described in the English language literature. This
case demonstrates the difficulties faced in diagnosing this rare condition and
our successful management of this case.

The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis. Wollina U. Am J Clin Dermatol. 2007;8(3):157-73.

The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are
approved for atopic dermatitis but have additional potential in other
inflammatory skin diseases. This article reviews their clinical use in non-atopic
dermatitis diseases. In seborrheic dermatitis, asteatotic eczema, and contact
dermatitis, TCIs are of great benefit and can compete with topical
corticosteroids. In psoriasis, TCIs have shown clinical efficacy and safety in
facial and intertriginous lesions. Further investigations into possible
combinations of TCIs with other established treatments such as UVB irradiation in
this disorder are necessary. Initial studies in cutaneous lupus erythematosus
have been promising, whereas the response in rosacea and rosacea-like eruptions
has been mixed. TCIs have been associated with good clinical responses in oral
lichen planus and anogenital lichen sclerosus et atrophicus. In vitiligo, TCIs
are associated with some degree of repigmentation, with better results being seen
in children and in facial and neck areas. TCIs have a synergistic effect with UVB
irradiation in vitiligo. There is a long list of small series and case reports
documenting use of TCIs in various other skin conditions that warrant further
validation. Although the established mode of action of TCIs is T-cell control,
other effects also need to be considered. Specifically, TCIs reduce pruritus and
erythema, which cannot be explained by T-cell interactions, and further
investigations are needed in these fields.

Azelaic acid (15% gel) in the treatment of acne rosacea. Gupta AK, Gover MD. Int J Dermatol. 2007 May;46(5):533-8.

In December of 2002, the FDA approved azelaic acid 15% gel for the topical
treatment of inflammatory papules and pustules of mild to moderate rosacea.
Azelaic acid is a saturated dicarboxylic acid, which is naturally occurring and
has been used in the treatment of rosacea, acne, and melasma. The 15% gel has a
high efficacy and is generally well tolerated, with the local irritation
(burning, stinging, itching, and scaling) being typically mild and transient.
Azelaic acid 15% gel is considered effective and safe as a therapy for
inflammatory papulo-pustular rosacea and is suitable for use on all skin types.

Anti-inflammatory activity of tetracyclines. Webster G, Del Rosso JQ. Dermatol Clin. 2007 Apr;25(2):133-5, v.

Tetracyclines are known to exhibit multiple significant anti-inflammatory
actions. This article describes the mechanisms of this anti-inflammatory
activity, such as inhibition of chemotaxis, granuloma formation, and protease.
The article also discusses the effectiveness of tetracyclines in treating such
diseases as acne vulgaris, rosacea, bullous dermatoses, granulomatous disease,
and livedo vasculitis.

[Oxytetracycline--mechanism of action and application in skin diseases] [Article in Polish] Olszewska M. Wiad Lek. 2006;59(11-12):829-33.

Oxytetracycline is a bacteriostatic antibiotic. Newly discovered, additional
mechanisms of action include antioxidant, antiinflammatory and immynosupresive
activity of oxytetracycline and other tetracyclines. These activities were the
basis for developing therapy regimens with oxytetracycline in subantimicrobial
doses. Due to its significant efficacy, limited adverse effects and low therapy
costs, oxytetracycline at the dose of 500 mg per day is presently considered as
therapy of choice in papulopustulous acne. Rosacea and perioral dermatitis are
other indications. Topical oxytetracycline shows significant efficacy in primary
and secondary skin infections with inflammatory reaction.

[Conditions bordering on allergy] [Article in French] Baudouin C. J Fr Ophtalmol. 2007 Mar;30(3):306-13.

Chronic allergic conjunctivitis constitutes a complex ocular surface disease
involving many mechanisms, extending well beyond the simple field of mast cells
and IgE. Lacrimal film, the eyelids, the environment, especially iatrogenic in
origin, closely interact with each other and involve many cell systems such as
goblet cells, eosinophils, and lymphocytes. It is therefore imperative to reach a
better understanding of the mechanisms associated and eliminate confounding
pathologies that may mimic allergic conjunctivitis. Dry eye syndrome or rosacea
may be very close to chronic allergic diseases, and long-term use of
preservative-containing eyedrops may result in inflammatory reactions that may be
very difficult to discriminate from a primarily allergic disease.

Systemic therapy for rosacea. Baldwin HE. Skin Therapy Lett. 2007 Mar;12(2):1-5, 9.

Rosacea is a common condition that affects people of all races. In addition to
the visible aspects of this disease, it can have a psychosocial impact that must
be evaluated when considering the treatment options. More aggressive and
innovative uses of existing oral agents have resulted in novel therapeutic
approaches, which can provide long-term therapy and sustained remission.

A review of deferasirox, bortezomib, dasatinib, and cyclosporine eye drops: possible uses and known side effects in cutaneous medicine. Scheinfeld N. J Drugs Dermatol. 2007 Mar;6(3):352-5.

Recently, a number of medications approved for nondermatologic use have proved
useful against dermatologic diseases. This article reviews the dermatologic uses
and effects of deferasirox, bortezomib, dasatinib, and cyclosporine eye drops.
Deferasirox–an oral iron chelator–could be an effective treatment against
porphyria cutanea tarda, hemochromatosis, and pathogens such as mucor that thrive
in iron rich environments. Bortezomib, a proteasome inhibitor and multiple
myeloma treatment, may be effective against nodular amyloid and has been
effectively used against squamous cell carcinoma; although trials demonstrate it
is ineffective against metastatic melanoma. Bortezomib has many cutaneous side
effects including erythematous plaques or nodules, a generalized morbilliform
erythema with ulcerations and fever, purpuric eruptions, leukocytoclastic
vasculitis, Sweet’s syndrome, and folliculitis. Dasatinib is a multi-targeted
tyrosine kinase inhibitor active in vitro against most cell lines containing
BCR-ABL mutations that confer resistance to imatinib. Dasatinib is likely to be
effective against dermatofibroma sarcoma protuberans and cutaneous acute
lymphoblastic leukemia, and has caused panniculitis. Cyclosporine 0.05% ocular
emulsion (eye drops) are approved to treat dry eyes including dry eyes caused by
collagen vascular disease. Cyclosporine eye drops might also have utility in
treating eye pathology of ocular rosacea, atopic keratoconjunctivitis, graft
versus host disease, herpes keratitis, chronic sarcoidosis of the conjunctiva,
conjunctival manifestations of actinic prurigo, keratitis of keratitis-ichthyosis
deafness (KID) syndrome, and lichen planus-related kerato-conjunctivitis. This
article speculates that cyclosporine eye drops would also be useful for any
disease causing ectropion or eclabion of the eye as well as toxic epidermal
necrolysis-related eye pathology (in particular corneal scarring).

Update on rosacea and anti-inflammatory-dose doxycycline. Berman B, Perez OA, Zell D. Drugs Today (Barc). 2007 Jan;43(1):27-34.

Approximately 13 million individuals in the United Sates suffer from rosacea, a
recurrent disease that may require long-term therapy. Topical and oral
antibiotics have been used to treat rosacea; however, high-dose antibiotics or
long-term, low-dose antibiotics commonly used for the treatment of rosacea flares
or for rosacea maintenance therapy, respectively, can lead to the development of
antibiotic-resistant organisms. The first oral medication approved by the U.S.
Food and Drug Administration for the treatment of rosacea in the United States is
Oracea (CollaGenex Pharmaceuticals Inc., Newtown, PA, USA). Oracea is a 40 mg
capsule of doxycycline monohydrate, containing 30 mg immediate-release and 10 mg
delayed-release doxycycline beads (“anti-inflammatory-dose doxycycline”).
Anti-inflammatory-dose doxycycline is not an antibiotic and does not lead to the
development of antibiotic-resistant organisms. Each capsule of
anti-inflammatory-dose doxycycline contains a total of 40 mg of anhydrous
doxycycline as 30 mg of immediate-release and 10 mg of delayed-release beads. In
contrast to other oral therapies, anti-inflammatory-dose doxycycline is taken
once daily, which may increase treatment compliance. The results of two phase III
trials have been encouraging, leading to the recent release (summer 2006) of
Oracea for the treatment of rosacea in the United States. Anti-inflammatory-dose
doxycycline should not be used by individuals with known hypersensitivity to
tetracyclines or increased photosensitivity, or by pregnant or nursing women
(anti-inflammatory-dose doxycycline is a pregnancy category-D medication). The
risk of permanent teeth discoloration and decreased bone growth rate make
anti-inflammatory-dose doxycycline contraindicated in infants and children.
However, when used appropriately in patients with rosacea, anti-inflammatory-dose
doxycycline may help prolong the effectiveness and life span of our most precious
antibiotics. c 2007 Prous Science. All rights reserved.

[Acne rosacea--diagnostic challenge] [Article in Polish] Wozniacka A, Kruk M, Robak E, Sysa-Jedrzejowska A. Przegl Lek. 2006;63(7):557-61.

Acne rosacea is a common skin disorder which affects adults, usually women.
Erythema, papules, pustules and telangiectases, the main clinical manifestations
of the disease are located on the face. Currently opinions dealing with
pathogenesis and clinical forms of rosacea are presented. As the clinical picture
might be confusing, similar to other illnesses, differential diagnosis with other
dermatoses like acne vulgaris, erysipelas, seborrhoeic and contact eczema as well
as systemic diseases like lupus erythematosus, dermatomyositis, scleroderma,
sarcoidosis and leukemia were discussed.

Systematic review of rosacea treatments. van Zuuren EJ, Gupta AK, Gover MD, Graber M, Hollis S. J Am Acad Dermatol. 2007 Jan;56(1):107-15. Epub 2006 Nov 7.

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.

Laser treatment of rosacea. Laube S, Lanigan SW. J Cosmet Dermatol. 2002 Dec;1(4):188-95.

Rosacea is a common condition often resulting in persistent erythema and
telangiectasia as well as rhinophyma in a number of patients. Over the last two
decades lasers have been increasingly used in the treatment of these permanent
changes. The literature is reviewed in terms of the different laser systems,
side-effects and comparison with other surgical techniques. Laser studies on
rosacea-associated telangiectasia and erythema are limited. Copper-bromide,
krypton and KTP lasers have been used with good to excellent results. However,
the most commonly applied system is the flash lamp-pumped pulsed dye laser.
Rhinophyma can be treated with a variety of different surgical methods, including
laser resurfacing. CO(2) lasers are the most widely used lasers, others are the
Er:YAG and Nd:YAG lasers. Cosmetic end results are comparable to partial excision
with a scalpel or electrosurgery. There does not appear to be an increased risk
of infection or scarring, but the conventional surgical methods are quicker to
perform and more cost effective.

Schools of pharmacology: retinoid update. Scheinfeld N. J Drugs Dermatol. 2006 Oct;5(9):921-2.

The most widely used retinoids include topical tretinoin (Retin-A), adapalene
(Differin), topical tazarotene (Tazorac), isotretinoin (Accutane), and acitretin
(Soriatane). This article will review new uses and developments in tazarotene
(its failure to secure FDA approval in oral form for psoriasis), adapalene (its
new 0.3% gel form and use in rosacea), alitretinoin (its use in photoaging),
bexarotene (its use for psoriasis and chronic hand dermatitis), isotretinoin (the
IPledge program, its use for neuroblastoma and branded formulation
pharmacological superiority to generics), and retinoic acid metabolism-blocking
agents (RAMBAs) (liarazole use for ichthyosis and psoriasis).

Pediatric rosacea. Kroshinsky D, Glick SA. Dermatol Ther. 2006 Jul-Aug;19(4):196-201.

Rosacea is a condition most commonly associated with adults; however, various
forms exist in the pediatric population and need to be considered when a child
presents with a facial rash. Acne rosacea, steroid rosacea, granulomatous
periorificial dermatitis, and other variants of rosacea are presented here and
are distinguished from their numerous mimickers. Various topical and systemic
therapeutic options exist for the treatment of rosacea with several adjustments
and considerations that must be taken into account when treating a child.

Update on rosacea pathogenesis and correlation with medical therapeutic agents. Del Rosso JQ. Cutis. 2006 Aug;78(2):97-100.

The pathogenesis of rosacea is poorly understood, though clinical features of the
disease are well-recognized. This article updates current views on mechanisms
potentially associated with rosacea. Although data is limited, correlation with
therapies is reviewed.

Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Liu RH, Smith MK, Basta SA, Farmer ER. Arch Dermatol. 2006 Aug;142(8):1047-52.

OBJECTIVE: To evaluate the clinical efficacy of topical 20% azelaic acid cream
and 15% azelaic acid gel compared with their respective vehicles and
metronidazole gel in the treatment of papulopustular rosacea. DATA SOURCES:
Electronic searches of MEDLINE, EMBASE, BIOSIS, and SciSearch through July or
August 2004 and the Cochrane Central Register of Controlled Trials through 2004
(issue 3). We performed hand searches of reference lists, conference proceedings,
and clinical trial databases. Experts in rosacea and azelaic acid were contacted.
STUDY SELECTION: Randomized controlled trials involving topical azelaic acid
(cream or gel) for the treatment of rosacea compared with placebo or other
topical treatments. Two authors independently examined the studies identified by
the searches. Ten studies were identified, of which 5 were included (873
patients). DATA EXTRACTION: Two authors independently extracted data from the
included studies, then jointly assessed methodological quality using a quality
assessment scale. DATA SYNTHESIS: Because standard deviation data were not
available for 4 of the 5 studies, a meta-analysis could not be conducted. Four of
the 5 studies demonstrated significant decreases in mean inflammatory lesion
count and erythema severity after treatment with azelaic acid compared with
vehicle. None of the studies showed any significant decrease in telangiectasia
severity. CONCLUSIONS: Azelaic acid in 20% cream and 15% gel formulations appears
to be effective in the treatment of papulopustular rosacea, particularly in
regard to decreases in mean inflammatory lesion count and erythema severity.
Compared with metronidazole, azelaic acid appears to be an equally effective, if
not better, treatment option.

Pharmacologic doses of nicotinamide in the treatment of inflammatory skin conditions: a review. Niren NM. Cutis. 2006 Jan;77(1 Suppl):11-6.

Various skin disorders with an inflammatory component often have been treated
with steroids and/or oral antibiotics. However, long-term use of these agents has
drawbacks: steroids may induce numerous serious side effects such as
hypertension, immunosuppression, and osteoporosis, and overuse of oral
antibiotics may contribute to the development of bacterial resistance, as well as
to a host of nuisance side effects such as diarrhea, yeast infections, and
photosensitivity. As a result, alternative oral treatments, such as nicotinamide,
have been investigated. During the past 50 years, many clinical reports have
identified nicotinamide as a beneficial agent in the treatment of a variety of
inflammatory skin disorders; what’s more, its exceptional safety profile at
pharmacologic doses makes it a potentially ideal long-term oral therapy for
patients with inflammatory skin diseases. A recent large study evaluating
nicotinamide for the treatment of acne or rosacea has confirmed the potential
benefits of oral nicotinamide as an alternative approach to managing inflammatory
lesions associated with acne vulgaris and acne rosacea. This article reviews the
substantial number of reports published over the past 50 years that document the
clinical utility and safety of oral and topical formulations of nicotinamide for
the treatment of a variety of inflammatory skin conditions.

[Current possibilities of using antimyocotic drugs in the treatment of various skin disorders] [Article in Polish] Choczaj-Kukuła A, Kwaśniewska J. Wiad Parazytol. 2004;50(2):125-33.

Current possibilities of using antimycotic drugs in the treatment of various skin
disorders. The purpose of this article is to review the literature data on the
therapeutic protocols and the results of using some antimycotics in different
skin diseases. In addition to the antimycotic action, particular antifungal drugs
such as itraconazole, ketoconazole and terbinafine exhibit anti-inflammatory
activity by inhibiting the synthesis of 5-lipooxygenase metabolites. As these
metabolites are involved in a number of inflammatory and immunoreactive processes
the dual action of the drugs may be suitably exploited in the treatment of some
skin diseases which are otherwise difficult to cure. Another rationale for the
use of antimycotics in certain skin disorders is their action against Malassezia.
It has been recently demonstrated that Malassezia, present as a commensal in the
epidermis, may play an important role in inducing certain inflammatory processes
by stimulating cytokine production by keratinocytes. The antimycotics proved to
be useful in the therapy of the following skin conditions: seborrheic dermatitis,
Malassezia folliculitis, perioral dermatitis and papulopustular rosacea, as well
as adult atopic dermatitis. The use of antimycotic drugs in amicrobial
palmoplantar pustulosis and sebopsoriasis remains controversial. These
medications are also an alternative in the treatment of leishmaniosis.

The flushing patient: differential diagnosis, workup, and treatment. Izikson L, English JC 3rd, Zirwas MJ. J Am Acad Dermatol. 2006 Aug;55(2):193-208.

Cutaneous flushing-a common presenting complaint to dermatologists, allergists,
internists, and family practitioners-results from changes in cutaneous blood flow
triggered by multiple conditions. Most cases are caused by very common, benign
diseases, such as rosacea or climacterum, that are readily apparent after a
thorough taking of history and physical examination. However, in some cases,
accurate diagnosis requires further laboratory, radiologic, or histopathologic
studies to differentiate several important clinicopathologic entities. In
particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma,
mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this
work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid,
pancreatic cell tumor, renal carcinoma, and others, should be considered.
LEARNING OBJECTIVE: At the completion of this learning activity, participants
should be familiar with the mechanisms of flushing, its clinical differential
diagnosis, the approach to establish a definitive diagnosis, and management of
various conditions that produce flushing.

The ocular manifestations of atopic dermatitis and rosacea. Eiseman AS. Curr Allergy Asthma Rep. 2006 Jul;6(4):292-8.

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

[Rosacea and UV light] [Article in French] Schmutz JL. Ann Dermatol Venereol. 2006 May;133(5 Pt 1):467-9.

Dermatologic problems of older women. Roberts WE. Dermatol Clin. 2006 Apr;24(2):271-80, viii.

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

Clinical significance of brand versus generic formulations: focus on oral minocycline. Del Rosso JQ. Cutis. 2006 Mar;77(3):153-6.

Minocycline is an oral antibiotic widely prescribed throughout the world,
primarily for the treatment of acne vulgaris; other uses include the treatment of
rosacea and perioral dermatitis. In the United States, Propionibacterium acnes
resistance is lowest with minocycline compared with other tetracyclines and with
erythromycin. The availability of generic formulations of minocycline has created
confusion regarding the clinical significance of brand versus generic minocycline
products. This article reviews available data on minocycline use for acne
vulgaris and discusses a patented brand of minocycline versus generic
formulations, including evaluations of pharmacologic activity and safety.

An update on the role of topical metronidazole in rosacea. Zip C. Skin Therapy Lett. 2006 Mar;11(2):1-4.

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

The use of topical azelaic acid for common skin disorders other than inflammatory rosacea. Del Rosso JQ. Cutis. 2006 Feb;77(2 Suppl):22-4.

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

A clinical overview of azelaic acid. Elewski B, Thiboutot D. Cutis. 2006 Feb;77(2 Suppl):12-6.

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

The evolution of azelaic acid. Fleischer AB Jr. Cutis. 2006 Feb;77(2 Suppl):4-6.

Azelaic acid (AzA) is a naturally occurring dicarboxylic acid that has a long and
complex history in the treatment of skin disorders. We summarize research on AzA
from the past 25 years and follow its progress from a treatment of
hyperpigmentation to a therapy for acne vulgaris and inflammatory
(papulopustular) rosacea.

Extragastric manifestations of Helicobacter pylori infection. Franceschi F, Roccarina D, Gasbarrini A. Minerva Med. 2006 Feb;97(1):39-45.

Since the discovery of Helicobacter pylory (H. pylori), several studies have been
published concerning a hypothetical role of this bacterium in different
extragastric diseases, such as ischemic heart disease, idiopathic
thrombocytopenic purpura, iron deficiency anemia or other disorders. The majority
of those studies may be classified as epidemiological or eradicating trials but
there are also case reports or in vitro studies. Idiopathic thromobocytopenic
purpura represents the disease showing a stronger link with H. pylori infection.
There are also increasing evidences on the role of H. pylori infection in iron
deficiency anemia and ischemic heart disease. On the contrary, the association
between H. pylori infection and other diseases is still controversial, as is
supported in the majority of the cases by case reports, small pilot studies or
just in vitro data.

Endocrinological masqueraders of allergy. Weldon D. Allergy Asthma Proc. 2005 Nov-Dec;26(6):440-4.

There are many endocrine conditions that can present with allergic symptoms and
signs. Thyroid conditions ranging from fatigue to orbitopathy associated with
Grave’s disease can be confused with allergic conjunctivitis and angioedema.
Autoimmune thyroid disease is commonly associated with idiopathic urticaria.
Symptoms of orthostatic hypotension and intolerance often present when least
expected and should be considered ahead of time to avoid confusion in treating
possible systemic allergic reactions. Flushing is a frequent sign and
differentiating from complaints commonly associated with allergic reactions,
rosacea, and endocrinopathies is helpful in sorting out some of the more complex
conditions associated with this symptom.

The use of photodynamic therapy in dermatology: results of a consensus conference. Nestor MS, Gold MH, Kauvar AN, Taub AF, Geronemus RG, Ritvo EC, Goldman MP, Gilbert DJ, Richey DF, Alster TS, Anderson RR, Bank DE, Carruthers A, Carruthers J, Goldberg DJ, Hanke CW, Lowe NJ, Pariser DM, Rigel DS, Robins P, Spencer JM, Zelickson BD. J Drugs Dermatol. 2006 Feb;5(2):140-54.

Photodynamic therapy (PDT) has significant promise in improving outcomes of
patients with a variety of cutaneous conditions. A group of experts met to review
the principles, indications, and clinical benefits of PDT with 5-aminolevulinic
acid (ALA). They also reviewed PDT with methyl aminolevulinate. The experts
established consensus statements for pretreatment, posttreatment, ALA contact
time, light sources, and numbers of sessions associated with ALA PDT for actinic
keratosis and superficial basal cell carcinoma, photorejuvenation and cosmetic
enhancement, acne, sebaceous skin, rosacea, and rhinophyma. They based consensus
recommendations on their clinical experience and the medical literature. They
also suggested future applications of ALA PDT. Experts concluded that ALA PDT is
a safe and effective modality for the treatment of conditions commonly
encountered in dermatology. Since downtime is minimal, the technique is suitable
for patients of all ages and lifestyles. Appropriate light sources are available
in many dermatology offices. The expanding clinical and financial benefits of PDT
justify the purchase of an appropriate light source.

Laser and light therapies for acne rosacea. Butterwick KJ, Butterwick LS, Han A. J Drugs Dermatol. 2006 Jan;5(1):35-9.

Acne rosacea is a multifactorial, somewhat mercurial disorder that can be a
challenge to control with standard pharmacologic agents. Laser and light sources
have been increasingly utilized, particularly for control of the generalized
erythema, flushing, and telangiectasia of rosacea. This paper will review the
clinical studies presented in the literature specifically treating patients with
rosacea. Long-pulsed dye lasers and intense pulsed light devices can offer
patients effective treatment without the purpura of short-pulsed dye lasers.
Long-term efficacy has not been studied but maintenance therapy may be necessary
to control the vascular manifestations of this disease.

Treatment of rosacea with herbal ingredients. Wu J. J Drugs Dermatol. 2006 Jan;5(1):29-32.

Since rosacea is a chronic disease and many patients find prescription therapies
unsatisfactory, they frequently turn to herbal ingredients for relief of their
persistent facial redness. The most useful and frequently used herbal compounds
include licorice, feverfew, green tea, oatmeal, lavender, chamomile, tea tree
oil, and camphor oil. The utility of most of these herbs is based on their
purported anti-inflammatory properties. Some of these herbs have proven effects,
many have potential benefits, and some may aggravate rosacea. Due to the fact
that many patients fail to inform their physicians about their use of herbal
ingredients, dermatologists should be aware of what patients may be using and be
able to advise them about the efficacy of these ingredients or the potential for
adverse effects.

Topical therapies for rosacea. Nally JB, Berson DS. J Drugs Dermatol. 2006 Jan;5(1):23-6.

Therapeutic options for rosacea include topical agents, oral therapies, laser and
light treatments, and surgical procedures. Topical therapies play a critical role
in the treatment of patients with papulopustular rosacea and
erythematotelangiectatic rosacea, and have the ability to effectively minimize
certain manifestations of the disease, including papules, pustules, and erythema.
The 3 primary agents for the topical treatment of rosacea are metronidazole,
azelaic acid, and sodium sulfacetamide-sulfur. Each of these therapies is
approved for the treatment of rosacea and has been validated by multiple studies.
Additional topical therapies including benzoyl peroxide, clindamycin, retinoids,
topical steroids, calcineurin inhibitors, and permethrin are not approved for the
treatment of rosacea and play variable roles in the management of this condition.

Oral therapy for rosacea. Baldwin HE. J Drugs Dermatol. 2006 Jan;5(1):16-21.

This article will examine oral therapies utilized in the treatment of rosacea.
Important topics include recognizing which types of rosacea can benefit from oral
therapy and concerns regarding the emergence of bacterial resistance.

Rosacea: clinical presentation and pathophysiology. Diamantis S, Waldorf HA. J Drugs Dermatol. 2006 Jan;5(1):8-12.

Acne rosacea is one of the most common diagnoses seen in the clinical
dermatologic practice. The classic presentation of rosacea, acneiform papules,
and pustules on a background of telangiectasia, is often easily identified by
primary care physicians, patients, or their similarly afflicted friends or family
members. However, rosacea actually represents a spectrum of disease from chronic
skin hypersensitivity and flushing to rhinophyma. Although the pathogenesis of
rosacea remains unknown, it is important to understand its various presentations
and possible etiologies prior to developing individualized treatment protocols.

Tetracyclines: nonantibiotic properties and their clinical implications. Sapadin AN, Fleischmajer R. J Am Acad Dermatol. 2006 Feb;54(2):258-65.

Tetracyclines are broad-spectrum antibiotics that act as such at the ribosomal
level where they interfere with protein synthesis. They were first widely
prescribed by dermatologists in the early 1950s when it was discovered that they
were effective as a treatment for acne. More recently, biologic actions affecting
inflammation, proteolysis, angiogenesis, apoptosis, metal chelation,
ionophoresis, and bone metabolism have been researched. The therapeutic effects
of tetracycline and its analogues in various diseases have also been
investigated. These include rosacea, bullous dermatoses, neutrophilic diseases,
pyoderma gangrenosum, sarcoidosis, aortic aneurysms, cancer metastasis,
periodontitis, and autoimmune disorders such as rheumatoid arthritis and
scleroderma. We review the nonantibiotic properties of tetracycline and its
analogues and their potential for clinical application.

Laser treatment of vascular lesions. Railan D, Parlette EC, Uebelhoer NS, Rohrer TE. Clin Dermatol. 2006 Jan-Feb;24(1):8-15.

Laser treatment of vascular lesions remains one of the more common applications
of lasers in dermatology. In fact, lasers have largely become the treatment of
choice for vascular birthmarks such as hemangiomas and port-wine stains and the
definitive treatment of the telangiectatic form of rosacea. The range of
congenital and acquired vascular lesions effectively treated with lasers
continues to expand.

Adverse effects of topical glucocorticosteroids. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. J Am Acad Dermatol. 2006 Jan;54(1):1-15; quiz 16-8.

Topical corticosteroids were introduced into medicine about 50 years ago. They
represent a significant milestone in dermatologic therapy. Despite encouragement
to report observed adverse drug reactions, the clinical practice of reporting is
poor and incomplete. Likewise, adverse effects and safety of topical
corticosteroids are neglected in the medical literature. The authors provide an
updated review of their adverse-effect profile. Children are more prone to the
development of systemic reactions to topically applied medication because of
their higher ratio of total body surface area to body weight. Cutaneous adverse
effects occur regularly with prolonged treatment and are dependent on the
chemical nature of the drug, the vehicle, and the location of its application.
The most frequent adverse effects include atrophy, striae, rosacea, perioral
dermatitis, acne, and purpura. Those that occur with lower frequency include
hypertrichosis, pigmentation alterations, delayed wound healing, and exacerbation
of skin infections. Of particular interest is the rate of contact sensitization
against corticosteroids, which is considerably higher than generally believed.
Systemic reactions such as hyperglycemia, glaucoma, and adrenal insufficiency
have also been reported to follow topical application. The authors provide an
updated review of local and systemic adverse effects upon administration of
topical corticosteroids, including the latest FDA report on the safety of such
steroids in children. LEARNING OBJECTIVE: At the completion of this learning
activity, participants should be familiar with topical corticosteroids and their
proper use.

[Periorbital contact eczema] [Article in German] Worm M, Sterry W. Klin Monatsbl Augenheilkd. 2005 Nov;222(11):853-5.

Periorbital contact eczema is most commonly the result of an allergic contact
dermatitis whereas other eczematous skin diseases like atopic eczema or
seborrheic eczema occur less frequently. Also, other diseases like autoimmune
disorders or rosacea need to be considered. Allergic contact dermatitis is a
T-cell-mediated immunological response towards ubiquitous contact allergens.
Activated T-cells migrate through the vessels into the skin and produce several
inflammatory mediators. Epicutaneous patch testing is an important tool for the
diagnosis of contact allergy whereby the allergens are analysed in terms of their
ability to induce eczematous skin reaction. Until now the short-term use of
corticosteroids are is employed for the treatment of allergic contact eczema.
Modern substances with an optimal therapeutic index should rather be used.

Molecular genetics of Erwinia amylovora involved in the development of fire blight. Oh CS, Beer SV. FEMS Microbiol Lett. 2005 Dec 15;253(2):185-92. Epub 2005 Oct 13.

The bacterial plant pathogen, Erwinia amylovora, causes the devastating disease
known as fire blight in some Rosaceous plants like apple, pear, quince, raspberry
and several ornamentals. Knowledge of the factors affecting the development of
fire blight has mushroomed in the last quarter century. On the molecular level,
genes encoding a Hrp type III secretion system, genes encoding enzymes involved
in synthesis of extracellular polysaccharides and genes facilitating the growth
of E. amylovora in its host plants have been characterized. The Hrp pathogenicity
island, delimited by genes suggesting horizontal gene transfer, is composed of
four distinct regions, the hrp/hrc region, the HEE (Hrp effectors and elicitors)
region, the HAE (Hrp-associated enzymes) region, and the IT (Island transfer)
region. The Hrp pathogenicity island encodes a Hrp type III secretion system
(TTSS), which delivers several proteins from bacteria to plant apoplasts or
cytoplasm. E. amylovora produces two exopolysaccharides, amylovoran and levan,
which cause the characteristic fire blight wilting symptom in host plants. In
addition, other genes, and their encoded proteins, have been characterized as
virulence factors of E. amylovora that encode enzymes facilitating sorbitol
metabolism, proteolytic activity and iron harvesting. This review summarizes our
understanding of the genes and gene products of E. amylovora that are involved in
the development of the fire blight disease.

[Clinical variants of acne] [Article in German] Jansen T, Grabbe S, Plewig G. Hautarzt. 2005 Nov;56(11):1018-26.

Acne is a very common dermatosis with characteristic clinical features. It is a
polymorphic disease. The clinical expression ranges from non-inflammatory closed
and open comedones to inflammatory papules, pustules, and nodules. Most patients
have a mixture of non-inflammatory and inflammatory lesions, although some have
predominantly one or the other. Acne varies in severity from a very distressing,
socially disabling disorder to a state that has been regarded as physiological by
some authors. The most severe forms of acne are acne fulminans and acne inversa.
Although acne may occur in all age groups, it is most prevalent during
adolescence. It is not known why acne subsides in most patients but persists into
adulthood in some. Certain medications may be associated with provocation,
perpetuation, or exacerbation of pre-existing acne or with acneiform eruptions.
Acne-like disorders include rosacea, pseudofolliculitis barbae, and other
conditions that share clinical features with acne.

Optical treatments for acne. Ross EV. Dermatol Ther. 2005 May-Jun;18(3):253-66.

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

Assessment of skin barrier function in rosacea patients with a novel 1% metronidazole gel. Draelos ZD. J Drugs Dermatol. 2005 Sep-Oct;4(5):557-62.

The skin of patients with rosacea is extremely sensitive and hyper-reactive to
dietary, environmental, and topical factors. Accordingly, the management of
rosacea involves not only choosing appropriate medication and treatment for daily
skin care, but also avoiding known trigger factors. Recently, 1% metronidazole, a
mainstay of topical rosacea therapy, was reformulated in a gel vehicle that
contains hydrosolubilizing agents (HSA) niacinamide, beta cyclodextrin, and a low
concentration of propylene glycol. It is designed to solubilize greater
concentrations of metronidazole than is possible in water alone while reducing
the potential for irritation and barrier disruption. A 2-week study was
undertaken by the author to evaluate the effect of the new 1% metronidazole gel
on the skin barrier in 25 women with mild to moderate rosacea. Statistically
significant improvement in disease severity, erythema, desquamation, and skin
irritation was noted by the investigator by the end of week 1, which continued
throughout the study. After 2 weeks, subjects noted improvements in skin
condition and rosacea. Results of noninvasive assessments showed no disruption of
the skin barrier. Furthermore, there was an increasing trend in skin hydration
that approached statistical significance.

Face up to rosacea. Roebuck HL. Nurse Pract. 2005 Sep;30(9):24-30, 35; quiz 36-7.

[Rosacea. Clinical features, pathogenesis and therapy] [Article in German] Lehmann P. Hautarzt. 2005 Sep;56(9):871-85; quiz 886-7.

Rosacea is a common facial dermatosis, which may have detrimental effects on the
patient’s psychological and social interactions. It is a disease of the middle
aged, skin types I and II are more often affected than darker skin types.
Clinically, pre-rosacea, and rosacea grade I-III may be distinguished.
Pre-rosacea is characterized by flushing and blushing, grade I to III by
erythemato-teleangiectasies, papulopustules, and inflammatory nodules. Especially
severe subtypes include rosacea conglobata and rosacea fulminans. Hyperglandular
subtypes lead to different forms of phyma, of which Rhinophyma is the most
frequent. Pathogenetically destruction of the dermal vessels and connective
tissue seems to be decisive for the development of a chronic inflammation, which
leads to the phenotype of the various forms of rosacea. Mild forms can be treated
exclusively by topical medication. Antibiotics (erythromycin, clindamycin,
tetracyclin), metronidazol, azelaic acid, and the retinoid adapalene have been
shown to be effective in well controlled randomized studies. The best evaluated
topical medication is metronidazol. In severe forms systemic therapy must be
applied. Systemic antibiotics are effective and especially isotretinoin has shown
a very good response even in low dose regimens. Rhinophyma must be treated
surgically.

Applications of aminolevulinic Acid-based photodynamic therapy in cosmetic facial plastic practices. Zakhary K, Ellis DA. Facial Plast Surg. 2005 May;21(2):110-6.

Photodynamic therapy (PDT) using aminolevulinic acid (ALA) is a promising new
technique that is being studied extensively and used in a variety of cosmetic
facial plastic arenas. These applications include U.S. Food and Drug
Administration-approved treatment of premalignant and malignant skin conditions,
as well as off-label uses for photorejuvenation, and the treatment of acne
vulgaris, sebaceous gland hyperplasia, rosacea, and hirsutism. This article
reviews the interplay of factors that contribute to the appearance of actinically
damaged or photoaged skin, also known as dermatoheliosis. This is followed by a
brief review of the mechanisms of action of ALA-based PDT and some of its
cosmetic facial plastic uses.

Interventions for rosacea. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK, Gover M. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD003262.

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. Frequently it can be controlled, but it is not clear
which treatments are most effective. OBJECTIVES: To assess the evidence for the
efficacy and safety of treatments for rosacea. SEARCH STRATEGY: We searched the
Skin Group Specialised Register (February 2005), Cochrane Central Register of
Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February
2005), EMBASE (1980 to February 2005), BIOSIS (1970 to March 2002) and the
Science Citation Index (1988 to February 2005). Reference lists of trials and key
review articles were searched. Relevant manufacturers and experts were contacted.
SELECTION CRITERIA: Randomised controlled trials in people with moderate to
severe rosacea were included. Studies judged by the authors to have seriously
flawed methodology were excluded. DATA COLLECTION AND ANALYSIS: Study selection,
assessment of methodological quality, data extraction and analysis were carried
out by two independent authors. Disagreements were resolved by discussion and
consensus. MAIN RESULTS: The evidence provided by twenty-nine included studies
was generally weak because of poor methodology and reporting. One of our primary
outcome measures, ‘quality of life’, was not assessed in any of the studies. Only
two studies of ocular rosacea were included.Pooled data from two trials involving
174 participants indicated that according to the participants, topical
metronidazole is more effective than placebo (odds ratio (OR) 5.96, 95%
confidence interval (CI) 2.95 to 12.06). Data pooled from three between-patient
trials showed a clear improvement in the azelaic acid group; the rates of
treatment success were approximately 70 to 80% versus 50% to 55% (OR 2.45, 95% CI
1.82 to 3.28). A within-patient trial of azelaic cream versus placebo could not
be pooled with the other three studies, but also showed good evidence of
efficacy. Data pooled from three studies of oral tetracycline versus placebo
involving 152 participants showed that, according to physicians, tetracycline was
effective (OR 6.06, 95% CI 2.96 to 12.42). Some evidence of efficacy of oral
metronidazole was provided by one small study. AUTHORS’ CONCLUSIONS: The quality
of studies evaluating rosacea treatments was generally poor. There is evidence
that topical metronidazole and azelaic acid are effective. There is some evidence
that oral metronidazole and tetracycline are effective.There is insufficient
evidence concerning the effectiveness of other treatments. Good RCTs looking at
these treatments are urgently needed.

Pathogenesis, clinical features and management of recurrent corneal erosions. Ramamurthi S, Rahman MQ, Dutton GN, Ramaesh K. Eye. 2006 Jun;20(6):635-44. Epub 2005 Jul 15.

Recurrent corneal erosions (RCE) are common. They are characterised by repeated
episodes of pain, difficulty in opening the eyes, watering, and photophobia
resulting from poor epithelial adhesion. In the majority of patients with RCE,
trauma is the initiating factor. Epithelial, stromal, and endothelial corneal
dystrophies have all been described in association with RCE. Other causes that
may lead to RCE include chemical and thermal injuries, previous herpetic
keratitis, meibomian gland dysfunction, ocular rosacea, diabetes mellitus,
Salzmann’s nodular degeneration, band keratopathy, previous bacterial ulceration,
kerato-conjunctivitis sicca, and epidermolysis bullosa. The conditions that are
associated with RCE can be either primary or secondary depending on whether the
basement membrane complex abnormality is intrinsic or acquired. Primary types
tend to be bilateral, symmetrical and develop in multiple corneal locations. The
pathogenetic mechanism of this disorder is related to poor adhesion of the
corneal epithelium to the underlying stroma. Excessive matrix metalloproteinase
(MMP) activity may play a role in the pathogenesis. Although the majority of
patients will respond to simple measures such as padding and antibiotic ointment,
RCE resistant to simple measures require approaches that are more elaborate. The
common goal of these approaches is to encourage proper formation of adhesion
complexes between the epithelium and the stroma. The use of long-term contact
lenses, autologous serum eye drops, botulinum toxin, induced ptosis, oral MMP
inhibitors, diamond burr polishing of Bowman’s membrane have been reported with
varying degree of success in treating RCE. Anterior stromal puncture with insulin
needles or Neodymium : aluminium-yttrium-garnet may enhance the epithelial
adhesion to the basement membrane by scar formation and success rates of up to
80% have been reported in the treatment of recalcitrant RCE. Excimer laser
photo-therapeutic keratectomy (PTK) is now a well-established treatment modality
for RCE and is being used both safely and effectively. Partial ablation of
Bowman’s layer with PTK gives a smooth surface for the newly generating
epithelium to migrate and form adhesion complexes. The pathogenesis, clinical
features, and management options of this common disorder are discussed in this
review article.

Topical metronidazole combination therapy in the clinical management of rosacea. Del Rosso JQ, Bikowski J. J Drugs Dermatol. 2005 Jul-Aug;4(4):473-80.

Metronidazole was the first topical agent approved by the U.S. Food and Drug
Administration for the treatment of rosacea. Several controlled studies have
confirmed the efficacy and safety of topical metronidazole 0.75% gel, lotion and
cream and 1% cream for rosacea. At present, little data exists regarding the use
of combination topical therapy in rosacea management, although anecdotal evidence
and preliminary studies suggest at least some additive benefit when topical
metronidazole is used in combination with sulfacetamide 10% /sulfur 5%. In this
paper, the results of observational experience evaluating topical metronidazole
0.75% gel used in combination with other topical rosacea therapies and/or
subantimicrobial dose doxycycline are reported.

Topical tacrolimus: a review of its uses in dermatology. Woo DK, James WD. Dermatitis. 2005 Mar;16(1):6-21.

Tacrolimus is one of the newer immunosuppressants that act by inhibiting T-cell
activation and cytokine release. It is approved for the treatment of atopic
dermatitis, and its safety and efficacy have been extensively studied in
large-scale randomized controlled trials and open-label studies worldwide
involving over 12,000 patients and up to 3 years of follow-up. Since its
introduction, anecdotal reports and case series have found topical tacrolimus
also to be effective and well tolerated in patients with a variety of other skin
disorders, including other types of eczema, papulosquamous disorders, disorders
of cornification, rosacea, other inflammatory skin conditions, vesiculobullous
diseases, vitiligo, connective-tissue diseases, graft-versus-host disease, and
follicular disorders. This paper reviews the currently available evidence on the
use of topical tacrolimus for these conditions, as well as its safety profile and
cost-effectiveness. Tacrolimus does appear to offer a safe and efficacious
alternative that minimizes the need for topical glucocorticoids and does not
cause skin atrophy. However, the risk of systemic absorption is increased with
generalized disruption of the skin barrier. Further large-scale studies are
needed to clarify the efficacy of topical tacrolimus in a variety of conditions
for which anecdotal reports of success exist, especially in regard to different
racial groups and in comparison to (as well as in combination with) other
existing therapies. Long-term safety data should continue to be monitored and
reported.

On the diagnosis of facial granulomatous dermatoses of obscure origin. Makkar R, Ramesh V. Int J Dermatol. 2005 Jul;44(7):606-9.

Non-acne dermatologic indications for systemic isotretinoin. Akyol M, Ozçelik S. Am J Clin Dermatol. 2005;6(3):175-84.

Systemic isotretinoin has been used to treat severe acne vulgaris for 20 years.
However, isotretinoin also represents a potentially useful choice of drugs in
many dermatologic diseases other than acne vulgaris. Diseases such as psoriasis,
pityriasis rubra pilaris, condylomata acuminata, skin cancers, rosacea,
hidradenitis suppurativa, granuloma annulare, lupus erythematosus and lichen
planus have been shown to respond to the immunomodulatory, anti-inflammatory and
antitumor activities of the drug. Isotretinoin also helps prevent skin cancers
such as basal cell carcinoma or squamous cell carcinoma. A combination of
systemic isotretinoin and interferon-alpha-2a may provide a more potent effect
than isotretinoin alone in the prevention and treatment of skin cancers.Systemic
isotretinoin may be considered as an alternative drug in some dermatologic
diseases unresponsive to conventional treatment modalities. However, randomized
clinical trials aimed at determining the role of systemic isotretinoin therapy in
dermatologic diseases other than acne vulgaris are required.

[Clinical significance of infection with cag A and vac A positive Helicobacter pylori strains] [Article in Serbian] Sokić-Milutinović A, Todorović V, Milosavljević T. Srp Arh Celok Lek. 2004 Nov-Dec;132(11-12):458-62.

Clinical relevance of infection with different Helicobacter pylori strains was
reviewed in this paper. Helicobacter pylori (H. pylori) infection plays a role in
pathogenesis of chronic gastritis, peptic ulcer disease, gastric adenocarcinoma
and MALT lymphoma. Extragastric manifestations of H. pylori infection most
probably include acne rosacea and chronic urticaria, while the importance of H.
pylori infection for pathogenesis of growth retardation in children, iron
deficiency anemia, coronary heart disease, stroke and idiopathic thrombocytopenic
purpura remains vague. The expression of two H. pylori proteins, cytotoxin
associated protein (cag A) and vacuolization cytotoxin (vac A) is considered to
be related with pathogenicity of the bacterium. It is clear that presence of cag
A+ strains is important for development of peptic ulcer; nevertheless, it is also
protective against esophageal reflux disease. On the other hand, cag A+ strains
are common in gastric adenocarcinoma and MALT lymphoma patients, but it seems
that certain subtypes of vac A cytotoxin are more important risk factors.
Infection with cag A+ strains is more common in patients with acne rosacea,
stroke and coronary heart disease.

[Photoexacerbated dermatoses] [Article in French] Goffin V, Nikkels AF, Piérard GE. Rev Med Liege. 2005;60 Suppl 1:83-7.

A series of viral and bacterial diseases are photoaggravated. Some autoimmune
connective tissue disorders including lupus erythematosus and dermatomyositis are
also affected. This category of photoexacerbated diseases also encompasses some
cases of atopic dermatitis, lichen and rosacea.

Rosacea: the battle goes on. Landow K. Compr Ther. 2005 Summer;31(2):145-58.

Rosacea presents an enigma to patients and physicians alike. Although new
insights and a plethora of therapies provide hope, the underlying etiology
remains unknown. This assures a certain amount of frustration as available
treatments temporize rather than cure the disease. This article examines the
current state of knowledge regarding this fascinating entity.

Rosacea, light, and phototherapy. Lee M, Koo J. J Drugs Dermatol. 2005 May-Jun;4(3):326-9.

The long-established notion that rosacea is worsened by light is of particular
concern in the phototherapy of diseases such as psoriasis, eczema, or vitiligo,
which often can be coexistent with rosacea. A literature search was conducted and
much evidence was found to challenge this belief that light adversely affects
rosacea. In fact, more patients actually improved with sunlight in a more recent
published survey. Several other studies have also shown that rosacea patients
were similar to control subjects in sun exposure, solar skin damage, and sun
sensitivity. Additionally, all clinical trials to date have failed to find a
difference between rosacea patients and control subjects when challenged with
ultraviolet light. Thus, phototherapy with rosacea may be safer than is commonly
believed.

Rosacea and its management: an overview. Gupta AK, Chaudhry MM. J Eur Acad Dermatol Venereol. 2005 May;19(3):273-85.

BACKGROUND: Rosacea is a chronic inflammatory disorder that affects 10% of the
population. The prevalence of rosacea is highest among fair-skinned individuals,
particularly those of Celtic and northern European descent. Since a cure for
rosacea does not yet exist, management and treatment regimens are designed to
suppress the inflammatory lesions, erythema, and to a lesser extent, the
telangiectasia involved with rosacea. OBJECTIVES: This review outlines the
treatment options that are available to patients with rosacea. METHODS: Published
literature involving the treatment or management of rosacea was examined and
summarized. RESULTS: Patients who find that they blush and flush frequently, or
have a family history of rosacea are advised to avoid the physiological and
environmental stimuli that can cause increased facial redness. Topical agents
such as metronidazole, azelaic acid cream or sulfur preparations are effective in
managing rosacea. Patients who have progressed to erythematotelangiectatic and
papulopustular rosacea may benefit from the use of an oral antibiotic, such as
tetracycline, and in severe or recalcitrant cases, isotretinoin to bring the
rosacea flare-up under control. Treatment with a topical agent, such as
metronidazole, may help maintain remission. Patients with ocular involvement may
benefit from a long-term course of an antibiotic and the use of metronidazole
gel. A surgical alternative, laser therapy, is recommended for the treatment of
telangiectasias and rhinophyma. Patients with distraught feelings due to their
rosacea may consider cosmetic camouflage to cover the signs of rosacea.
CONCLUSIONS: With the wide variety of oral and topical agents available for the
effective management of rosacea, patients no longer need to feel self-conscious
because of their disorder.

Acneiform facial eruptions: a problem for young women. Cheung MJ, Taher M, Lauzon GJ. Can Fam Physician. 2005 Apr;51:527-33.

OBJECTIVE: To summarize clinical recognition and current management strategies
for four types of acneiform facial eruptions common in young women: acne
vulgaris, rosacea, folliculitis, and perioral dermatitis. QUALITY OF EVIDENCE:
Many randomized controlled trials (level I evidence) have studied treatments for
acne vulgaris over the years. Treatment recommendations for rosacea,
folliculitis, and perioral dermatitis are based predominantly on comparison and
open-label studies (level II evidence) as well as expert opinion and consensus
statements (level III evidence). MAIN MESSAGE: Young women with acneiform facial
eruptions often present in primary care. Differentiating between morphologically
similar conditions is often difficult. Accurate diagnosis is important because
treatment approaches are different for each disease. CONCLUSION: Careful visual
assessment with an appreciation for subtle morphologic differences and associated
clinical factors will help with diagnosis of these common acneiform facial
eruptions and lead to appropriate management.

The pharmacologic therapy of rosacea: a paradigm shift in progress. Bikowski JB. Cutis. 2005 Mar;75(3 Suppl):27-32; discussion 33-6.

A number of topical and systemic pharmacologic therapies, some of which remain
investigational, have been used to treat rosacea. The pathophysiology of rosacea
appears to be inflammatory, and most of the interventions modulate the
inflammatory process in some way. Topical agents include various formulations of
sodium sulfacetamide and sulfur, metronidazole, azelaic acid, and benzoyl
peroxide/clindamycin. Oral agents include antibiotics in conventional and
subantimicrobial doses. A paradigm shift in progress in the management of rosacea
encompasses the use of these and other agents either alone or, increasingly, in
different combinations, based on the subtype of rosacea.

Lasers and light sources for rosacea. Goldberg DJ. Cutis. 2005 Mar;75(3 Suppl):22-6; discussion 33-6.

Pharmacologic agents remain the mainstay for initial and maintenance treatment of
rosacea. However, monochromatic (i.e., laser) and polychromatic light-based
therapies are increasingly being used for the treatment of certain signs of
rosacea. Despite the increased use of lasers and other light-based therapies, few
well-controlled studies have been conducted on their use for the treatment of
rosacea. The studies that do exist suggest that these modalities have value in
treating erythematotelangiectatic rosacea, including persistent erythema and
phymatous rosacea. Light-based therapies should be strongly considered in cases
of serious erythema, flushing, and telangiectasia because these signs are not
optimally addressed by pharmacologic interventions.

Adjunctive skin care in the management of rosacea: cleansers, moisturizers, and photoprotectants. Del Rosso JQ. Cutis. 2005 Mar;75(3 Suppl):17-21; discussion 33-6.

Certain skin characteristics, such as altered vascular reactivity, appear to be
common among patients with rosacea. This may partly explain the observation that
these patients appear to have increased sensitivity to certain components of
commonly used topical agents. Accordingly, patients with rosacea should be
educated regarding which general skin care products to use and to avoid. This
review summarizes information regarding 3 classes of these products–cleansers,
moisturizers, and photoprotectants–with emphasis on barrier function and skin
irritation.

The rigor of trials evaluating Rosacea treatments. van Zuuren EJ, Graber MA. Cutis. 2005 Mar;75(3 Suppl):13-6; discussion 33-6.

The Cochrane Collaboration is an international nonprofit organization that
conducts systematic reviews of healthcare interventions. The organization has
recently reviewed all studies meeting designated criteria on interventions for
rosacea. To be included in the review, trials had to be randomized controlled
trials (RCTs) that met the methodological criteria of the reviewers and that were
conducted in an adult patient population with moderate to severe rosacea. The
electronic databases searched included The Cochrane Skin Group Specialised Trials
Register, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE,
BIOSIS, and Science Citation Index. The reviewers tried to obtain details of
unpublished and ongoing RCTs through correspondence with authors and
pharmaceutical companies. After evaluating the included studies, the reviewers
concluded there is evidence that topical metronidazole in 1% cream and 0.75% gel
formulations and azelaic acid in 20% cream formulation are effective and safe.
Furthermore, there is some evidence that oral metronidazole and tetracycline are
effective. The reviewers also made suggestions about future rosacea research.

Evidence-based dermatology. Margolis DJ. Cutis. 2005 Mar;75(3 Suppl):8-12; discussion 33-6.

Evidence-based dermatology (EBD) is the application of the principles of
evidence-based medicine to the diagnosis and treatment of skin disorders. EBD
does not discount the individual dermatologist’s clinical judgment. In fact, EBD
is based on the interaction of external evidence, the physician’s clinical
experience, and the patient’s experience. Randomized controlled trials constitute
one of the highest levels of evidence and are the gold standard for validating a
therapeutic intervention. For the treatment of rosacea, oral tetracycline,
topical metronidazole, topical azelaic acid, and topical sulfur/sodium
sulfacetamide have been validated by more than one randomized controlled trial.

Present and future rosacea therapy. Wolf JE Jr. Cutis. 2005 Mar;75(3 Suppl):4-7; discussion 33-6.

Despite its prevalence, rosacea has not received the same attention of
researchers as other dermatologic disorders. Nevertheless, new pharmacologic and
nonpharmacologic therapies for the condition continue to be developed. The future
of rosacea treatment will probably involve a combination of drugs and devices.
Certain core therapies (i.e., topical metronidazole, topical azelaic acid, oral
tetracyclines, and topical sulfur/sodium sulfacetamide) are validated by the
greatest amount of high-order clinical evidence and will undoubtedly remain
first-line therapeutic choices. However, more research is necessary to validate
the efficacy and safety of newer pharmacologic agents and light-based therapy.
Because rosacea is a chronic condition, pharmacologic maintenance therapy is
necessary to maintain remission.

Disorders of flushing. Yale SH, Vasudeva S, Mazza JJ, Rolak L, Arrowood J, Stichert S, Stratman ES. Compr Ther. 2005 Spring;31(1):59-71.

Disorders of flushing encompass a broad spectrum of diverse acquired and
inherited conditions. Chemical mediators involved in the flushing response are
incompletely understood. Flushing episodes rarely can be associated with
significant morbidity and mortality. The goal of the physician is to separate
benign from potentially life-threatening conditions. Accurate diagnosis requires
a thorough history and physical examination emphasizing the age of the patient,
temporal association of flushing with occupation, environmental, stress, food, or
drug exposure, and the duration of the episode. In some cases, despite a thorough
evaluation, the etiology for flushing remains unknown. Understanding the distinct
mechanisms that lead to flushing helps provide a rational approach to treatment.

A review of clinical experience and recommendations for improving patient care. Weiss J. Cutis. 2005 Feb;75(2 Suppl):32-8; discussion 39.

This article reviews the history of retinoids from the 1960s to the present,
clinical experiences, and recommendations for improving care for patients with
acne. How a retinoid is chosen by the clinician based on irritation potential,
treatment outcome, patient profile, type of acne, and the patient’s clinical
experience is discussed, as well as the use of retinoids in the treatment of
photoaging and other approved and off-label uses.

Clinical practice. Rosacea. Powell FC. N Engl J Med. 2005 Feb 24;352(8):793-803.

Rosacea: an update. Buechner SA. Dermatology. 2005;210(2):100-8.

Rosacea is a common chronic cutaneous disorder of unknown etiology which occurs
most commonly in middle-aged individuals. Cutaneous manifestations include
transient or persistent facial erythema, telangiectasia, edema, papules and
pustules that are usually confined to the central portion of the face. The
National Rosacea Society’s Expert Committee on the Classification and Staging of
Rosacea identified four subtypes of rosacea: erythematotelangiectatic,
papulopustular, phymatous and ocular. Recently, a standard grading system for
assessing gradations of the severity of rosacea has been reported. Little is
known about the cause of rosacea. Genetic, environmental, vascular, inflammatory
factors and microorganisms such as Demodex folliculorum and Helicobacter pylori
have been considered. Topical metronidazole and azelaic acid have been
demonstrated to be effective treatments for rosacea. Severer or persistent cases
may be treated with oral metronidazole, tetracyclines or isotretinoin.

Light-emitting diode-based therapy. Abramovits W, Arrazola P, Gupta AK. Skinmed. 2005 Jan-Feb;4(1):38-41.

Rosacea. An overview of diagnosis and management. Lindow KB. Adv Nurse Pract. 2004 Dec;12(12):27-32.

[Psychodermatology: current state of the problem] [Article in Russian] Smulevich AB, Ivanov OL, L’vov AN, Dorozhenok IIu. Zh Nevrol Psikhiatr Im S S Korsakova. 2004;104(11):4-13.

An analysis of comorbidity of psychiatric and dermatological pathology in
historical, epidemiological and clinical aspects is presented. Psychocutaneous
disorders (delusional parasitosis, hypochondria circumscripta,
obsessive-compulsive disorders with self-mutilations, pathomimia) play a central
role in systematics elaborated in the present study. The authors suggest that
delusional parasitosis is a subtype of paranoiac psychosis (paranoia, paranoiac
schizophrenia). Psychiatric disorders triggered by dermatological pathology were
specified as nosogenous reactions, depressive reactions with sociophobia,
pathologic personality development (paranoiac, sensitive, hypochondriac). Atopic
dermatitis, eczema, urticaria, psoriasis, herpes simplex, alopecia areata,
rosacea, etc, are regarded among dermatological psychosomatic disorders with
psychogenic manifestation/exacerbation.

Use of macrolides and tetracyclines for chronic inflammatory diseases. Voils SA, Evans ME, Lane MT, Schosser RH, Rapp RP. Ann Pharmacother. 2005 Jan;39(1):86-94. Epub 2004 Nov 23.

OBJECTIVE: To review the efficacy of macrolides and tetracyclines in several
chronic inflammatory conditions. DATA SOURCES: Searches of MEDLINE (1966-March
2004) and an extensive bibliography search were undertaken. Key terms included
acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis,
rosacea, and rheumatoid arthritis. STUDY SELECTION AND DATA EXTRACTION: Data were
obtained primarily from randomized placebo-controlled trials upon which key
recommendations are based. DATA SYNTHESIS: Antibiotics are often prescribed for
months or even years for treatment of chronic inflammatory conditions such as
acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis,
rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that
azithromycin is useful in the management of cystic fibrosis and the tetracyclines
are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and
periodontitis. Several large, randomized controlled trials have failed to show
any benefit of macrolides in the secondary prevention of cardiovascular disease.
No randomized placebo-controlled clinical trials have been performed to assess
the efficacy of macrolides or tetracyclines in patients with rosacea.
CONCLUSIONS: The use of tetracyclines and macrolides for rosacea is based
primarily on anecdotal reports or open-label trials. Limited clinical trials
support the use of tetracyclines or macrolides in acne, blepharitis,
periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not
support the use of antibiotics for secondary prevention of cardiovascular
disease.

Advances in the topical treatment of acne and rosacea. Ceilley RI. J Drugs Dermatol. 2004 Sep-Oct;3(5 Suppl):S12-22.

Acne and rosacea are common skin diseases which may present similarly and both
involve inflammation. Both can result in significant cosmetic impairment and lead
to quality of life decrements if not optimally treated. The conventional approach
for both diseases involves the use of topical therapy to treat inflammatory
lesions in combination, when needed, with a systemic or topical antibiotic. An
important issue in the management of both diseases at present is the need to
reduce antibiotic usage due to the increasing problem of bacterial resistance.
One of the emerging treatment paradigms that is becoming increasingly useful as
an antibiotic-sparing strategy is the use of procedural therapies in combination
with medical management. Such procedural modalities include lasers, intense
pulsed light (IPL), and photodynamic therapies (PDT). Topical regimens are used
pre-treatment and following physical modalities for maintenance of remission.

Combination therapy in clinical and cosmetic dermatology: the marriage of device and drug. Nestor MS. J Drugs Dermatol. 2004 Sep-Oct;3(5 Suppl):S4-11.

The first generations of lasers used in clinical and cosmetic dermatology
achieved their effects by means of epidermal and dermal ablation. While effective
in removing some of the stigmata of photodamage including pigmentary changes and
rhytides, vascular abnormalities associated with such conditions as melasma and
rosacea, were not sufficiently effective. The new generation of laser and
non-laser light devices (eg, intense pulsed light or IPL) offer excellent results
in the management of clinical and cosmetic conditions, including significant
changes in improvement in vascular conditions such as rosacea and actinic damage
and stimulating dermal collagen production, without significant injury to the
epidermis. The combination of light therapies and topical agents adds to the
efficacy of these procedures, particularly in post-procedural maintenance.
Light-based therapies have been an important addition to the anti-acne
armamentarium as they are effective and do not add to the increasing bacterial
resistance problem.

[The red face] [Article in German] Schuster Ch, Burg G. Praxis (Bern 1994). 2004 Oct 13;93(42):1727-32.

Facial erythema may not only present clinically as a distinct entity, but can
also be a symptom of other diseases. It is seen in common dermatoses such as
eczema, psoriasis, acne and urticaria, as well as in rarer conditions such as
disorders of keratinization, infectious diseases, porphyrias and neoplasia.
Facial erythema may also present as a symptom of carcinoid syndrome, drug
allergies, cardiac disease or in rare cases as a feature of Bloom’s syndrome,
sarcoidosis, lymphoma, amyloidosis and other disease processes. We would like to
concentrate on the practical aspects of facial erythema as a presenting symptom,
rather than discussing every disease in detail.

Ocular rosacea: an update on pathogenesis and therapy. Stone DU, Chodosh J. Curr Opin Ophthalmol. 2004 Dec;15(6):499-502.

PURPOSE OF REVIEW: Ocular rosacea is a common and potentially blinding eye
disorder with an uncertain etiology. Therapies currently in vogue for ocular
rosacea have not been rigorously studied with regards to specific indications,
optimal dosing regimens, or treatment efficacy. This review will summarize the
recent literature with regards to etiology and therapy of ocular rosacea, and
will also examine current thinking about the parent disorder, acne rosacea.
RECENT FINDINGS: Comparatively few papers on ocular rosacea were published in the
past year. Recent articles on the prevalence of ocular rosacea in patients with
acne rosacea suggested that between 6 and 18% of acne rosacea patients have signs
or symptoms of ocular rosacea, but few cases were confirmed by an
ophthalmologist. Recent articles on the pathogenesis of ocular rosacea have
focused on the role of bacterial lipases, and interleukin-1alpha and matrix
metalloproteinases in the blepharitis and corneal epitheliopathy, respectively.
Other reports highlighted the presence of the disorder in children, and the lack
of masked, placebo-controlled studies for those therapies currently in common
use. SUMMARY: The epidemiology, etiology, and optimal therapy of ocular rosacea
remain to be determined, and will require a more concerted effort to delineate.

Treating beyond the histology of rosacea. Draelos ZD. Cutis. 2004 Sep;74(3 Suppl):28-31, 32-4.

Current treatment paradigms for rosacea focus on inflammatory lesions and other
signs and symptoms of rosacea that appear on the skin surface. However, it is
important to recognize the effects of the disease and its various treatments not
only on the stratum corneum barrier but also on the biofilm. The effects of skin
care products, cosmetics, and medications on the stratum corneum and biofilm must
be carefully assessed, and nonirritating formulations should be used whenever
possible.

Rosacea subtypes: a treatment algorithm. Dahl MV. Cutis. 2004 Sep;74(3 Suppl):21-7, 32-4.

Based on various signs and symptoms, the National Rosacea Society (NRS) Expert
Committee has divided the syndrome of rosacea into 4 major subtypes:
erythematotelangiectatic, papulopustular (inflammatory), phymatous, and ocular.
Each of the subtypes can be divided further into more specific subgroups. For
example, sensory rosacea is an additional subtype that can be recognized and
treated. Signs and symptoms may direct therapy. This article proposes an overview
of common treatments based on subtypes. Treatments that have been validated by
randomized controlled trials are reviewed. However, many excellent treatments
have not been validated by double-blind randomized trials.

Reactive oxygen species and rosacea. Jones D. Cutis. 2004 Sep;74(3 Suppl):17-20, 32-4.

Although the fundamental pathogenesis of rosacea remains unknown, inflammation is
a central process in this disorder. Recent evidence suggests that this
inflammation is associated with the generation of reactive oxygen species (ROS)
that are released by inflammatory cells such as neutrophils. In vitro studies
suggest that certain core therapies for rosacea, including metronidazole and the
tetracyclines, show antioxidant effects, and this may be one aspect of their
mechanism of action.

Ultraviolet light and rosacea. Murphy G. Cutis. 2004 Sep;74(3 Suppl):13-6, 32-4.

The general consensus among clinicians is that rosacea is a photoaggravated
disorder. Pathophysiologic processes induced by UV radiation, which are processes
similar to those seen in photoaging, contribute to the signs and symptoms of
rosacea. Because of the purported role of solar radiation, clinicians may want to
use photosensitizing antibiotics with discretion in patients with rosacea. In
addition to topical and oral therapy for rosacea, clinicians should recommend
that patients use sunscreens or sunblocks (inorganic chemicals such as zinc oxide
or titanium dioxide).

Rosacea and the pilosebaceous follicle. Powell FC. Cutis. 2004 Sep;74(3 Suppl):9-12, 32-4.

The pathophysiology of rosacea remains unknown. A leading theory suggests a
vascular basis; however, clinical observations and histopathologic studies
suggest that inflammation of the pilosebaceous follicle may be central to the
pathogenesis of rosacea. Demodex folliculorum is a frequently seen commensal in
the follicles of facial skin. According to evidence from biopsies of the skin
surface, individuals with rosacea have a higher density of this parasite. This
increased mite density may play a role in the pathophysiology of rosacea by
triggering inflammatory or specific immune reactions, mechanically blocking the
follicles, or acting as a vector for bacteria. Ongoing research has shown that
bacteria from patients with rosacea may behave differently at the higher skin
temperature that may be present in patients with rosacea. Another group has
isolated bacteria from the Demodex mites; these bacteria may play a pathogenic
role in papulopustular rosacea by facilitating follicular-based inflammatory
changes.

The nosology of rosacea. Odom R. Cutis. 2004 Sep;74(3 Suppl):5-8, 32-4.

The National Rosacea Society (NRS) convened a committee of dermatology thought
leaders to develop a standard classification system for rosacea. Based on the
primary and secondary characteristics of this disorder, the NRS Expert Committee
identified 4 types of rosacea: erythematotelangiectatic, papulopustular,
phymatous, and ocular; one variant, granulomatous, also was recognized. The NRS
Expert Committee also developed a grading system for rosacea signs and symptoms
that will complement this classification system. The classification system and
forthcoming grading system will help practitioners refine their diagnosis and
treatment of rosacea to ensure better outcomes for patients.

Rosacea: II. Therapy. Pelle MT, Crawford GH, James WD. J Am Acad Dermatol. 2004 Oct;51(4):499-512; quiz 513-4.

Despite an incomplete understanding of the pathogenesis of rosacea, therapeutic
modalities continue to expand. The principal subtypes of rosacea include
erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and
ocular rosacea. These phenotypic expressions are probably caused by divergent
pathogenic factors and consequently respond to different therapeutic regimens. A
subtype-directed approach to therapy is discussed in part II of this review. We
provide an overview of the available topical, oral, laser, and light therapies in
the context of these cutaneous subtypes, review the evidence that supports their
use, and outline their therapeutic approach. Suggestions for future areas of
study also are provided.Learning objective At the completion of this learning
activity, participants should be familiar with the subtype-directed approach to
therapy for rosacea including available topical, oral, laser, and light
therapies.

A status report on the use of subantimicrobial-dose doxycycline: a review of the biologic and antimicrobial effects of the tetracyclines. Del Rosso JQ. Cutis. 2004 Aug;74(2):118-22.

Rosacea in the pediatric population. Lacz NL, Schwartz RA. Cutis. 2004 Aug;74(2):99-103.

Rosacea is a condition of vasomotor instability characterized by facial erythema
most notable in the central convex areas of the face, including the forehead,
cheek, nose, and perioral and periocular skin. Rosacea tends to begin in
childhood as common facial flushing, often in response to stress. A diagnosis
beyond this initial stage of rosacea is unusual in the pediatric population. If a
child is identified with the intermediate stage of rosacea, consisting of papules
and pustules, an eye examination should be performed to rule out ocular
manifestations. It may be beneficial to recognize children in the early stage of
rosacea; however, it is uncertain if prophylactic treatment is necessary.

Skin diseases in alcoholics. Kostović K, Lipozencić J. Acta Dermatovenerol Croat. 2004;12(3):181-90.

Alcohol abuse is associated with many health problems, especially skin changes.
As a small, water- and lipid-soluble molecule, alcohol reaches all tissues of the
body and affects most vital functions. Cutaneous diseases are now emerging as
useful markers of alcoholism detectable at an early and possibly reversible stage
of the disease, thus being of substantial importance to dermatologists and
general practitioners. The most common skin manifestations of alcoholism
presented in this review article are urticarial reactions, porphyria cutanea
tarda, flushing, cutaneous stigmata of cirrhosis, psoriasis, pruritus, seborrheic
dermatitis, and rosacea.

Rosacea: I. Etiology, pathogenesis, and subtype classification. Crawford GH, Pelle MT, James WD. J Am Acad Dermatol. 2004 Sep;51(3):327-41; quiz 342-4.

Rosacea is one of the most common conditions dermatologists treat. Rosacea is
most often characterized by transient or persistent central facial erythema,
visible blood vessels, and often papules and pustules. Based on patterns of
physical findings, rosacea can be classified into 4 broad subtypes:
erythematotelangiectatic, papulopustular, phymatous, and ocular. The cause of
rosacea remains somewhat of a mystery. Several hypotheses have been documented in
the literature and include potential roles for vascular abnormalities, dermal
matrix degeneration, environmental factors, and microorganisms such as Demodex
folliculorum and Helicobacter pylori. This article reviews the current literature
on rosacea with emphasis placed on the new classification system and the main
pathogenic theories.Learning objective At the conclusion of this learning
activity, participants should be acquainted with rosacea’s defining
characteristics, the new subtype classification system, and the main theories on
pathogenesis.

The use of sulfur in dermatology. Gupta AK, Nicol K. J Drugs Dermatol. 2004 Jul-Aug;3(4):427-31.

Sulfur has antifungal, antibacterial, and keratolytic activity. In the past, its
use was widespread in dermatological disorders such as acne vulgaris, rosacea,
seborrheic dermatitis, dandruff, pityriasis versicolor, scabies, and warts.
Adverse events associated with topically applied sulfur are rare and mainly
involve mild application site reactions. Sulfur, used alone or in combination
with agents such as sodium sulfacetamide or salicylic acid, has demonstrated
efficacy in the treatment of many dermatological conditions.

Granulomatous periorificial dermatitis. Tarm K, Creel NB, Krivda SJ, Turiansky GW. Cutis. 2004 Jun;73(6):399-402.

Granulomatous periorificial dermatitis (GPD) is a distinct facial eruption in
prepubertal children that should be distinguished from granulomatous rosacea,
perioral dermatitis, and cutaneous sarcoidosis. We describe a case of GPD and
review the key distinguishing features of this condition.

Rosacea: where are we now? Bikowski JB, Goldman MP. J Drugs Dermatol. 2004 May-Jun;3(3):251-61.

Advances continue to be made in the classification and treatment of rosacea, a
chronic dermatologic syndrome. A new empiric classification system identifies 4
rosacea subtypes (erythematotelangiectatic, papulopustular, phymatous, and
ocular) that may aid in more precise diagnosis. Several new therapies have
recently been approved for treatment of rosacea. Azelaic acid 15% gel is a new
first-tier topical agent proven effective in reducing inflammatory lesions and
erythema. New formulations of metronidazole and sulfacetamide 10%/sulfur 5% that
offer cosmetic or tolerability advantages are now available. Intense pulsed light
therapy has demonstrated effectiveness in reducing flushing, erythema, and
telangiectases, with greater tolerability than existing laser systems. Other
treatments under investigation include low-dose doxycycline hyclate (which may
provide greater safety than existing oral antibiotics), benzoyl
peroxide/clindamycin gel, and tacrolimus ointment (for steroid-induced rosacea).
With this expanded armamentarium of medical and light-based therapies, clinicians
can now implement a multifaceted approach to treatment, crafting new treatment
combinations to address the unique and evolving features of rosacea in each
individual patient.

Demodicidosis in scalp rosacea? Wong CS, Kirby B. Clin Exp Dermatol. 2004 May;29(3):318-9.

[Rosacea as a multisystemic disease] [Article in Serbian] Djaković Z, Milenković S, Pesko P, Djukić N. Srp Arh Celok Lek. 2003 Nov-Dec;131(11-12):474-8.

Rosacea is a chronic skin disorder, affecting the face and chest, and develops
mostly in the 3rd to 6th decades of life. It is characterized by erythema,
telangiectasias, and recurrent flushings. During the time of this chronic
inflammation, skin typically develops papules, pustules, and swelling. Ocular
involvement occurs in 3 to 58% of patients with skin changes. Common ocular signs
include blepharoconjunctivitis, meibomitis, and dry eyes. Rosacea keratitis, when
present, however, has a poor prognosis and may lead to blindness. Among skin
diseases, Helicobacter pylori infection has been often related with rosacea. A
higher prevalence of indigestion and Helicobacter pylori infection in rosacea
patients than in healthy controls has been reported. However, no causal relation
has been identified. On the other hand, oral treatment with metronidazole is
beneficial in all of three mentioned manifestations of rosacea (skin, eye,
indigestion). There is obvious need for multidisciplinary approach, and
investigation to rosacea.

Facial hygiene and comprehensive management of rosacea. Draelos ZD. Cutis. 2004 Mar;73(3):183-7.

The skin of patients with rosacea is exquisitely sensitive to various dietary,
environmental, and topical factors that initiate the facial erythema
characteristic of this sensitive skin condition. This sensitivity is probably due
to epidermal barrier dysfunction. Overall management of rosacea involves the
avoidance of dietary and environmental triggers, concurrent with the use of
prescription therapies. The appropriate selection of over-the-counter and
prescription skin care products is equally important. This article reviews the
use of therapeutic skin cleansers, including the newest category of prescription
antimicrobial cleansers, which can enhance the overall management of this
inflammatory dermatologic disorder.

Use of the KTP laser in the treatment of rosacea and solar lentigines. Bassichis BA, Swamy R, Dayan SH. Facial Plast Surg. 2004 Feb;20(1):77-83.

Numerous techniques have evolved in facial plastic surgery to treat rosacea and
solar lentigines. The treatment regimens range from avoidance of causative
factors to the use of topical agents or other modalities that target the
superficial layers of the skin. Of the modalities that target the epidermis,
lasers offer the physician and patient the ability to target specific
chromophores in the skin. Advances in laser technology led to the implementation
of targeting certain characteristic pigments of abnormal areas with minimal
damage to surrounding normal tissue. Rosacea and solar lentigines have
characteristic cells that are targeted by a potassium-titanyl-phosphate (KTP)
laser. The lesions are different in their origins but share the ability to be
treated successfully with the KTP laser. A review of both conditions and other
treatment options is discussed.

The use of polyhydroxy acids (PHAs) in photoaged skin. Grimes PE, Green BA, Wildnauer RH, Edison BL. Cutis. 2004 Feb;73(2 Suppl):3-13.

The beneficial effects of alpha-hydroxyacids (AHAs) on skin were discovered by
Drs. Van Scott and Yu in the early 1970s, including exfoliation, skin smoothing,
and antiaging effects. A new generation of AHAs, called polyhydroxy acids (PHAs),
was discovered that provide similar effects as AHAs but do not cause the sensory
irritation responses that can limit the use of classical AHAs. PHAs have been
found to be compatible with clinically sensitive skin, including rosacea and
atopic dermatitis, and can be used after cosmetic procedures. PHAs provide
additional humectant and moisturization properties compared with AHAs and can
enhance stratum corneum barrier function, therefore increasing the skin’s
resistance to chemical challenge. Most PHAs also possess antioxidant properties.
PHAs such as gluconolactone or lactobionic acid may be used in combination with
other products, ingredients, or procedures such as laser and microdermabrasion to
provide additional benefits to therapy or to enhance the therapeutic effect.
Several studies were conducted in support of this, and methods and results are
discussed. In summary, PHA-containing products were used in combination with
retinoic acid in treating adult facial acne and were found to be well tolerated.
PHAs plus retinyl acetate (pro-vitamin A) in a cream base exhibited significant
antiaging skin benefits such as skin smoothing and plumping. PHAs plus
hydroquinone showed excellent improvement in antiaging and skin lightening
parameters. Finally, PHA-containing products were shown to be compatible with
African American, Caucasian, and Hispanic/Asian skin and provided significant
improvements in photoaging in these populations.

[Microcystic adnexal carcinoma (malignant syringoma) of the nose: case report and review of the literature] [Article in German] Bewer F, Förster C, Welkoborsky HJ. Laryngorhinootologie. 2004 Feb;83(2):113-6.

A case of Malignant Syringoma (syn. = Microcystic Adnexal Carcinoma, Sclerosing
Swat Duct Carcinoma) of the nose in a 44 year old female patient is reported. The
tumor had been misdiagnosed as a Rhinophyma some 20 years before and had thus
been treated under cosmetic aspects. Besides the appearance, the patient did not
suffer any complaints and was referred to the ENT-department of the Klinikum
Hannover for cosmetic reasons. Histopathological examination after removal
revealed a malignant syringoma, which, due to its extensive size and
subepithelial growth pattern, made a complete ablation of the entire nose and the
adjacent soft tissue of the face necessary. Pathohistologically cellular atypia,
invasive growth pattern, perineural and perivascular infiltration was
characteristic. Quantitative DNA anaylsis revealed a tumor with a diploid stem
line and only few aneuploid cells. Malignant syringoma is a rare differential
diagnosis of face skin tumors. The present case is discussed based on a review of
the literature.

Azelaic acid 15% gel: in the treatment of papulopustular rosacea. Frampton JE, Wagstaff AJ. Am J Clin Dermatol. 2004;5(1):57-64.

Azelaic acid is a naturally occurring, straight-chain dicarboxylic acid which is
effective in the treatment of rosacea, presumably on account of its
anti-inflammatory properties. In randomized, double-blind, multicenter studies
involving patients with moderate papulopustular facial rosacea, twice-daily
topical application of azelaic acid 15% gel to the face was significantly more
effective than twice-daily administration of either its vehicle (two studies) or
metronidazole 0.75% gel (one study) in reducing inflammatory lesion counts and
erythema severity. However, neither active treatment had a clinically discernable
effect on telangiectasia. In all three studies, azelaic acid 15% gel recipients
experienced continuous decreases in lesion counts and erythema throughout the 12-
to 15-week treatment periods. However, the effects of metronidazole 0.75% gel
plateauxed after 8 weeks. In other efficacy assessments in these studies, azelaic
acid 15% gel was superior to its vehicle and metronidazole 0.75% gel in both the
investigators’ global assessment of rosacea and the investigators’ end-of-study
evaluation of overall improvement, and superior to its vehicle in the patients’
end-of-study evaluation of overall improvement. The most frequent
treatment-related cutaneous adverse events during administration of azelaic acid
15% gel include burning/stinging/tingling and pruritus (itching); however, these
events are predominantly transient in nature and mild-to-moderate in intensity.

Interventions for rosacea. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK. Cochrane Database Syst Rev. 2004;(1):CD003262.

BACKGROUND: Rosacea is a common skin condition affecting the face, characterised
by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are
often also involved. The cause of rosacea is unclear. It is a chronic disease,
which can be controlled in most cases with appropriate treatment. Numerous
treatments are in use although it is unclear which are best, and which are most
appropriate for the different types of rosacea. OBJECTIVES: To assess and
summarise current evidence for the efficacy and safety of treatments for rosacea.
SEARCH STRATEGY: We searched the Skin Group Specialised Trials Register (March
2002), Cochrane Central Register of Controlled Trials (CENTRAL, March 2002),
MEDLINE (from 1966 to March 2002), EMBASE (from 1980 to March 2002), Biosis (from
1970 to March 2002) and the Science Citation Index (from 1988 to March 2002).
Reference lists of trials and key review articles were also searched. Relevant
manufacturers and experts were contacted. SELECTION CRITERIA: Randomised
controlled trials in people with moderate to severe rosacea were included.
Studies judged by the reviewers to have seriously flawed methodology were
excluded. DATA COLLECTION AND ANALYSIS: Study selection, assessment of
methodological quality, data extraction and analysis were carried out by two
independent reviewers. MAIN RESULTS: The evidence provided by twenty-two included
studies was generally weak because of poor methodology and reporting. One of our
primary outcome measures, ‘quality of life’, was not assessed in any of the
studies. Only two studies of ocular rosacea could be included.Pooled data from
two trials involving 174 participants indicated that topical metronidazole is
more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95 to
12.06). Data from a between-patient trial (114 patients) and a within-patient
trial (33 patients) of azelaic cream versus placebo were not pooled, but both
showed good evidence of efficacy. Data pooled from three studies of oral
tetracycline versus placebo involving 152 participants showed that, according to
physicians’ ratings, tetracycline was effective (odds ratio 6.06, 95% confidence
interval 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was
provided by one small study. REVIEWER’S CONCLUSIONS: The quality of studies
evaluating rosacea treatments was generally poor. There is evidence that topical
metronidazole and azelaic acid cream have a therapeutic effect. There is some
evidence that oral metronidazole and tetracycline are effective.There is
insufficient evidence concerning the effectiveness of other treatments. As many
of these treatments are used for rosacea, good RCTs are urgently needed.

Evaluating the role of topical therapies in the management of rosacea: focus on combination sodium sulfacetamide and sulfur formulations. Del Rosso JQ. Cutis. 2004 Jan;73(1 Suppl):29-33.

The combination of sodium sulfacetamide and sulfur is unique in the rosacea
armamentarium because of its dual use as topical therapy and therapeutic
cleanser. Several formulations of sulfacetamide 10% and sulfur 5% are now
available as topical lotions and cleansers. The sulfacetamide/sulfur cleansers
serve as adjunctive therapy by providing additive effects to other topical and
oral therapies for rosacea with favorable tolerability and cosmetic appeal.

The role of topical metronidazole in the treatment of rosacea. Wolf JE Jr. Cutis. 2004 Jan;73(1 Suppl):19-28.

Many topical and oral pharmacologic agents have shown well-tolerated efficacy for
the treatment of rosacea. Metronidazole was the first topical therapy approved
for rosacea and is still considered the foundation therapy by many researchers
and dermatologists. The efficacy and tolerability of topical metronidazole in
combination with an oral antibiotic or as monotherapy to maintain remissions have
been shown in multiple well-controlled trials.

Mechanism-based selection of pharmacologic agents for rosacea. Shalita A, Leyden J. Cutis. 2004 Jan;73(1 Suppl):15-8.

All effective agents used to treat rosacea have a common mechanism of action:
anti-inflammatory effects. Concomitant with this, many of these agents also show
antioxidant effects. Both anti-inflammatory and antioxidant effects may address
the proposed underlying pathophysiology of rosacea. Future topical formulations
may involve the combination of active pharmacologic agents and sunscreens or sun
blocks to address the proposed etiologic role played by UV radiation in the
pathophysiology of rosacea.

The subtypes of rosacea: implications for treatment. Odom RB. Cutis. 2004 Jan;73(1 Suppl):9-14.

Lack of standardized rosacea nosology was the rationale for the National Rosacea
Society to convene a committee of dermatology thought leaders to develop a
standard classification system. Standardization of rosacea classification should
be followed by standardization of treatment. Many pharmacologic and
nonpharmacologic interventions for rosacea are being used based on clinical
observation alone. Many oral and topical pharmacologic agents, however, are
validated by randomized controlled trials (RCTs). Topical therapies (eg,
metronidazole or an alternative agent such as azelaic acid) and oral antibiotics
(eg, the tetracycline family) should remain as foundation therapies for subtypes
1 and 2 rosacea, based on the strength of the evidence.

Rosacea as an inflammatory disorder: a unifying theory? Millikan LE. Cutis. 2004 Jan;73(1 Suppl):5-8.

Rosacea is increasingly being viewed as an immune-based disorder. Various immune
factors, such as eicosanoids, proinflammatory cytokines, and polymorphonuclear
leukocytes, appear to be involved in the vascular, inflammatory, and
proliferative subtypes of this disorder. Many pharmacologic agents that
effectively treat the symptoms of rosacea show anti-inflammatory and/or
immunomodulating effects, providing further evidence that rosacea is an
inflammatory disorder.

Role of mild cleansing in the management of patient skin. Subramanyan K. Dermatol Ther. 2004;17 Suppl 1:26-34.

Routine everyday care of skin is an essential part of optimal patient management.
Common problems such as xerosis, dermatitis, eczema, psoriasis, acne, rosacea,
and photodamage leave the skin vulnerable to external insults, partly as a result
of varying levels of barrier dysfunction. Cosmetic surgery procedures also
typically damage the stratum corneum (SC) and leave skin with a very weak barrier
during recovery phase. Cleansing is an important aspect of any skin care, since
it not only removes unwanted dirt, soil, and bacteria from skin, but also removes
dead surface cells, preparing skin to better absorb topically applied
drugs/medication. Care must be taken to minimize any further weakening of the SC
barrier during cleansing. Cleansers based on mild synthetic surfactants and/or
emollients that cause minimal barrier perturbation are ideal for these patients.
The present paper is a brief review of four clinical trials that evaluated the
efficacy and compatibility of either mild syndet bars or cleansers in patients
with atopic dermatitis, acne, rosacea, or patients who had received chemical
peels or Retin-A(R) (tretinoin) treatment for sustained photodamage.

Acne in ethnic skin. Halder RM, Brooks HL, Callender VD. Dermatol Clin. 2003 Oct;21(4):609-15, vii.

Acne is the most common disorder observed in ethnic skin. Clinical presentation
is different than in white skin. Postinflammatory hyperpigmentation is a common
sequelae of acne in darker skin. The management of acne in ethnic skin is based
largely on the prevention and treatment of hyperpigmentation.

Oral tetracyclines for ocular rosacea: an evidence-based review of the literature. Stone DU, Chodosh J. Cornea. 2004 Jan;23(1):106-9.

PURPOSE: To review the basis for the use of oral tetracyclines in ocular rosacea.
METHODS: Review of the published literature. RESULTS: Two prospective, masked,
and placebo-controlled studies of oxytetracycline for ocular rosacea demonstrated
a modest treatment benefit. Studies performed with tetracycline and doxycycline
for ocular rosacea were not placebo controlled, and the optimal drug, dose, and
schedule of administration were not evaluated. CONCLUSIONS: Available evidence
supports a moderate treatment benefit in ocular rosacea for oxytetracycline, a
tetracycline derivative not currently available in the United States. The
efficacies of doxycycline and tetracycline, including treatment effect, optimal
dose, duration of therapy, and side effects when used for ocular rosacea have not
been established.

Medical treatment of rosacea with emphasis on topical therapies. Del Rosso JQ. Expert Opin Pharmacother. 2004 Jan;5(1):5-13.

Due to the development and release of newer topical formulations, the diagnosis
and treatment of rosacea has received renewed attention over the past 3-5 years
both in the literature and at medical symposia. Rosacea is a very common facial
dermatosis. In the US, rosacea is estimated to affect > 14 million people,
predominantly adults with approximately 60% of cases diagnosed before the age of
50. A frustrating aspect of the disease is its inherent chronicity punctuated
with periods of exacerbation and relative remission. A variety of subtypes have
been identified which correlate with clinical presentation. Although the
pathogenesis of rosacea is poorly understood, multiple topical agents are
available. The efficacy of topical therapy for rosacea relates primarily to
reduction in inflammatory lesions (papules, pustules), decreased intensity of
erythema, a reduction in the number and intensity of flares and amelioration of
symptoms, which may include stinging, pruritus and burning. The list of main
topical agents utilised for the treatment of rosacea include metronidazole,
sulfacetamide-sulfur, azelaic acid and topical antibiotics (clindamycin,
erythromycin). Depending on the severity at initial presentation, topical therapy
may be combined with systemic antibiotic therapy (e.g., oral tetracycline
derivative). Newer therapeutic choices primarily involve improved vehicle
formulations, which demonstrate favourable skin tolerability and cosmetic
elegance.

The proposed inflammatory pathophysiology of rosacea: implications for treatment. Millikan L. Skinmed. 2003 Jan-Feb;2(1):43-7.

The pathophysiology of the vascular and inflammatory stages of facial rosacea and
proposes an underlying cause is reviewed. It can be argued that all the stigmata
of rosacea are manifestations of an inflammatory process: neutrophilic
dermatosis. For this reason, treatments that block neutrophil involvement in the
development of rosacea, such as topical metronidazole and systemic antibodies,
should be considered first-line therapy for all stages of the disease.

Subantimicrobial dose doxycycline for acne and rosacea. Bikowski JB. Skinmed. 2003 Jul-Aug;2(4):234-45.

Acne vulgaris and rosacea present therapeutic challenges due to their chronicity,
potential for disfigurement, and psychosocial impact. Although
pathophysiologically distinct, both conditions have major inflammatory
components. Consequently, topical and systemic antimicrobial agents are routinely
prescribed for extended periods. Emergence of resistant strains of
Propionibacterium acnes, adverse events, and compliance issues associated with
chronic systemic tetracycline use have led to new treatment approaches. At
subantimicrobial doses, tetracyclines reduce inflammation via anticollagenolytic,
antimatrix-degrading metalloproteinase, and cytokine down-regulating properties.
Subantimicrobial dose (SD) doxycycline (Periostat 20 mg) has clinical utility in
periodontitis and has been investigated in a double-blind, placebo-controlled
trial in the treatment of moderate facial acne as well as in an open label study
in the treatment of rosacea. The results of subantimicrobial dose doxycycline
treatment in early trials support its benefits and further investigation in acne
and rosacea.

Etiopathogenesis, classification, and current trends in treatment of rosacea. Tisma VS, Basta-Juzbasić A, Dobrić I, Ljubojević S, Mokos ZB. Acta Dermatovenerol Croat. 2003 Dec;11(4):236-46.

Rosacea is a common chronic dermatosis characterized by varying degrees of
flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and
phymas. Etiology and pathogenesis of rosacea are still unknown. Many possible
causes have been described as inducing the disease or contributing to its
manifestation, such as genetic predisposition, abnormal vascular reactivity,
changes in vascular mediating mechanisms, Helicobacter pylori infection, Demodex
folliculorum infestation, seborrhea, sunlight, hypertension, and psychogenic
factors. However, none of these factors has been proved. Rosacea shows a wide
spectrum of clinical presentations, which vary over time and with age. Successful
management of rosacea requires careful patient evaluation and individualized
therapy with appropriate variations and modifications, as the severity of the
disorder fluctuates. In mild cases of rosacea, patients are instructed to avoid
sun, to apply sun-protective creams, and to avoid facial irritants and other
triggers that provoke symptoms. At later stage, drug therapy is often necessary.
The disease commonly requires long-term treatment with topical or oral
medicaments. Surgical correction may be required for rhinophyma and
telangiectasia. We reviewed the current literature on the aspects of the
pathogenesis, diagnostic criteria, and treatment options for rosacea.

Use of topical metronidazole in moderate to severe rosacea. Lowe NJ. Adv Ther. 2003 Jul-Aug;20(4):177-90.

Rosacea is a chronic condition requiring long-term therapy for control and
maintenance. Numerous controlled studies have shown that metronidazole 0.75% in
combination with oral antibiotics significantly reduces the number of papules and
pustules and erythema severity scores in patients with severe disease. Topical
metronidazole 0.75% also maintains long-term remissions after oral tetracycline
has been discontinued. Although original studies involving topical metronidazole
0.75% used a twice-daily regimen, subsequent work has shown that this formulation
used once daily is as effective as 1% metronidazole.

Critical review of the manner in which the efficacy of therapies for rosacea are evaluated. Gupta AK, Chaudhry MM. Int J Dermatol. 2003 Nov;42(11):909-16.

BACKGROUND: Rosacea is a relatively common disorder that may affect individuals
of all races, particularly those of northern European decent. Its onset generally
occurs in individuals between the ages of 20 and 50 years. Rosacea may be
classified into four subtypes and one variant. Although individuals with rosacea
may not pass through all of the stages, the primary features of the disorder
include frequent flushing and blushing, nontransient erythema, the presence of
papules and pustules, and telangiectasia. Many agents have been used to treat
rosacea stigmata, especially because none of these is uniformly effective. AIM:
To identify the parameters that are used to evaluate the response to therapy when
different agents are used to treat rosacea. For a given parameter, to determine
whether the different trials are consistent in the manner in which this variable
is measured. METHODS: The reports on the efficacy and safety of the different
drug therapies used to treat rosacea were identified. We searched MEDLINE (1966
to June 2002) for studies where rosacea was treated. The parameters used to
evaluate the efficacy of therapy were determined. For each parameter, the ways in
which it has been measured were identified. RESULTS: Efficacy of treatment is
generally judged by evaluating the effect of the intervention on papules and
pustules, erythema, and telangiectasia. Manual lesional counts of papules and
pustules are usually performed. There is, however, substantial variation in the
methodology chosen for comparison of erythema and telangiectasias. Color scales
are popular for erythema and telangiectasia, while grading scales are most
commonly used for physician and patient evaluations. CONCLUSIONS: For each of the
parameters that are commonly used to measure the efficacy of treatments for
rosacea, the different approaches by which it has been measured in the various
trials have been highlighted; these dissimilarities can make it problematic to
compare between clinical trials. A greater degree of uniformity in the manner in
which the various parameters are evaluated would enable a more objective
comparison between the studies.

Rosacea therapy update. Pelle MT. Adv Dermatol. 2003;19:139-70.

Seborrheic dermatitis. Gupta AK, Bluhm R, Cooper EA, Summerbell RC, Batra R. Dermatol Clin. 2003 Jul;21(3):401-12.

Seborrheic dermatitis is present in 1% to 3% of immunocompetent adults, and is
more prevalent in men than in women. Seborrheic dermatitis may be seen in
conjunction with other skin diseases, such as rosacea, blepharitis or ocular
rosacea, and acne vulgaris. Malassezia yeasts have been associated with
seborrheic dermatitis. Abnormal or inflammatory immune system reactions to these
yeasts may be related to development of seborrheic dermatitis. Treatment
modalities for seborrheic dermatitis include keratolytic agents, corticosteroids,
and more recently, antifungal agents. Antifungal agents do not carry a risk of
skin atrophy or telangiectasia with prolonged use, and it is more prudent to
consider antifungals than corticosteroid preparations. The wide range of
antifungal formulations available (creams, shampoos, or oral) provides safe,
effective, and flexible treatment options for seborrheic dermatitis.

Potential future dermatological indications for tacrolimus ointment. Ruzicka T, Assmann T, Lebwohl M. Eur J Dermatol. 2003 Jul-Aug;13(4):331-42.

Tacrolimus ointment is a steroid-free topical immunomodulator developed for the
treatment of atopic dermatitis, a common, chronic inflammatory skin disease. By
inhibiting T-cell activation and cytokine production, topically applied
tacrolimus modulates inflammatory responses in the skin. Numerous clinical trials
have shown that it is effective and well tolerated for the treatment of atopic
dermatitis, its licensed indication. In addition, numerous publications suggest
that tacrolimus ointment may provide effective treatment for a variety of other
inflammatory skin disorders, many of which are very difficult to manage with
standard therapy. This paper reviews currently available evidence regarding the
use of tacrolimus ointment in a range of dermatological disorders, including
psoriasis, lichen planus, pyoderma gangrenosum, lichen sclerosus, contact
dermatitis, leg ulcers in rheumatoid arthritis, steroid-induced rosacea and
alopecia areata. It also provides recommendations for future clinical studies
with tacrolimus ointment.

Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind? Shenefelt PD. Dermatol Ther. 2003;16(2):114-22.

Biofeedback can improve cutaneous problems that have an autonomic nervous system
component. Examples include biofeedback of galvanic skin resistance (GSR) for
hyperhidrosis and biofeedback of skin temperature for Raynaud’s disease. Hypnosis
may enhance the effects obtained by biofeedback. Cognitive-behavioral methods may
resolve dysfunctional thought patterns (cognitive) or actions (behavioral) that
damage the skin or interfere with dermatologic therapy. Responsive diseases
include acne excoriée, atopic dermatitis, factitious cheilitis, hyperhidrosis,
lichen simplex chronicus, needle phobia, neurodermatitis, onychotillomania,
prurigo nodularis, trichotillomania, and urticaria. Hypnosis can facilitate
aversive therapy and enhance desensitization and other cognitive-behavioral
methods. Hypnosis may improve or resolve numerous dermatoses. Examples include
acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform
erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia,
herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus,
neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus,
psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo.
Hypnosis can also reduce the anxiety and pain associated with dermatologic
procedures.

Measuring the severity of rosacea: a review. Gessert CE, Bamford JT. Int J Dermatol. 2003 Jun;42(6):444-8.

BACKGROUND: Assessment of severity is essential in the clinical care of rosacea
patients and in the research on rosacea. OBJECTIVE: To determine the range of
methods used to assess rosacea severity in clinical trials. METHODS: The medical
literature from 1965 through 2001 was searched for rosacea clinical trials using
MEDLINE and published citations. Forty-seven articles were reviewed. RESULTS: The
most frequently assessed signs of rosacea were papules/pustules (43 studies),
erythema (35), and telangiectasia (24). Other signs and symptoms of rosacea and
adverse reactions to therapies were assessed in 27 studies. Counts of
papules/pustules were conducted in 34 studies. Four-point scales were the most
frequently used assessment tools for erythema (17) and telangiectasia (11). Other
frequently used techniques included global assessment by clinicians (29) and by
patients (21), and photography (13). CONCLUSIONS: At present, there are no
standard validated tools for assessing the severity of rosacea or its signs or
symptoms.

Identifying rosacea: what all dentists should know. Fuchs SS. J Am Dent Assoc. 2003 May;134(5):603-7; quiz 632.

BACKGROUND: Dentists frequently encounter adult patients who have facial rosacea.
This common dermatologic condition can undermine a patient’s appearance. Although
rosacea can be progressive, the condition responds well to treatment, especially
when started early. RESULTS: This article will help dentists recognize rosacea
and differentiate it from other dermatologic disorders. Clinicians then will be
able to refer patients suspected of having rosacea to the appropriate medical
specialist for confirmation of the diagnosis and treatment. CONCLUSION: Dentists
can provide a service to patients to improve their overall health and appearance
by early recognition of this condition. CLINICAL IMPLICATIONS: Recognizing
rosacea in dental patients and properly referring them for diagnosis and
treatment constitutes a medical service that is relatively easy for dentists to
perform. This service, in addition to others, such as measuring blood pressure,
will make the dental examination more comprehensive.

Acne vulgaris and rosacea: evaluation and management. Webster GF. Clin Cornerstone. 2001;4(1):15-22.

Acne vulgaris, commonly termed acne, is an extremely common disease. It can be
found in nearly all teenagers to some degree as well as in women in their 30s.
Regardless of severity, acne often has a greater psychologic effect than
cutaneous effect. Indeed, most patients overestimate the severity of their
disease, while most physicians underestimate its impact on their patients.
Studies have shown that people with severe acne as teens are less employable as
adults and that self-esteem is low. When combined with other adolescent tensions,
acne can be a difficult disease to treat. Rosacea, which usually starts in the
late 20s, may affect the eyes as well as the skin. This article describes the
pathogenesis of acne and rosacea and treatment approaches the primary care
physician can use.

Managing facial redness and rashes. Tavadia S, Tillman D. Practitioner. 2003 Feb;247(1643):90-4, 96-100.

Topical tacrolimus Protopic. Lazarous MC, Kerdel FA. Drugs Today (Barc). 2002 Jan;38(1):7-15.

Topical tacrolimus is the first topical immunomodulator of its kind, and its
mechanism of action, pharmacokinetics, metabolism and efficacy will be discussed.
Multiple studies have supported the safety and efficacy of topical tacrolimus in
the treatment of atopic dermatitis in both adults and children. Studies have also
suggested that topical tacrolimus may be effective in the treatment of acute
contact dermatitis. Although oral administration of tacrolimus proved to be
efficacious in psoriasis, results with topical tacrolimus have been disappointing
in some studies. Additional reports of success in the use of topical tacrolimus
in the treatment of pyoderma gangrenosum show promise, although there is a
paucity of randomized, placebo-controlled trials examining its use. It has also
been suggested that topical tacrolimus is useful in the treatment of alopecia
areata, erosive lichen planus, isolated ichthyosis linearis circumflexa,
steroid-induced rosacea, and in the prevention of allograft rejection, however
more clinical trials need to be performed.

Intense pulsed-light photorejuvenation. Sadick NS, Weiss R. Semin Cutan Med Surg. 2002 Dec;21(4):280-7.

Intense pulsed light photorejuvenation represents a novel mode of treatment of
photodamaged skin. A broad-spectrum flashlamp (500-1200 nm) targets chromophores
reversing pigmentation, vascular and pilosebaceous aberrations. Both cytokine
mediated as well as thermally induced deep dermal remodeling may be achieved
using the varied polychromatic wavelengths associated with this technology.
Inflammatory dermatosis such as rosacea may also be addressed as well. A
structural approach to non-ablative rejuvenation utilizing intense pulsed light
is associated with high patient satisfaction and minimal adverse sequelae.

Clinical situations conducive to proactive barrier enhancement. Draelos ZD. Cutis. 2002 Dec;70(6 Suppl):17-20; discussion 21-3.

[The role of Helicobacter pyroli in the development of skin diseases] [Article in Polish] Deroń E, Kieć-Swierczyńska M. Med Pr. 2002;53(4):333-7.

The paper presents the current state-of-the-art concerning the effect of
Helicobacter pyroli infection on the progress of some skin diseases (Raynaud’s
disease, purpura hyperergica, rosacea, prurigo nodularis, atopic dermatitis,
chronic urticaria). The attention was turned to the lack of unanimity among
authors respective to the effect of Helicobacter pylori on the progress of some
skin diseases, especially those of allergic etiology. The methods of bacteria
identification were discussed. The methods are as follows: invasive tests
involving endoscopy of the upper segment of the alimentary tract–a traumatic
test, histologic examination and bacteria culture as well as noninvasive tests:
respiratory test and serological tests able to detect the humoral response to
infection or examination of the bacteria genetic material by means of PCR. The
therapeutic methods used to eradicate effectively the infection, recommended by
the Working Group of the Polish Association of Gastroenterology (a
three-component treatment for seven days–a drug able to diminish gastric
secretion and two antibiotics) are also discussed.

A status report on the medical management of rosacea: focus on topical therapies. Del Rosso JQ. Cutis. 2002 Nov;70(5):271-5.

Ivermectin-responsive Demodex infestation during human immunodeficiency virus infection. A case report and literature review. Aquilina C, Viraben R, Sire S. Dermatology. 2002;205(4):394-7.

We report the case of a 56-year-old HIV-seropositive man who presented a facial
Demodex infection developed 2 months after initiation of highly active
antiretroviral therapy. The Demodex infection was confirmed by scrapings and
histopathologic examination and by the dramatic response to antiparasitic
treatment with oral ivermectin associated with 5% permethrin cream. Copyright
2002 S. Karger AG, Basel

[Doxycycline] [Article in French] Bonnetblanc JM. Ann Dermatol Venereol. 2002 Jun-Jul;129(6-7):874-82.

Doxycyclin is a semi-synthetic structural isomer of the tetracycline family. It
exhibits good intra-cellular penetration, with bacteriostatic activity on many
bacteria. Different types or bacterial resistance are known. Acquired resistance
has a ribosomal or a plasmidic mechanism. Resistance of Propionibacterium acnes
is secondary to a mutation of ARNr. Doxycyclin also has an anti-inflammatory
activity, via numerous pathways. Doxycyclin is rapidly and almost completely
absorbed by the digestive tract. Food has no incidence on the absorption. It has
a high but labile affinity for proteins with 90 p. 100 of the molecule linked. It
rapidly diffuses in the extravascular compartment and in most of the tissues.
Bile excretion is the main excretion route. It occurs more slowly by the kidney
with tubular reabsorption. The main dermatological indication is acne with daily
dose varing between 50 mg and 100 mg. Although good assays are lacking, a large
professional consensus has validated its use. It is also active at the same
dosage in rosacea. Chlamydial and mycoplasma urethritis may be treated by
doxycyclin, and this antibiotic is presently used as second choice. Many other
diseases may be treated as a primary or secondary choice, such as treponematoses,
brucellosis, pasteurellosis, borreliosis, rickettsioses and cholera. Some non
infectious diseases have been occasionally treated by doxycycline. Digestive side
effects are the more frequent. Esophageal toxicity has been reduced with tablets
and sufficient concomitant water ingestion. Phototoxicity is dose-dependent.
Various cutaneous side effects have been described, some of them severe. Systemic
toxicity is rare. Pregnancy is a contra-indication, and as other tetracyclines,
it should not be given to children and during lactation. Doxycycline is
commercialized as tablets. No reduction of the dose is necessary in renal
failure. Association with retinoids is not recommended. Anticoagulants are
potentialized. Didanosin, iron, and mineral salts lower its activity.

Rosacea: a common, yet commonly overlooked, condition. Blount BW, Pelletier AL. Am Fam Physician. 2002 Aug 1;66(3):435-40.

Rosacea is a common, but often overlooked, skin condition of uncertain etiology
that can lead to significant facial disfigurement, ocular complications, and
severe emotional distress. The progression of rosacea is variable; however,
typical stages include: (1) facial flushing, (2) erythema and/or edema and ocular
symptoms, (3) papules and pustules, and (4) rhinophyma. A history of exacerbation
by sun exposure, stress, cold weather, hot beverages, alcohol consumption, or
certain foods helps determine the diagnosis; the first line of treatment is
avoidance of these triggering or exacerbating factors. Most patients respond well
to long-term topical antibiotic treatment. Oral or topical retinoid therapy may
also be effective. Laser treatment is an option for progressive telangiectasis or
rhinophyma. Family physicians should be able to identify and effectively treat
the majority of patients with rosacea. Consultation with subspecialists may be
required for the management of rhinophyma, ocular complications, or severe
disease. (Am Fam Physician 2002;66:442.)

The management of rosacea. Rebora A. Am J Clin Dermatol. 2002;3(7):489-96.

Rosacea is a multiphasic disease which is associated with flushing, erythrosis,
papulopustular rosacea and phymas; each phase is likely to have its own
treatment. Flushing is better prevented rather than treated, and its etiology
investigated. Beta-blockers, atenolol in particular, are worthy of prophylactic
trials examining their efficacy in treating the flushing associated with rosacea.
Currently, clonidine is the only drug available for the treatment of flushing.
Treatment for erythrosis includes topical and systemic therapies. Metronidazole
1% cream and azelaic acid 20% cream have been reported to reduce the severity
score of erythema. The systemic treatment of erythrosis is based on the
association of Helicobacter pylori with rosacea. However, this role is still
being debated. Eradication of H. pylori can be achieved using a triple therapy
regimen lasting 1 to 2 weeks [omeprazole and a combination of two antibacterials
(a choice from clarithromycin, metronidazole or amoxicillin)]. Both the
flashlamp-pumped long-pulse dye laser and the potassium-titanyl-phosphate laser
may be used in the treatment of facial telangiectases. Both systemic and topical
remedies may be used to treat the papulopustules of rosacea. Systemic treatment
includes metronidazole, doxycycline, minocycline, clarithromycin and
isotretinoin, while topical treatment is based on metronidazole cream and gel.
The presence of Demodex folliculorum is important in the inflammatory reaction,
whether it is pathogenetic or not. Crotamiton 10% cream or permethrin 5% cream
may be useful medications for papulopustular rosacea, although they are rarely
successful in eradicating D. folliculorum. Oral or topical ivermectin may also be
useful in such cases. Ocular involvement is common in patients with cutaneous
rosacea and can be treated with orally administered or topical antibacterials.
Once rhinophyma starts to be evident, the only way to correct it is by aggressive
dermatosurgical procedures. Decortication and various types of lasers can also be
used. Associated conditions, such as seborrheic dermatitis and possible contact
sensitizations, deserve attention.

Rhinophyma: review and update. Rohrich RJ, Griffin JR, Adams WP Jr. Plast Reconstr Surg. 2002 Sep 1;110(3):860-69; quiz 870.

Learning Objectives: After studying this article, the participant should be able
to discuss: 1. Clinical features and anatomy of rhinophyma. 2. The etiology and
epidemiology of rhinophyma. 3. Associated diagnosis that can complicate
rhinophyma. 4. Common nonsurgical and surgical therapies for rhinophyma. 5. A
safe and integrated treatment plan for the patient with rhinophyma.

Pustular skin disorders: diagnosis and treatment. Mengesha YM, Bennett ML. Am J Clin Dermatol. 2002;3(6):389-400.

The differential diagnosis for pustular skin disorders is extensive. The
distribution of the lesions and the age of the patient are characteristics that
may provide strong clues to the etiology of cutaneous pustular eruptions. In
adults, generalized pustular dermatoses include pustular psoriasis, Reiter’s
disease and subcorneal pustular dermatosis. Medications can cause generalized
pustular eruptions, such as in the case of acute generalized exanthematous
pustulosis; or more localized reactions, such as acneiform drug eruptions, which
usually involve the face, chest and back. Localized pustular eruptions are seen
on the hands and feet in adults with pustulosis palmaris et plantaris and
acrodermatitis continua (both of which may be variants of psoriasis); on the face
in patients with acne vulgaris, rosacea, and perioral dermatitis; and on the
trunk and/or extremities in patients with folliculitis. A separate condition
known as eosinophilic folliculitis occurs in individuals with advanced human
immunodeficiency disease. Severely pruritic, sterile, eosinophilic pustules are
found on the chest, proximal extremities, head and neck. Elevated serum
immunoglobulin E and eosinophilia are often concurrently found. In neonates, it
is especially important to make the correct diagnosis with respect to pustular
skin disorders, since pustules can be a manifestation of sepsis or other serious
infectious diseases. Generalized pustular eruptions in neonates include erythema
toxicum neonatorum and transient neonatal pustular melanosis, both of which are
non-infectious. Pustules are seen in infants with congenital cutaneous
candidiasis, which may or may not involve disseminated disease. Ofuji’s syndrome
is an uncommon generalized pustular dermatosis of infancy with associated
eosinophilia. As in adults, neonates and infants may develop acne or scabies
infestations. In this article, we review the most common pustular dermatoses and
offer a systematic approach to making a diagnosis. We also report the most
up-to-date information on the treatment of these various cutaneous pustular
conditions.

Steroid dermatitis resembling rosacea: aetiopathogenesis and treatment. Ljubojeviae S, Basta-Juzbasiae A, Lipozenèiae J. J Eur Acad Dermatol Venereol. 2002 Mar;16(2):121-6.

BACKGROUND: Corticosteroids were first introduced for topical use in dermatology
in 1951. Since then uncontrolled use (abuse) has caused many different reactions,
often with manifestations resembling those of rosacea. OBJECTIVE: The prolonged
use of local corticosteroids (usually 2-6 months) may lead to a clinical picture
of severe dermatitis with erythema, papules and pustules that are classified
according their localization to three types. The treatment of choice is
tetracycline in combination with local application of neutral ointments.
CONCLUSIONS: Trivial skin dermatoses, especially on the face, should not be
treated with local corticosteroids.

Rosacea and atopic dermatitis. Two common oculocutaneous disorders. Barankin B, Guenther L. Can Fam Physician. 2002 Apr;48:721-4.

OBJECTIVE: To increase awareness of the oculocutaneous manifestations of two
common skin diseases. QUALITY OF EVIDENCE: We reviewed clinically relevant
articles from the dermatologic and ophthalmologic literature. The PubMed database
was searched from January 1965 to January 2001 to locate retrospective and
prospective cohort and descriptive studies using the MeSH terms acne rosacea;
eczema; and dermatitis, atopic. Most literature on the topic is based on
descriptive research. MAIN MESSAGE: Several dermatologic problems are known to
have ophthalmologic sequelae. Rosacea and atopic dermatitis are two common skin
conditions that can have concomitant eye disease. Degrees of skin and eye disease
vary; certain cases require specialty referral and other cases can be managed
effectively by family physicians. CONCLUSION: Better appreciation of how rosacea
and atopic dermatitis overlap with eye disease will result in more appropriate
referrals and more comprehensive patient care.

Diagnosis and treatment of rosacea. Cohen AF, Tiemstra JD. J Am Board Fam Pract. 2002 May-Jun;15(3):214-7.

BACKGROUND: Rosacea is a common skin disorder affecting middle-aged and older
adults. Many patients mistakenly assume that early rosacea is normally aging skin
and are not aware that effective treatments exist to prevent progression to
permanent disfiguring skin changes. METHODS: The medical literature was reviewed
on the pathophysiology, diagnosis, and treatment of rosacea. MEDLINE was searched
using the key search terms “rosacea,” “rhinophyma,” “metronidazole,”
“Helicobacter pylori,” and “facial redness.” RESULTS AND CONCLUSIONS: Rosacea is
easily diagnosed by physician observation, and physicians should initiate
discussion of rosacea treatment with patients. Effective treatment of rosacea
includes avoidance of triggers, topical and oral antibiotic therapy, both topical
and oral retinoid therapy, topical vitamin C therapy, and cosmetic surgery.

Demodicidosis revisited. Baima B, Sticherling M. Acta Derm Venereol. 2002;82(1):3-6.

Demodex mites are common commensals of the pilosebaceous unit in mammals. In
humans, only two species (Demodex folliculorum and D. brevis) have been
identified and have been implied to play a role in at least three facial
conditions: pityriasis folliculorum, rosacea-like demodicidosis and so-called
“demodicidosis gravis”. However, there is no consensus to what degree the mites
are causative of the skin pathology and how they might contribute to the disease.
This review presents a demodicidosis case, discusses the clinical features of
Demodex infestation in man and reviews its pathogenetic implications and the
therapeutic options.

Helicobacter pylori infection in skin diseases: a critical appraisal. Wedi B, Kapp A. Am J Clin Dermatol. 2002;3(4):273-82.

More than 50% of the human population have long-term Helicobacter pylori
infection, causing, in some cases, severe diseases such as peptic ulcers and
stomach cancer. In the last few years several extra-gastrointestinal disorders
have been associated with H. pylori infection. This review summarized the current
medical literature, identified through hand searching and MEDLINE research,
including our own studies, with regard to H. pylori and skin diseases. From the
literature it can be seen that the role of H. pylori in skin diseases is still a
controversial subject. Randomized controlled trials with adequate masking and
sample sizes are still lacking. The best evidence comes from studies
investigating chronic urticaria in which chronic urticaria disappeared in many
patients with H. pylori infection after careful eradication of the H. pylori.
Moreover, there are promising recent reports of beneficial H. pylori eradication
in Behçet’s disease, pruritus cutaneus, prurigo chronica, prurigo nodularis and
in some patients with lichen planus, but not in rosacea or psoriasis. Before any
conclusions with respect to other skin diseases such as atopic dermatitis,
Schoenlein-Henoch Purpura, Sweet’s syndrome, Sjögren syndrome or systemic
sclerosis may be drawn, additional randomized, double-blinded and
placebo-controlled studies including adequate diagnostic schedules, sufficient
eradication treatment protocols, confirmation of eradication and adequate control
groups are needed. The cutaneous pathology of H. pylori is far from being clear,
but it is speculated that the systemic effects may involve increased mucosal
permeability to alimentary antigens, immunomodulation, an autoimmune mechanism or
the impairment of vascular integrity.

[Sports as a risk factor and therapeutic principle in dermatology] [Article in German] Karamfilov T, Elsner P. Hautarzt. 2002 Feb;53(2):98-103.

Sporting activities may exert positive and negative health effects. This applies
not only to the cardiovascular and musculoskeletal system, but also to skin.
During sporting activities a person is exposed to environmental factors such as
temperature, irradiation, and allergens. These factors may play a key role in the
development of skin diseases. Mechanical trauma is caused by acute injury as well
as chronic damage. Infectious skin diseases caused by viruses, bacteria or fungi
can be transmitted by body contact or the use of communal showers or locker
rooms. Intake of performance-enhancing substances may provoke skin changes such
as striae distensae, androgenetic alopecia, hypertrichosis and acne. Preexisting
skin diseases such as psoriasis, lichen planus, vitiligo, polymorphous light
eruption, lupus erythematosus, porphyria, urticaria, and acne rosacea may be
aggravated by sporting activities. On the other hand, physical exercise has a
therapeutic potential which has hardly been exploited by dermatologists.
Especially in chronic skin diseases positive effects have been observed.
Therapeutic use of team sports has been shown to decrease suffering, depression,
and emotional disturbances and increase life quality in patients with atopic
eczema, psoriasis, and venous leg ulcers.

Microbial ecology of human skin in health and disease. Fredricks DN. J Investig Dermatol Symp Proc. 2001 Dec;6(3):167-9.

Cultivation of human skin reveals numerous bacteria and at least one fungus to be
normal inhabitants of this ecosystem; however, most of our knowledge about the
microbiology of human skin was acquired decades ago. Modern techniques employing
nucleic acid-based microbial identification methods demonstrate the limitations
of cultivation for appreciating microbial diversity in many ecosystems. The
application of modern molecular methods to the study of skin may offer new
perspectives on the resident microfora, and new insights into the causes of
antibiotic responsive dermatologic conditions, such as acne and rosacea.

[Indications for medical lasers in dermatology] [Article in French] Mazer JM. Presse Med. 2002 Feb 9;31(5):223-31.

FOUR CATEGORIES OF LASERS ARE USED IN DERMATOLOGY: These are vascular,
depigmentation, depilatory or resurfacing or vaporization lasers. Today, there
are more potential or suggested indications than good methodological studies that
confirm these indications. Nevertheless, there are indisputable indications for
these lasers. VASCULAR LASERS: They are indicated in the treatment of capillary
nevus in adults and children and, with pulsed dye lasers, infants can be treated
within the first weeks of life. Another indication for vascular lasers is
treatment of Stage II rosacea, i.e., at the stage of telangiectasic erythrosis or
couperose. Other indications include radiodermatitis, ulcerated hemangioma and
erythrosis of the neck. DEPILATORY LASERS: Treatment of patients with pale
phototype and dark hairs appears possible. However, around 4 to 6 sessions are
required to obtain significant lasting hair removal. DEPIGMENTATION LASERS: The
best indications are the removal of tattoos, Ota’s nevus and, to a lesser degree,
liver spots and Becker’s nevus. Melasma and chloasma are not indications or
exeresis of nevo-cellular nevi using this technique, since no histological
control is possible. PULSED VAPORIZATION LASERS (CO2 OR ERBIUM LASER): They
permit dermabrasion in the treatment of verrucous harmatoma, extensive benign
superficial dermo-epidermal lesions and the esthetic treatment of non-muscular
wrinkles, i.e., excepting wrinkles of the forehead and nasal sulcus. Continuous
CO2 lasers destroy small dermo-epidermal lesions. They are particularly indicated
for profuse lesions, in which there is a risk of hemorrhage or when direct
contact should be avoided because of potential HIV infection. CONCLUSION: There
are many potential indications, but a consensus has only been reached on those
mentioned. The others remain to be confirmed.

Nonpharmacologic treatments in psychodermatology. Fried RG. Dermatol Clin. 2002 Jan;20(1):177-85.

The author believes that psychocutaneous medicine has indeed come of age and is
being incorporated into mainstream medical practice. Patients presenting to
dermatologists today are more sophisticated and are frequently dissatisfied with
traditional medical therapies. They actively seek alternative approaches and
adjuncts to standard treatments. In contrast to many other “alternative” (or)
“holistic” treatments offered through non-medical venues, dermatologists can
assure their patients that controlled studies support the efficacy of
psychocutaneous techniques in improving many dermatologic conditions. Psoriasis,
rosacea, herpes simplex, body dysmorphic disorder, acne, eczema, urticaria,
neurotic excoriations, excoriated acne, trichotillomania, dysesthetic syndromes,
and delusions parasitosis are included in this incomplete list. The author
believes it is helpful for both the patient and therapist to define concrete and
realistic goals for psychocutaneous intervention. Concrete observable or
measurable goals can help the patient and clinician gauge therapeutic progress
and success. Specifically, goals can include reduction in pruritus (rating
severity from 1-10), decreased scratching activity, decreased plaque extent or
thickness, decreased number of urticarial plaques, decreased flushing, decreased
anxiety, decreased anger, decreased social embarrassment, decreased social
withdrawal, and improved sleep. More global goals can include an improved sense
of well-being, increased sense of control, and enhanced acceptance of some of the
inevitable aspects of a given skin disease. Cure should never be a goal, because
most disorders amenable to psychocutaneous techniques are chronic in nature;
thus, cure as an endpoint would only lead to disappointment. The author
encourages dermatologists to align themselves with what he euphemistically calls
“a skin-emotion specialist.” The skin-emotion specialist may be a psychiatrist,
psychologist, social worker, biofeedback therapist, or other mental health or
behavioral specialist. Patients are more likely to accept a referral to a
“skin-emotion specialist,” because this term destigmatizes psychologic
interventions. Incorporating these techniques and specialists into a clinical
practice will expand therapeutic horizons and improve the quality of life of many
of the patients afflicted with chronic skin disease. A final caveat must be
offered about attempting to make prognostic statements regarding the likelihood
of therapeutic success. Although all patients can potentially benefit from
psychocutaneous interventions, those with severe psychopathology and poor
pretreatment functional status are likely to be more difficult to treat and to
achieve less optimal outcomes. Patients with personality disorders such as
borderline, narcissistic, and schizotypal disorders, and patients with any active
psychotic process certainly constitute a more resistant and difficult population
with whom therapeutic success is less likely. These patients, however, are often
the ones in the greatest subjective distress and certainly can profit from any of
the described interventions. Quoting W. Mitchell Sams, Jr., “although the
physician is a scientist and clinician, he or she is and must be something more.
A doctor is a caretaker of the patient’s person–a professional advisor, guiding
the patient through some of life’s most difficult journeys. Only the clergy share
this responsibility with us.” This commitment is and must always be the guiding
force in the provision of comprehensive and compatient patient care.

Topical metronidazole for rosacea. Gupta AK, Chaudhry M. Skin Therapy Lett. 2002 Jan;7(1):1-3, 6.

Rosacea is relatively common, typically occurring in individuals of Northern
European and Celtic origin between 30 and 50 years of age. It is more common in
women, but may be more severe in men. Currently there is no cure available for
rosacea, but it can be controlled with topical and oral drug therapy. Topical
metronidazole 1% cream is approved by the US FDA for the treatment of
inflammatory lesions (papules and pustules) and erythema associated with rosacea.
This treatment option is effective, safe and well tolerated.

The use of therapeutic moisturizers in various dermatologic disorders. Bikowski J. Cutis. 2001 Dec;68(5 Suppl):3-11.

Moisturizers can serve as important adjunctive therapeutic modalities for
patients with various dermatologic disorders, including acne vulgaris, rosacea,
retinoid-induced irritant dermatitis, atopic dermatitis, psoriasis, and the skin
dryness that appears to occur with intrinsic and extrinsic aging. Therapeutic
moisturizers, defined as those proven in clinical trials to be both compatible
with topical therapies and biocompatible with the skin, not only improve the
signs and symptoms of dry skin but also, as research has demonstrated, help
maintain hydration and overall integrity of the stratum corneum. The type of
humectants and emollients contained in a therapeutic moisturizer can affect the
overall tolerability of the formulation. Dermatologists should recommend
therapeutic moisturizers that are noncomedogenic, devoid of irritant ingredients,
and compatible with many therapeutic regimens.

The use of cleansers as therapeutic concomitants in various dermatologic disorders. Bikowski J. Cutis. 2001 Dec;68(5 Suppl):12-9.

The choice of a mild cleansing agent is important in the adjunctive management of
various skin conditions, such as atopic dermatitis, acne vulgaris, rosacea,
photoaging, retinoid-induced irritant dermatitis, and sensitive skin. There are 3
major categories of cleansing agents: soaps, synthetic detergents, and lipid-free
cleansing agents. The irritancy potential of cleansing agents is a function of a
number of factors, including the pH, type of surfactants, and amount of skin
residue. Furthermore, the presence of humectants and emollients also can
influence the overall mildness of a cleansing agent. Agents with slightly acidic
or neutral pH, nonionic surfactants, and minimal skin residue may be preferable
for people who are at increased risk for irritancy reactions.

Medication adherence: a key factor in effective management of rosacea. Wolf JE Jr. Adv Ther. 2001 Nov-Dec;18(6):272-81.

Rosacea is a chronic condition associated with relapses. Unsuccessful treatment
is predicated, in part, on suboptimal adherence with the medication regimen.
Motivating long-term compliance remains a challenge. The literature on adherence
with rosacea medication is scant, but data from other diseases suggest that a
multifactorial approach combining nonpharmacologic and adherence-enhancing
pharmacologic interventions appears to offer the greatest success. The variety of
topical metronidazole formulations that are relatively well tolerated and
convenient to administer has been a notable advance in rosacea management. The
dermatologist, by emphasizing the importance of adherence with therapy, can do
much to facilitate this most critical behavior.

New and established topical corticosteroids in dermatology: clinical pharmacology and therapeutic use. Brazzini B, Pimpinelli N. Am J Clin Dermatol. 2002;3(1):47-58.

Currently, topical glucocorticosteroids are the most frequently used drugs in
dermatologic practice. Over the years, research has focused on strategies to
optimize potency and, in particular, the anti-inflammatory and immunosuppressive
capacity of these drugs, while minimizing adverse effects. However, ‘ideal’
topical corticosteroids have not yet been synthesized. They should be able to
permeate the stratum corneum and reach adequate concentrations in the skin
without reaching high serum concentrations. Such characteristics can be obtained
by increasing the natural lipophilicity of corticosteroids, e.g. by
esterification. In the past, many structural modifications have been made to
improve the efficacy of topical corticosteroids to produce drugs with greater
potency, although this has often been associated with a higher likelihood of
adverse effects. Betamethasone dipropionate and clobetasol propionate, known as
fifth-generation corticosteroids, are a typical example of potent molecules that
can control specific dermatoses very rapidly, but which are associated with a
high risk of topical and systemic adverse effects. Recently, steroid components
have been synthesized that aim to have adequate anti-inflammatory effects and
minimal adverse effects. The newest topical corticosteroids used for the
treatment of different dermatoses and allergic reactions of the respiratory tract
(in particular asthma) are budesonide, mometasone furoate, prednicarbate, the
di-esters 17,21-hydrocortisone aceponate and
hydrocortisone-17-butyrate-21-propionate, methylprednisolone aceponate,
alclometasone dipropionate, and carbothioates such as fluticasone propionate.
These new topical corticosteroids are evaluated in the current review, which
compares the risk/benefit ratio of each molecule with established agents. The new
molecules, compared with the well known and established corticosteroids,
generally have a higher anti-inflammatory effect, good compliance among patients
(only a once-daily application is needed), rarely induce cross-sensitivity
reactions and have weak atrophogenicity.

Rhinophyma: plastic surgery, rehabilitation, and long-term results. Jung H. Facial Plast Surg. 1998;14(4):255-78.

Rhinophymas are characterized by slowly progressive enlargement of the nasal skin
that will not resolve spontaneously. The usual indication for treatment has
plastic cosmetic and functional reasons, above all in advanced cases with an
obstruction of the nasal respiration or reduction of the visual field. Treatment
of rhinophyma consists of surgical removal of the hyperplastic alterations. It
should always be carried out by an experienced rhinosurgeon, because of possible
complications and injury to the more deeply situated nasal structures. Different
surgical procedures have been described, such as excision with primary suture or
extirpation with plastic covering of the defect by free transplants, subcutaneous
rhinophyma resection, as well as decortication with peeling off the
proliferations, dermal abrasion, or dermal shaving. In addition, there are
various abrasion procedures with abrasive cylinders, burrs, or wire brushes. The
methods of exfoliation and abrasive polishing can be effectively combined. Care
should be taken to preserve follicular epidermal islets from the more deeply
situated layers of the skin. The follicular epithelium left behind is the point
of departure for re-epithelization of the wound surface. If decortication is too
deep, injuries to the perichondrium or the nasal cartilage may arise, leading to
cosmetically unattractive scar formations and necessitate plastic surgery. The
author’s own method, which involves a combined procedure with peeling or dermal
abrasion, remodeling with abrasive cylinders, as well as preoperative injection
into the nasal tumor masses and a subsequent covering of the wound area with
fibrin glue, is shown with reference to several examples of more than 60 cases.
The cosmetic and long-term results are excellent.

Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities. Jansen T, Plewig G. Facial Plast Surg. 1998;14(4):241-53.

Phymas are slowly progressive, disfiguring disorders of the face and ears that
represent the end stage of rosacea, a common centrofacial dermatosis. Phymas are
probably caused by the sequelae of chronic edema and its related connective
tissue and sebaceous gland hypertrophy. Rhinophyma is the commonest among them.
Analogous swellings may occur on the chin (gnatophyma), forehead (metophyma), one
or both ears (otophyma), and eyelids (blepharophyma). Although rhinophyma has
been traditionally associated with alcoholism, there is no evidence to support
this association. Four variants of rhinophyma (glandular, fibrous,
fibroangiomatous, actinic) can be recognized on clinical and histological basis.
The development of skin cancer, such as basal cell carcinoma or squamous cell
carcinoma, in rhinophyma appears to be a matter of accidental coincidence of
different diseases. Although phymas are best treated surgically, they may be a
worthwhile indication for nonsurgical treatment modalities such as systemic
isotretinoin. Phymas do not resolve spontaneously.

Tacrolimus clinical studies for atopic dermatitis and other conditions. Bergman J, Rico MJ. Semin Cutan Med Surg. 2001 Dec;20(4):250-9.

The first topical immunomodulator approved for human use, tacrolimus ointment
(Protopic, Fujisawa, Healthcare, Inc, Deerfield, IL), has been shown to be
effective and safe in the treatment of children (aged 2 years and older) and
adults with atopic dermatitis (AD). Clinical trials conducted worldwide have
involved 12,000 patients, with safety and efficacy data available for up to 3
years of treatment. In addition to its beneficial effects in the management of
AD, topical tacrolimus has also been reported to be of benefit in other
immunologically mediated skin diseases including: hand dermatitis, contact
dermatitis, eyelid dermatitis, erosive lichen planus, steroid-induced rosacea,
pyoderma gangrenosum, and graft-versus-host disease. This article reviews the
clinical experience of topical tacrolimus in the treatment of AD and other skin
conditions.

Rashes in infants. Pitfalls and masquerades. Orchard D. Aust Fam Physician. 2001 Nov;30(11):1047-51.

BACKGROUND: Physiological and pathological skin eruptions are extremely common in
neonates and are often presented to the general practitioner as either a primary
or incidental problem at consultation. OBJECTIVE: To discuss the presentation and
treatment of common dermatological conditions presenting in the first six months
of life. DISCUSSION: Common conditions such as pityrosporum folliculitis,
neonatal acne, cradle cap, eczema and food allergy are discussed. The rarer
conditions of zinc deficiency and neonatal lupus are described because they may
pose significant potential medical consequences.

Diseases associated with photosensitivity. Murphy GM. J Photochem Photobiol B. 2001 Nov 15;64(2-3):93-8.

Photosensitive disorders may be classified as those entirely caused by solar
exposure and the photoaggravated disorders. Those in the former category include
polymorphic light eruption, juvenile spring eruption, actinic prurigo, hydroa
vacciniforme, solar urticaria, also chronic actinic dermatitis. Genodermatoses
whose expression mainly depends on UV or light exposure include the DNA repair
deficient disorders, some disorders of cornification, the Smith-Lemli-Opitz
syndrome and porphyria. Examples of photoaggravated diseases include lupus
erythematosus, erythema multiforme, atopic eczema, psoriasis, viral exanthemata,
pemphigus, dermatitis herpetiformis and rosacea. Drugs and chemicals may interact
with UV to induce photosensitivity. In many of these diseases the action spectrum
is known or may be determined by phototesting. Recognition of the reaction
patterns associated with the photodermatoses greatly assists clinical
classification of the photodermatoses.

alpha-Hydroxy acid-based cosmetic procedures. Guidelines for patient management. Tung RC, Bergfeld WF, Vidimos AT, Remzi BK. Am J Clin Dermatol. 2000 Mar-Apr;1(2):81-8.

alpha-Hydroxy acid (AHA) peels and home regimens have recently been recognized as
important adjunctive therapy in a variety of conditions including photodamage,
actinic damage, melasma, hyperpigmentation disorders, acne, and rosacea. Overall
in our experience and in the literature, AHAs have a proven level of safety and
efficacy in a variety of skin types. Although their exact mechanism of action is
unknown, it has been demonstrated that AHAs improve these disorders by thinning
the stratum corneum, promoting epidermolysis, dispersing basal layer melanin, and
increasing collagen synthesis within the dermis. In patients with photodamage,
AHA peels and topical products are often combined with retinoids and other
antioxidants for maximum benefit. Similarly, synergistic effects of fluorouracil
and glycolic acid are observed in the treatment of diffuse actinic keratoses. For
patients with melasma, AHA peels and combination products containing bleaching
agents such as hydroquinone, kojic acid, and glycolic acid seem to have increased
efficacy. Acne and rosacea patients can see improved results when standard
regimens like antibacterials and topical retinoids are supplemented with AHA
peels and lotions. However, care should always be taken prior to commencing
treatment with AHA peels and topical products. By obtaining a thorough history
and physical examination, the physician will identify any specific factors like
medications, prior procedures and medical conditions which can affect the outcome
of the peel. During the interview, there should be open discussion of patient
questions and concerns so that realistic expectations can be made. Pre- and
post-peel regimens should also be reviewed in full as patient compliance is
essential to ensure the success of a series of AHA peels.

Topical metronidazole. A review of its use in rosacea. McClellan KJ, Noble S. Am J Clin Dermatol. 2000 May-Jun;1(3):191-9.

Topical application of the antibacterial agent metronidazole is effective in the
treatment of moderate to severe rosacea, although its mechanism of action has yet
to be clearly established. Metronidazole preparations (0.75 and 1% cream, 0.75%
gel and 0.75% lotion) were significantly more effective than placebo in patients
with moderate to severe rosacea when administered to the affected area once or
twice daily for 7 to 12 weeks. The mean number of papules and pustules decreased
by between 48 and 65.1% during the treatment period. Reductions were fairly
consistent regardless of formulation, strength or application frequency and were
significant compared with placebo (p < 0.05). In 1 study, most of the overall
effects of metronidazole were observed within the first 3 weeks. Although data
are limited, topical metronidazole appears to improve inflammatory lesions and
erythema as effectively as oral tetracyclines. Like tetracyclines, however,
metronidazole has no effect on telangiectasia. Metronidazole 0.75% gel seems to
be effective in maintaining remission of rosacea symptoms in patients
successfully treated with both oral tetracycline and topical metronidazole. In
the only study, 77% of patients treated with metronidazole gel compared with 58%
of placebo recipients (p < 0.05) remained in remission 6 months after the
tetracycline was stopped. The effects of topical metronidazole preparations on
rosacea symptoms are palliative, not curative, but preliminary data suggest that
relapse rates after cessation of therapy are no worse than those after cessation
of oral oxytetracycline. Topical metronidazole formulations are generally well
tolerated locally, with stinging, dryness, burning and itching reported in < or =
2% of patients. Because minimal concentrations of metronidazole are absorbed
after topical administration, systemic adverse events and drug interactions seen
with oral or intravenous metronidazole are unlikely. CONCLUSIONS: Topical
metronidazole formulations are significantly more effective than placebo when
used in the initial treatment of patients with moderate to severe rosacea.
Furthermore, limited evidence suggests that the use of topical metronidazole
alone may be as effective as oral tetracyclines against the disorder’s
inflammatory component. Therefore, for those patients with a preference for
topical rather than oral therapy, the use of a topical metronidazole formulation
must be a consideration.

Understanding rosacea. A guide to facilitating care. Lindow KB, Warren C. Am J Nurs. 2001 Oct;101(10):44-51; quiz 52.

Common triggers of facial erythema in adults. Heiberger K, Brenman S. JAAPA. 2001 Sep;14(9):49-50, 53-4.

Cosmetics in acne and rosacea. Draelos ZD. Semin Cutan Med Surg. 2001 Sep;20(3):209-14.

Cosmetics that are appropriate for use in patients with rosacea and acne must be
noncomedogenic, nonacnegenic, nonirritating, and hypoallergenic. This requires a
basic understanding of cosmetic fromulation and the selection of products that
meet guidelines for sensitive skin.

Rosacea: current thoughts on origin. Bamford JT. Semin Cutan Med Surg. 2001 Sep;20(3):199-206.

Rosacea is a clinical pattern beginning and evolving in the genetically
susceptible individual in response to a host of exposures. It produces a variety
of clinical presentations, which vary over time and with age. Recently, many
specific mediators of rosacea development have been described. A primary genetic
cause for rosacea is suggested as single genes often control such mediators:
enzymes, neuroendocrine transmitters, and cytokines are found in pathways to
rosacea signs and symptoms. Currently, neither a specific cause nor a laboratory
indicator of rosacea has been suggested. However, broadening interest in rosacea
portends future increase in knowledge.

[Metronidazole] [Article in French] Martinez V, Caumes E. Ann Dermatol Venereol. 2001 Sep;128(8-9):903-9.

Metronidazole was first introduced for the treatment of trichomoniasis. Now, its
therapeutics use has subsequently been expanded to include protozoal and
anaerobic infections. Oral administration is recommended: rosacea, perioral
dermatitis, Helicobacter pylori, Trichomonas vaginalis and Giardia lamblia
infections and bacterial vaginosis. Metronidazole given orally is absorbed almost
completely. Metronidazole has limited plasma protein binding but can reach very
favourable tissue distribution, including central nervous system and placenta.
This drug is extensively metabolised by the liver to form 5 oxydative
metabolites. The majority of this drug and metabolites are excreted in urine and
feces. The half-life is 6 to 10 hours. The recommended dose is 500 mg three time
per day and an adaptation is necessary in renal insufficiency. Metronidazole is
well tolerated when administered in dosages of less than 2 g per day. Some
adverse reactions appear to be related to the high dosages and treatment
duration. Drug interactions with alcohol, warfarin and phenytoin have been
reported. Mutagenesis and cancerogenesis is only described in mouse. Resistance,
both clinical and microbiological, has been described only rarely.

Retinoids–which dermatological indications will benefit in the near future? Zouboulis CC. Skin Pharmacol Appl Skin Physiol. 2001 Sep-Oct;14(5):303-15.

Retinoids are compounds with pleiotropic functions and a relatively selective
targeting of certain skin structures. They are vitamins, because retinol (vitamin
A) is not synthesized in the body and must be derived from diet, but also
hormones with intracrine activity, because retinol is transformed into molecules
that bind to nuclear receptors, exhibit their activity, and are subsequently
inactivated. Retinoids exert their effects on target cells by binding and
activating nuclear retinoid receptors. Retinoid receptors bind their ligands in
form of dimers. Heterodimers can be formed between two different retinoid
receptor molecules but also between retinoid X receptors and the vitamin D
receptor as well as the triiodothyronin receptor. This fact indicates complex
interactions between retinoids and further hormonal signal transduction
molecules. Interaction of retinoid receptors with transcriptional factors
activated by other signal transduction mechanisms, e.g. AP-1, may provide
dissociation of the retinoid effects. Retinoids can exhibit agonistic activity
but also be neutral antagonists and inverse agonists. Topical and oral retinol,
tretinoin, isotretinoin, and bexarotene, topical alitretinoin, retinaldehyde,
motretinide, adapalene, tazarotene, and systemin acitretin compose the list of
launched retinoids. Psoriasis and related disorders, congenital disorders of
keratinization, acne, photoaging and hypovitaminosis A are classical approved
indications of retinoid treatment, whereas cutaneous T-cell lymphoma,
AIDS-associated Kaposi’s sarcoma, acute promyelocytic leukemia and actinic
lentigines were currently confirmed. In addition, retinoids have been
successfully used in several other dermatoses, e.g. epithelial precanceroses and
tumors, seborrhea, rosacea and acneiform dermatoses, lichen planus, eosinophilic
folliculitis, condylomata accuminata, lichen sclerosus and atrophicus. Highly
receptor selective molecules, retinoic acid receptor-beta-inducers, AP-1 complex
antagonists, and inverse agonists will be probably lead the retinoid development
in the near future. New, more effective and less toxic retinoids, alone or in
combination with other drugs and new delivery systems may provide therapeutic
solutions for benign and malignant proliferative skin diseases, such as psoriasis
and non-melanoma tumors, cancer chemoprevention and differentiation therapy.
Copyright 2001 S. Karger AG, Basel

[Rosacea in the year 2001] [Article in Dutch] Thissen MR, Neumann HA. Ned Tijdschr Geneeskd. 2001 Sep 15;145(37):1778-82.

Rosacea is a chronic skin disorder of the face. Initially erythema and
telangiectasia develop, followed at a later stage by papules and papulopustules.
Females between 30 and 50 years of age are most affected. Pathogenesis is not
clearly understood. Finally rhinophyma and persistent lymphoedema can develop. It
can be difficult to distinguish acne vulgaris, seborrheic eczema, perioral
dermatitis and lupus erythematosus from rosacea. Treatment of first choice
consists of topically or systemically applied antibiotics. More severe cases can
be treated with isotretinoin. Erythema and telangiectasia respond well to
treatment with vascular lasers.

The ocular manifestations of rosacea. Tanzi EL, Weinberg JM. Cutis. 2001 Aug;68(2):112-4.

The ocular manifestations of rosacea are commonly nonspecific and variable. The
etiology of the inflammation is unknown and there is no diagnostic test for the
disease. Ocular rosacea is often underdiagnosed, despite the potential for
serious sight-threatening sequelae. When evaluating patients with rosacea,
dermatologists should obtain a careful history of eye complaints and examine the
eyelid margins thoroughly. Treatment is aimed at controlling symptoms and is
multifaceted. The foundation of treatment is good lid hygiene and oral
tetracyclines. Those patients with moderate-to-severe ocular findings will
benefit from a multidisciplinary approach, including evaluation by an
ophthalmologist.

Chronic cicatrizing conjunctivitis. Faraj HG, Hoang-Xuan T. Curr Opin Ophthalmol. 2001 Aug;12(4):250-7.

Conjunctival fibrosis may result from chronic inflammation and may lead to
alterations of conjunctival architecture. This results in ocular dryness,
entropion and trichiasis, and corneal complications. Causes of conjunctival
cicatrization are not limited to autoimmune diseases, such as ocular cicatricial
pemphigoid, a severe disease associated with poor ocular prognosis. Other
well-known causes include thermal and chemical burns, postinfectious
conjunctivitis, and Stevens-Johnson syndrome. Ocular rosacea and atopic
keratoconjunctivitis often are underdiagnosed causes of conjunctival fibrosis.
Medical history, physical exam, and laboratory tests often allow for diagnosis of
the underlying disease. Medical management varies according to specific causes,
and many surgical strategies are available to restore corneal transparency and
normal palpebral architecture.

[The lipid layer of the lacrimal tear film: physiology and pathology] [Article in French] Lozato PA, Pisella PJ, Baudouin C. J Fr Ophtalmol. 2001 Jun;24(6):643-58.

The preocular tear film (POTF) is composed of a deep aqueous-mucin phase that
supports a thin superficial lipid phase. The tear lipid layer (TLL), although
thin, stabilizes the POTF providing a 25% surface-tension decrease and a 90-95%
aqueous evaporation reduction. TLL is formed from lipids secreted by tarsal
meibomian glands and spread onto the ocular surface by blinking. The TLL itself
is composed of two phases. A thin and deep polar phase, adjacent to the
aqueous-mucin layer, has a surfactant role. A thicker and superficial nonpolar
phase has antievaporative properties. At the same time, tear lipocalins help the
TLL spread and stabilize the lipid-aqueous interface. For clinical examination,
TLL is directly observed with the Tearscope. POTF stability and the evaporation
rate depend on the lipid layer pattern. When chronic, POTF qualitative trouble
(evaporative syndrome) due to a TLL anomaly, leads to secondary ocular surface
impairment with increased tear instability and self-propagation of ocular
dryness. Meibomian gland dysfunction (MGD) results from local pathology,
dermatologic disease (ocular rosacea) or iatrogenic etiology. Cosmetic use is the
other principal cause of TLL destabilization. Lid hygiene is the mainstay of MGD
treatment. Systemic antibiotics (cyclins) can be associated in cases of severe
symptoms. Topical treatment is useful if there is marginal lid inflammation or
infection.

Systemic therapy for rosacea: focus on oral antibiotic therapy and safety. Del Rosso JQ. Cutis. 2000 Oct;66(4 Suppl):7-13.

Although potentially significant adverse reactions and drug interactions have
been reported in association with erythromycin, oral tetracyclines, and
trimethoprim-sulfamethoxazole, overall these agents are associated with excellent
safety profiles, especially considering their widespread use over many years. It
must be considered that when these antibiotics are used for the treatment of
rosacea and also for acne vulgaris, their use is on a long-term basis rather than
their typical short-course regimens for most infectious diseases. As a result,
dermatologists prescribing these agents may feel assured that most patients will
not encounter any significant problems, but they do need to be aware of potential
adverse reactions to allow for early recognition and discontinuation of the
offending drug when needed. Early recognition also allows for favorable
management of adverse reactions. In addition, potentially significant drug
interactions may be recognized by obtaining a thorough medical history and
avoiding combinations of drugs that may interact unfavorably. Fortunately, there
are several choices that allow us to individually select a treatment regimen that
is optimal for the individual patient, allowing for effective control of rosacea.

Rosacea: a tiered approach to therapy. Bikowski JB. Cutis. 2000 Oct;66(4 Suppl):3-6.

Rosacea skin care. Torok HM. Cutis. 2000 Oct;66(4 Suppl):14-6.

[Alcohol and the skin] [Article in Polish] Wegrzynek I, Budzanowska E. Przegl Lek. 2001;58(4):198-203.

The cutaneous changes typical of patients, who are alcohol misusers have been
reported in this study. We discuss also certain skin disorders which seem to be
affected by alcohol misuse. We made an attempt to explain the ways of the
influence of alcohol on mentioned skin diseases. It seems some skin disorders may
be markers of alcohol misuse. Physicians who see patients with these particular
diseases should be aware that there is a greater chance a patient is also an
alcoholic. This additional risk factor needs to be considered when physicians
design a treatment strategy.

Identifying and treating rosacea. Cuevas T. Nurse Pract. 2001 Jun;26(6):13-5, 19-23; quiz 24-5.

Rosacea is a chronic, cutaneous vascular disorder that affects approximately 13
million Americans. The facial disorder, which often affects people of Northern
European descent, is characterized by four stages. Although rosacea is not
curable, early recognition and treatment can prevent progression to permanent
disfigurement or blindness. Pharmacologic therapy, patient education, and symptom
management can provide symptom control and remission.

Evidence based medicine and extradigestive manifestations of Helicobacter pylori. De Koster E, De Bruyne I, Langlet P, Deltenre M. Acta Gastroenterol Belg. 2000 Oct-Dec;63(4):388-92.

A putative pathogenetic role has been ascribed to Helicobacter pylori in several
extradigestive diseases, including vascular (atherosclerosis and ischaemic heart
disease, primary Raynaud phenomenon, primary headache), autoimmune (Sjögren’s
syndrome, Henoch-Schönlein purpura, autoimmune thyroiditis, idiopathic
arrythmias, Parkinson’s disease, nonarterial anterior optic ischemic neuropathy),
and skin diseases (chronic idiopathic urticaria, rosacea, alopecia areata),
sideropenic anemia, growth retardation, late menarche, extragastric MALT
lymphoma, diabetes mellitus, hepatic encephalopathy, sudden infant death
syndrome, and anorexia of aging. We examine critically the strength of the
evidence linking these diseases to Helicobacter pylori, using ischaemic heart
disease as an example of epidemiological techniques, and skin diseases as an
example of treatment studies. By the standards of evidence-based medicine,
studies have been often of low quality. The best evidence usually is not
indicative of a role for Helicobacter pylori in these diseases.

F.I.GU.R.E.: facial idiopathic granulomas with regressive evolution. is ‘lupus miliaris disseminatus faciei’ still an acceptable diagnosis in the third millennium? Skowron F, Causeret AS, Pabion C, Viallard AM, Balme B, Thomas L. Dermatology. 2000;201(4):287-9.

We report the case of a 69-year-old woman who presented a papular eruption on the
eyelids. Histological features revealed a tuberculoid granuloma with a central
caseating necrosis. Laboratory and radiological investigations revealed no
tuberculosis and no systemic granulomatosis. Absence of vascular symptoms,
inefficiency of cyclines and histopathological findings excluded
granulomatous-type rosacea. Lupus miliaris disseminatus faciei (LMDF) was our
final diagnosis. On the basis of our findings and a literature review, we believe
that LMDF is an entity distinct from either skin tuberculosis or
granulomatous-type rosacea. However, its name is confusing, and we propose to
change it to ‘facial idiopathic granulomas with regressive evolution (FIGURE)’.
Copyright 2000 S. Karger AG, Basel

[Helicobacter pylori and skin diseases--a (still) intact myth?] [Article in German] Böni R, Burg G, Wirth HP. Schweiz Med Wochenschr. 2000 Sep 16;130(37):1305-8.

Helicobacter pylori plays a key role in the aetiology of peptic ulcer, gastric
cancer and gastric MALT-lymphoma. Based on a number of reports, a possible
relationship of Helicobacter pylori infection to a variety of different
dermatoses has been suggested, including urticaria, rosacea, acne-rosacea, atopic
dermatitis, alopecia areata, Sjögren’s syndrome, Schönlein-Henoch purpura, and
Sweet syndrome. Larger case-control studies, however, do not confirm this
relationship. Therefore, Helicobacter pylori eradication therapy cannot be
generally recommended in these dermatoses.

Rosacea 2000. Hirsch RJ, Weinberg JM. Cutis. 2000 Aug;66(2):125-8.

Rosacea fulminans in a patient with Crohn’s disease: a case report and review of the literature. Romiti R, Jansen T, Heldwein W, Plewig G. Acta Derm Venereol. 2000 Mar-Apr;80(2):127-9.

Rosacea fulminans is a rare disorder of unknown cause that mainly affects
postadolescent women, with abrupt onset and disfiguring course if left untreated.
The simultaneous occurrence of rosacea fulminans and inflammatory bowel disease
is rare and has been reported predominantly in the setting of ulcerative colitis.
We describe here a case of rosacea fulminans in a patient with Crohn’s disease
and discuss a possible association between the two conditions.

[Rosacea, acne and other diseases of the seborrheic spectrum] [Article in German] Böni R. Praxis (Bern 1994). 2000 Mar 30;89(14):566-70.

Diseases of seborrhoic origin include rosacea, acne, gram-negative folliculitis,
demodex-folliculorum, perioral dermatitis as well as seborrhoic dermatitis. An
important prerequisite for adequate therapy is the knowledge of these different
diseases. Unfortunately, topic steroids are often applied, resulting in well
known corticosteroid side-effects like skin atrophy and teleangiectasias. The
different clinical diseases of seborrhoic origin are reviewed here and a
treatment guide is presented.

Rosacea. Zuber TJ. Prim Care. 2000 Jun;27(2):309-18.

Rosacea is a common skin disorder most often seen in individuals between the ages
of 30 and 60. The condition frequently produces erythema, papules, pustules, and
edema of midfacial skin. Ocular rosacea occurs in a high percentage of patients,
and is a major cause of red eye. A variety of treatments exist that can eliminate
pustules, but no therapy is highly effective in eliminating the vascular flushing
associated with rosacea.

Helicobacter pylori. One bacterium and a broad spectrum of human disease! An overview. Pakodi F, Abdel-Salam OM, Debreceni A, Mózsik G. J Physiol Paris. 2000 Mar-Apr;94(2):139-52.

Since the historical rediscovery of gastric spiral Helicobacter pylori in the
gastric mucosa of patients with chronic gastritis by Warren and Marshall in 1983,
peptic ulcer disease has been largely viewed as being of infectious aetiology.
Indeed, there is a strong association between the presence of H. pylori and
chronic active gastritis in histology. The bacterium can be isolated in not less
than 70% of gastric and in over 90% of duodenal ulcer patients. Eradication of
the organism has been associated with histologic improvement of gastritis, lower
relapse rate and less risk of bleeding from duodenal ulcer. The bacterium
possesses several virulence factors enabling it to survive the strong acid milieu
inside the stomach and possibly damaging host tissues. The sequence of events by
which the bacterium might cause gastric or duodenal ulcer is still not fully
elucidated and Koch’s postulates have never been fulfilled. In the majority of
individuals, H. pylori infection is largely or entirely asymptomatic and there is
no convincing data to suggest an increase in the prevalence of peptic ulcer
disease among these subjects. An increasingly growing body of literature suggests
an association between colonization by H. pylori in the stomach and a risk for
developing gastric mucosa-associated lymphoid tissue (MALT), MALT lymphoma,
gastric adenocarcinoma and even pancreatic adenocarcinoma. The bacterium has been
implicated also in a number of extra-gastrointestinal disorders such as ischaemic
heart disease, ischaemic cerebrovascular disease, atherosclerosis, and skin
diseases such as rosacea, but a causal role for the bacterium is missing.
Eradication of H. pylori thus seems to be a beneficial impact on human health.
Various drug regimens are in use to eradicate H. pylori involving the
administration of three or four drugs including bismuth compounds, metronidazole,
clarithromycin, tetracyclines, amoxycillin, ranitidine, omeprazole for 1-2 weeks.
The financial burden, side effects and emergence of drug resistant strains due to
an increase in the use in antibiotics for H. pylori eradication therapy need
further reconsideration.

Acne, perioral dermatitis, flushing, and rosacea: unapproved treatments or indications. Katsambas AD, Nicolaidou E. Clin Dermatol. 2000 Mar-Apr;18(2):171-6.

Hypnosis in dermatology. Shenefelt PD. Arch Dermatol. 2000 Mar;136(3):393-9.

BACKGROUND: Hypnosis is an alternative or complementary therapy that has been
used since ancient times to treat medical and dermatologic problems. OBJECTIVE:
To describe the various uses for hypnosis as an alternative or complementary
therapy in dermatologic practice. METHODS: A MEDLINE search was conducted from
January 1966 through December 1998 on key words related to hypnosis and skin
disorders. RESULTS: A wide spectrum of dermatologic disorders may be improved or
cured using hypnosis as an alternative or complementary therapy, including acne
excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform
erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia,
herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus,
neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus,
psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo.
CONCLUSION: Appropriately trained clinicians may successfully use hypnosis in
selected patients as alternative or complementary therapy for many dermatologic
disorders.

Conventional cold excision combined with dermabrasion for rhinophyma. Gupta S, Handa S, Saraswat A, Kumar B. J Dermatol. 2000 Feb;27(2):116-20.

A 65-year-old man, farmer by occupation, presented with redness and gradual
enlargement of the nose. Examination revealed marked nodular enlargement of the
nose and loss of normal nasal contours. Sebaceous material could be expressed
from widened pores. The patient was diagnosed as rhinophyma of moderate degree.
He was treated with cold knife excision combined with dermabrasion. A literature
scan revealed that currently there is no evidence of superiority of much popular
laser surgery over conventional cold knife surgery combined with dermabrasion for
rhinophyma. Conventional surgery is time-tested, and it does not require
expensive equipment or special training.

Helicobacter pylori infection and skin diseases. Wedi B, Kapp A. J Physiol Pharmacol. 1999 Dec;50(5):753-76.

There is increasing evidence for systemic effects of gastric H. pylori infection
which may result in extragastrointestinal disorders. This review summarizes the
available medical literature up to September 1999, identified through a MEDLINE
research including own studies, regarding H. pylori and skin diseases. Due to
current knowledge best evidence for a potential link of H. pylori infection
exists for chronic urticaria although the data are still conflicting. Thus, the
search for H. pylori should be included in the diagnostic management of chronic
urticaria. With regard to other skin diseases such as rosacea, hereditary or
acquired angioedema due to C1-esterase inhibitor deficiency, systemic sclerosis,
Schönlein-Henoch purpura, Sjögren’s syndrome, sweet’s syndrome, and atopic
dermatitis only single of few cases have been reported so far. Thus, we clearly
need further randomized, double-blind and placebo-controlled studies including
adequate diagnostic schedules, sufficient eradication treatment protocols,
confirmation of eradication, and adequate control groups to establish a role of
H. pylori in skin diseases. Caution must be taken not to accuse H. pylori as the
infectious agent responsible for every disease, particularly since H. pylori
infection is very common. Although from an epidemiological and morphological view
the skin diseases to which H. pylori has been linked seem to be completely
different it is striking that in most of them an autoimmune pathogenesis is
suspected or considerable vascular impairment can be found.

Acne and rosacea. New and emerging therapies. Thiboutot DM. Dermatol Clin. 2000 Jan;18(1):63-71, viii.

The goal of this article is to highlight recent developments in the treatment of
acne and rosacea. An update on the use of isotretinoin, minocycline, topical
retinoids, and hormones in the treatment of acne are presented. Highlights of
research findings that may lead to future acne therapies are discussed. New in
the management of rosacea are studies demonstrating the efficacy of 1% topical
metronidazole in the treatment of rosacea, reports on the successful maintenance
of remissions of rosacea with 0.75% metronidazole gel, and data regarding the
controversial association of rosacea with Helicobacter pylori infection.

An unusual case of a relationship between rosacea and dental foci. Lesclous P, Maman L. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Dec;88(6):679-82.

Rosacea is a chronic disorder affecting the facial convexities, characterized by
frequent flushing, persistent erythema, and telangiectases. During episodes of
inflammation, additional features are swelling, papules, and pustules. The exact
etiology of this dermatitis is unknown, and theories abound. Infectious foci,
especially dental foci, seem to be rarely associated with the onset and
progression of this disease. Dermatologic treatments are determined by the
severity of the disease. But eradication of infectious foci, and in this case
eradication of dental foci, may generate a significant improvement and may lead
to a recovery.

[Local corticosteroid therapy in dermatology] [Article in French] Chosidow O, Lebrun-Vignes B, Bourgault-Villada I. Presse Med. 1999 Nov 27;28(37):2050-6.

FOUR LEVELS OF ACTION: The introduction of dermocorticosteroids (corticosteroids
for topical application) has revolutionized management of many skin diseases.
Depending on their antiinflammatory action, these products can be classed into
four levels of action. Dermocorticosteroids have antiinflammatory,
vasoconstrictor, antiproliferative, antisynthetic and immunosuppressive actions.
SKIN PENETRATION: Penetration depends on the intrinsic characteristics of the
drug, but also on many other factors including the nature of the excipient,
additives, occlusion, localization, nature of the treated skin disease, and
patient age. There is a reservoir effect, explaining why a single application is
effective for dermatoses with a normal keratin layer. INDICATIONS AND
CONTRAINDICATIONS: Dermocorticosteroids can be indicated in numerous inflammatory
skin diseases (psoriasis, eczema …). They are formally contraindicated in case
of skin infections, diaper rash, acne and rosacea. Contact allergies have been
reported. IN PRACTICE: The choice of a dermatocorticosteroid depends on the
suspected sensitivity of the disease to treat, its degree of extension, and its
localization as well as the patient’s age and the planned duration of treatment.
Cremes provide good cosmetic satisfaction. The number of tubes to be used must be
strictly controlled. Occlusion is indicated in case of palmo-plantar or the scalp
involvement.

Newer concepts in antimicrobial therapy. Parish LC. Adv Exp Med Biol. 1999;455:397-406.

Antimicrobial agents continue to play a significant role in clinical practice not
only due to their active role in the treatment of bacterially induced infections.
The accompanying anti-inflammatory characteristics and their antagonism against
superantigens add to their importance. The practitioner must also be aware of
both overt and covert unwanted effects. During the past decade, the new
quinolones, advanced macrolides, and better cephalosporins have been introduced.
The staid penicillins have been up-graded with the addition of a beta-lactamase
inhibitor. Many antibiotics have been available for several decades but new uses
for them and their derivatives permit the dermatologist to have a more versatile
armamentarium. Rifamycin has been shown to be effective in the treatment of
leishmaniasis. The new macrolide, clarithromycin, will reduce the lesions of acne
vulgaris and acne rosacea. Although phototoxicity was well recognised in the
sulfonomides, several quinolones can create similar light-induced problems.
Bullous diseases are known to be instigated by the penicillins, while vasculitis
may be caused by a quinolone. Even porphyria has been reported to be induced by a
tetracycline. Antimicrobial therapy has been an integral part of dermatologic
practice since the introduction of the sulfa drugs six decades ago. Whether skin
is affronted by more pathogenic bacteria than any other organ or whether the
percentage of infectious etiologies is greater for cutaneous maladies than for
other organ afflictions is not germane to this presentation. The facts remain
that signs and symptoms of many dermatitides are diminished or even eliminated by
antimicrobials [1, 2, 3, 4].

[Cutaneous complications after organ transplantation] [Article in Norwegian] Gjersvik PJ. Tidsskr Nor Laegeforen. 1999 Oct 20;119(25):3789-92.

Organ transplant recipients may develop cutaneous complications related to
long-term immunosuppressive drug treatment (prednisolone, azathioprine,
cyclosporine). These complications are either related to the immunosuppression
per se, such as common warts, dermatophytosis, premalignant lesions, and skin
cancer, or drug-specific effects, such as acne, rosacea, and hypertrichosis.
Organ transplant recipients have a markedly increased risk of developing skin
cancer, especially squamous cell carcinoma, but also basal cell carcinoma,
Kaposi’s sarcoma and malignant melanoma. Patients should be encouraged to avoid
sun exposure, a well-known risk factor for skin cancer, and to use sun protection
measures. Patients with skin lesions suspected to be malignant should be referred
to a dermatologist. Close dermatological follow-up of patients diagnosed with
post-transplant skin cancer is essential.

Alcohol intake and other skin disorders. Higgins E, du Vivier A. Clin Dermatol. 1999 Jul-Aug;17(4):437-41.

[The black thyroid syndrome. A case report] [Article in Spanish] Cos M, Fernández-Real JM, Ricart W, Ortiz MR. Rev Clin Esp. 1999 Jul;199(7):478-9.

Perioral dermatitis in children. Laude TA, Salvemini JN. Semin Cutan Med Surg. 1999 Sep;18(3):206-9.

Perioral dermatitis is a unique skin disorder of childhood. Its exact origin is
unknown; it is probably an idiosyncratic response to exogenous factors such as
the use of a topical fluorinated corticosteroid or other substances on the face.
It is uncommon but not rare. The age of affected children has ranged from 7
months to 13 years, with the median being in the prepubertal period. Boys and
girls, blacks and whites are equally affected. Clinical features include the
following: (1) absence of systemic symptoms; (2) periorificial distribution
(perioral, perinasal, periorbital); (3) skin lesions that consist of flesh
colored or erythematous inflammed papules, micronodules, and rare pustules; and
(4) variable pruritus. Laboratory tests are negative. Histologically, it is
indistinguishable from rosacea; there is a superficial perifollicular granuloma
consisting of epitheliod cells, and lymphohistiocytic infiltrate, with occasional
giant cells. The disease waxes and wanes for weeks and months. Treatment consists
of discontinuing topical fluorinated corticosteroid use if any, and using topical
metronidazole alone or in combination with either oral tetracycline or
erythromycin depending on the child’s age. A low-potency topical steroid may also
be used to suppress the inflammation and to wean off the strong steroid. Perioral
dermatitis in childhood is probably a juvenile form of rosacea.

[Ocular rosacea] [Article in French] Valanconny C, Michel JL, Gain P, Fond L, Tchaplyguine F, Maugery J, Cambazard F. Ann Dermatol Venereol. 1999 May;126(5):450-4.

A lifetime of healthy skin: implications for women. Bergfeld WF. Int J Fertil Womens Med. 1999 Mar-Apr;44(2):83-95.

During her lifetime, a woman faces the possibility of seeking dermatological
assistance for a myriad of conditions, including acne, rosacea, striae,
photodamage, and skin cancers. It is important for clinicians and patients to be
aware of the symptoms of these conditions as well as the most beneficial
approaches for prevention, diagnosis, treatment, and management. The life
expectancy of women has increased and predictions for the year 2050 estimate the
average age at 81 years. This will place women at greater risk for dermatological
problems, especially photodamage and skin cancer. In addition, various ethnic
groups may manifest these conditions differently. Although acne is most prevalent
among teenaged males, most can expect clearing by age 25. Females may continue to
experience acne into the adult years, sometimes beyond the age of 40. Although it
is not a life-threatening disease, acne may have psychosocial and quality-of-life
consequences. Treatments for acne can be topical or systemic, and include
retinoids, antibiotics, benzoyl peroxide, azelaic acid, and hormonal therapy.
Rosacea is more common in women (especially during menopause) than in men. It is
a chronic condition that can cause complications, including telangiectasia,
conjunctivitis, and blepharitis. Although there is no cure, rosacea can be
managed and controlled with medication. Topical antibiotics, such as
metronidazole, and systemic antibiotics, such as tetracycline, clarithromycin,
and doxycycline, are used to manage rosacea. Striae, or stretch marks, occur most
frequently in pregnant women, adolescents experiencing growth spurts, weight
lifters, and the obese. Although not a health threat, they can be psychologically
distressing. There are not many treatment options for striae, but topical
tretinoin and the pulsed dye laser offer promising results. Intrinsic, or normal,
aging of the skin results from the process of chronological aging. Photodamage is
skin damage caused by chronic exposure to ultraviolet (UV) light. It is the
leading cause of extrinsic aging, or alterations of the skin due to environmental
exposure. Estimates indicate that almost half of a person’s UV exposure occurs by
age 18. Photoaging causes numerous histologic, physiologic, and clinical changes;
it also increases the risk for skin cancer. Photodamage can be prevented through
the use of sun screens, protective clothing, and avoidance of the sun during peak
intensity time. The only product approved by the FDA for the treatment of
photodamage (fine wrinkles, mottled hyperpigmentation, and skin roughness),
topical tretinoin emollient cream, may help prevent additional photoaging when it
is used to treat existing photoaging. Other management options for photodamaged
skin include alpha-hydroxy acids, antioxidants, antiandrogens, moisturizers, and
exfoliants. In patients with excessive manifestations of photodamage, surgical
management may be needed, including dermabrasion, chemical peels, soft tissue
augmentation, laser resurfacing, botulism toxin, and Gortex threads. Clinicians
must educate their patients about the most appropriate skin care regimen as well
as approaches for preventing and treating common afflictions. In this way, women
will have the best opportunity for having and maintaining healthy skin.

[On the problem of rhinophyma management] [Article in Polish] Szmeja Z, Kulczyński B, Golusiński W, Kordylewska M, Obrebowska-Karsznia Z. Otolaryngol Pol. 1999;53(1):29-33.

On the basis of cases of their own and the literature the authors review the
etiology, pathophysiology and management of rhinophyma.

The red face-an overview and delineation of the MARSH syndrome. Griffiths WA. Clin Exp Dermatol. 1999 Jan;24(1):42-7.

The problem of the red face in females is reviewed. After excluding common causes
such as contact dermatitis, seborrhoeic eczema and photodermatitis the diseases
affecting the remaining patients fall into three groups: marked erythema with no
feeling of heat or sensitivity, usually erythromelanosis faciei; marked flushing
and burning with intense sensitivity for which the term facial
erythrodysaesthesia is proposed; the so-called MARSH syndrome in which an overlap
of androgen-dominant symptoms occurs – melasma, acne, rosacea, seborrhoeic
eczema, and hirsutism. The latter group may respond best to low dose oral
isotretinoin.

Rosacea. Tackett-Fletcher W, Roberts K. Geriatr Nurs. 1999 Jan-Feb;20(1):44, 47.

Recognizing rosacea. Millikan L. Postgrad Med. 1999 Feb;105(2):149-50, 153-8.

Rosacea is a common disorder of the facial skin that tends to become apparent
after age 30. Symptoms are usually progressive, but early diagnosis and
appropriate management can alleviate patient discomfort and psychological
distress as well as prevent serious long-term complications.

[Selective brain cooling] [Article in French] Corrard F. Arch Pediatr. 1999 Jan;6(1):87-92.

The brain is especially sensitive to heat stress. To limit the increase of
intracranial heat in case of hyperthermia or fever, a system of selective cooling
is put on. It includes two heat-exchangers. The first one, in the face and scalp
skin, disperses calories through sweat evaporation. The second one is
intracranial, close to the arteries which irrigate the brain. They are connected
by a vascular network. In these conditions, the arterial blood temperature, of
which cerebral temperature depends upon, is reduced by the cooled venous blood
which comes from subcutaneous tissues through the skull wall. On feverish
children, increasing such a selective cooling by face fanning can limit cerebral
thermal stress.

Use of topical products for maintaining remission in rosacea. Wilkin JK. Arch Dermatol. 1999 Jan;135(1):79-80.

Laser therapy in the management of rosacea. Laughlin SA, Dudley DK. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-24-9.

Drug therapy of rosacea: a problem-directed approach. Singer MI. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-20-3.

Psychological aspects of rosacea. Garnis-Jones S. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-16-9.

Differential diagnosis of a red face. Murray AH. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-11-5.

Rosacea: epidemiology and pathogenesis. Katz AM. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-5-10.

The many faces of rosacea. Gratton D. J Cutan Med Surg. 1998 Jun;2 Suppl 4:S4-2-4.

Acne and rosacea. Webster GF. Med Clin North Am. 1998 Sep;82(5):1145-54, vi.

The diagnosis of acne and rosacea are reviewed in this article, and specific
therapeutic strategies are discussed for these extremely common diseases.

Adult skin disease in the pediatric patient. Howard R, Tsuchiya A. Dermatol Clin. 1998 Jul;16(3):593-608.

The incidence of many skin diseases peak in adulthood, and these disorders may be
difficult to recognize when they do present in childhood. Their clinical features
may be distinct in pediatric patients, and they may be managed differently in
children as compared to adults. Therefore, it is important that dermatologists
are able to identify “adult” skin disease in the pediatric patient, and know how
to appropriately manage these problems in young patients. The epidemiology,
clinical features, differential diagnosis, and management of the following
“adult” skin diseases in children are reviewed: psoriasis, lichen planus,
rosacea, Sweet’s syndrome, and mucosis fungoides. Distinctive features of lichen
sclerosus and immunobullous diseases in childhood will also be briefly discussed.

[Granuloma eosinophilicum faciei simulating rhinophyma. Therapeutic long-term outcome after surgical intervention] [Article in German] Chatelain R, Bell SA, Konz B, Röcken M. Hautarzt. 1998 Jun;49(6):496-8.

A 53 year old man presented with a giant variant of granuloma faciale, closely
resembling rhinophyma. Therapeutic approaches with cryosurgery and dapsone were
unsuccessful. Surgical reconstruction of the nasal skin resulted in an excellent
and long lasting effect. We give a short overview of this relatively rare
disease, describe an unusual manifestation and discuss the therapeutic
possibilities. Surgical procedures seem to offer the best results, despite the
inflammatory pathogenesis of the disease.

[Diseases suspected to have relationship to Helicobacter pylori] [Article in Japanese] Kawano S. Nippon Naika Gakkai Zasshi. 1998 May 10;87(5):851-5.

Clarithromycin: a new perspective in rosacea treatment. Torresani C. Int J Dermatol. 1998 May;37(5):347-9.

Dermabrasion. As a complement to aesthetic surgery. Baker TM. Clin Plast Surg. 1998 Jan;25(1):81-8.

Dermabrasion remains an effective and reliable resurfacing option for perioral
rhytides, acne scars, traumatic facial scars, and rhinophyma. It is inexpensive,
portable, and widely available. It is well taught in most plastic surgical
training programs and, therefore, does not require expensive secondary training
courses. Dermabrasion requires no specialized accessory equipment and poses no
fire hazard in the operating room. Extensive literature and clinical experience
document its efficacy. Proper patient selection and recognition of planing depth
are both essential to successful outcome. Despite the recent popularity of the
carbon dioxide laser, dermabrasion should remain a fundamental working skill for
all plastic surgeons.

Helicobacter pylori: beyond peptic ulcer disease. Wisniewski RM, Peura DA. Gastroenterologist. 1997 Dec;5(4):295-305.

Beyond peptic ulcer disease, Helicobacter pylori infection is associated with
intestinal-type gastric cancer and low-grade gastric mucosa-associated lymphoid
tissue (MALT) lymphoma. It is also currently implicated as a possible cause of
dyspepsia and extraintestinal disorders such as coronary artery disease, rosacea,
chronic urticaria, and delayed growth in children. There are strong
epidemiological data from large cohort studies linking H. pylori to gastric
adenocarcinoma. Several cofactors, including early childhood acquisition of
infection, strain-specific differences, genetic predisposition of the host, and
the environment, appear to play a role in the progression of chronic gastritis to
gastric cancer. H. pylori infection is seen in over 90% of MALT lymphomas, and
about 70% of localized nonbulky tumors will undergo complete histological
regression after eradication of the bacterium. Because follow-up data are limited
to less than 2 years, those undergoing H. pylori eradication as primary therapy
for MALT lymphoma require frequent histological surveillance for tumor
recurrence. There are conflicting data from short-term studies regarding the
effect of H. pylori eradication on dyspeptic symptoms. The decision to test or
not for H. pylori in the dyspeptic patient may become easier when well-controlled
studies with longer periods of follow-up become available. Because H. pylori
induces a systemic inflammatory response, investigators are beginning to explore
possible extraintestinal disease associations with the infection. The global
prevalence of both peptic ulcer disease and gastric cancer has led to studies
focusing on noninvasive screening for H. pylori in high-risk populations and
prevention of primary infection by means of vaccination.

Rosacea: how to recognize and treat an age-related skin disease. Litt JZ. Geriatrics. 1997 Nov;52(11):39-40, 42, 45-7.

Rosacea is an age-related disorder of the central portion of the facial skin
whose peak onset occurs in persons in their 40s and 50s. A chronic and
progressive condition of flare-ups and remissions, rosacea can be disfiguring if
left untreated. Rosacea can be characterized as having three stages. Target areas
for all symptoms include the cheeks, nose, chin, or forehead. Rosacea resembles a
number of other dermatologic conditions, particularly acne vulgaris. The
combination of oral and topical antibiotic therapy usually brings about
remission. The key is to recognize the early signs and clinical picture so that
accurate diagnosis can be made and therapy and counseling instituted.

Rosacea: recognition and management for the primary care provider. Chalmers DA. Nurse Pract. 1997 Oct;22(10):18, 23-8, 30.

Rosacea is a common facial dermatitis that currently affects an estimated 13
million Americans. It is a chronic and progressive cutaneous vascular disorder,
primarily involving the malar and nasal areas of the face. Rosacea is
characterized by flushing, erythema, papules, pustules, telanglectasia, facial
edema, ocular lesions, and, in its most advanced and severe form, rhinophyma.
Ocular lesions are common, including mild conjunctivitis, burning, and
grittiness. Blepharitis, the most common ocular manifestation, is a nonulcerative
condition of the lid margins. Rosacea most commonly occurs between the ages of 30
to 60, and may be seen in women experiencing hormonal changes associated with
menopause. Women are more frequently affected than men; the most severe cases,
however, are seen in men. Fair complexioned individuals of Northern European
descent are most likely to be at risk for rosacea; most appear to be pre-disposed
to flushing and blushing. Alcohol, stress, spicy foods, and extremes of
temperature have all been implicated, but have not been found to actually cause
rosacea. Early diagnosis by the primary care practitioner, management with
systemic antibiotics such as tetracycline, and topical agents such as
metronidazole, in conjunction with patient education and lifestyle modifications,
can achieve remission in most instances.

Periorbital edema as an initial presentation of rosacea. Chen DM, Crosby DL. J Am Acad Dermatol. 1997 Aug;37(2 Pt 2):346-8.

Rosacea is a common dermatosis with a variety of clinical manifestations. The
eyes are often affected. The most frequent ocular findings are blepharitis and
conjunctivitis. We describe three patients with rosacea in whom periorbital edema
was the initial presentation. This symptom may be confused with other dermatoses
and may be refractory to conventional treatments for rosacea.

Minocycline-induced scleral pigmentation. Fraunfelder FT, Randall JA. Ophthalmology. 1997 Jun;104(6):936-8.

PURPOSE: Minocycline is a commonly used drug in the management of acne and
rosacea. Four individual cases of oral minocycline-induced scleral pigmentation
are reported in the dermatologic literature. This is the first report in the
ophthalmic literature and will add three new cases of probable
minocycline-induced scleral pigmentation. MATERIALS AND METHODS: Data on
minocycline from the spontaneous reporting systems of the National Registry of
Drug-Induced Ocular Side Effects, Food and Drug Administration, World Health
Organization, and Lederle Laboratories were reviewed as to minocycline-related
scleral pigmentation. Photographs, published cases, discussions with the
examining ophthalmologists, and the personal observation of one patient (case 1)
are the basis of the authors’ conclusions. RESULTS: Seven cases of probable oral
minocycline-induced scleral pigmentation are presented. These changes may or may
not be associated with minocycline-induced pigmentary changes in other tissues,
such as the skin, teeth, fingernails, bone, thyroid, or mucosa. The
characteristic scleral pattern is a blue-gray 3- to 5-mm band starting at the
limbus, which usually is enhanced in the palpebral aperture, possible due to the
photosensitizing properties of the drug. CONCLUSIONS: Oral minocycline can cause
scleral pigmentation. This pigmentation may resolve within years, or it may be
permanent.

Rosacea. Knox CM, Smolin G. Int Ophthalmol Clin. 1997 Spring;37(2):29-40.

Rosacea: classification and treatment. Jansen T, Plewig G. J R Soc Med. 1997 Mar;90(3):144-50.

Current use and future potential role of retinoids in dermatology. Orfanos CE, Zouboulis CC, Almond-Roesler B, Geilen

Since their introduction 15 years ago, retinoids have been increasingly used for
topical and systemic treatment of psoriasis and other hyperkeratotic and
parakeratotic skin disorders, keratotic genodermatoses, severe acne and
acne-related dermatoses, and also for therapy and/or chemoprevention of skin
cancer and other neoplasia. Oxidative metabolites of vitamin A (retinol) are
natural retinoids present at low levels in the peripheral blood. Synthetic
retinoids are classified into 3 generations including nonaromatic, monoaromatic
and polyaromatic compounds. They are detectable in plasma 30-60 minutes after
systemic administration, and reach maximum concentrations 2 to 4 hours later.
Elimination half-life is 10 to 20 hours for isotretinoin, 80 to 175 days for
etretinate and 2 to 4 days for, trans-acitretin; the latter, however, partially
converts into etretinate. Retinoid concentrations in skin are rather low in
contrast to subcutaneous fat tissue. Intracellularly, retinoids interact with
cytosolic proteins and specific nuclear receptors. Two classes of nuclear
receptors have been suggested to mediate retinoid activity at the molecular
level, RARs and RXRs. The expression of retinoid receptors is tissue specific;
skin mainly espresses RAR gamma and RXR alpha. Retinoids affect epidermal cell
growth and differentiation as well as sebaceous gland activity and exhibit
immunomodulatory and anti-inflammatory properties. Current retinoid research
targets the development of receptor-selective retinoids for tailoring and/or
improving their therapeutic profile. Currently, tretinoin is used systemically
for acute promyelocytic leukaemia, etretinate and acitretin for psoriasis and
related disorders, as well as other disorders of keratinisation and isotretinoin
for seborrhoea, severe acne, rosacea and acneiform dermatoses. Systemic retinoids
are also applied for chemoprevention of epithelial skin cancer and cutaneous T
cell lymphoma. The major adverse effect of retinoids is teratogenicity; all other
adverse effects are dose-dependent and controllable. Contraception is, therefore,
essential during retinoid treatment in women of child-bearing age. Clinical
monitoring requires physical examination for adverse effects every 3 to 4 weeks
and proper laboratory investigations, also including analysis of retinoid
bioavailability in selected cases. Topical retinoids are rapidly developing at
present and seem promising for the future; their clinical application includes
acne, aging, photodamage, precanceroses, skin cancer and disorders of skin
pigmentation. The development of receptor-specific retinoids for topical
treatment of psoriasis and/or acne may lead to interesting new compounds based on
our current concepts of retinoid function.

[Pathogenesis and therapy of rosacea. 2: Differential diagnosis, therapy and follow-up] [Article in German] Jansen T, Plewig G. Fortschr Med. 1997 Jan 20;115(1-2):50-3.

Oral isotretinoin treatment policy. Do we all agree? Ortonne JP. Dermatology. 1997;195 Suppl 1:34-7; discussion 38-40.

A consensus meeting was held in Brussels in 1995 to review current oral
isotretinoin (Roaccutane/Accutane) treatment policies among internationally
renowned experts and to improve service to needy patients by proposing treatment
guidelines based upon a review of 1,000 acne patients who received this therapy.
The group agreed that acne conditions warranting oral isotretinoin treatment
include severe acne and poorly responsive acne which improves less than 50% after
6 months of therapy with combined oral and topical antibiotics. Furthermore, acne
which relapses, scars or induces consequential psychological distress should be
treated with oral isotretinoin. Other indications are gram-negative folliculitis,
inflammatory rosacea such as rhinophyma, pyoderma faciale, acne fulminans and
hidradenitis suppurativa. Treatment was usually initiated at a daily dose of 0.5
mg/kg (but may be higher) and increased to 1.0 mg/kg. Aiming at a total does of
120-150 mg/kg per treatment course treatment lasted 4-7 months depending upon
daily doses. The same dosage guidelines were applied to repeated courses of oral
isotretinoin therapy with no evidence of increased risk. Mucocutaneous
side-effects were predictable; dose-dependent and systemic side-effects were
rarely problematic. Acne patients gain immeasurable physical and emotional relief
from isotretinoin treatment and society benefits from limiting bacterial
resistance evolution and reducing health care costs.

[Pathogenesis and therapy of rosacea. 1: Clinical picture—chief symptoms--pathogenesis] [Article in German] Jansen T, Plewig G. Fortschr Med. 1996 Dec 20;114(35-36):494-6.

Association of Melkersson-Rosenthal syndrome with rosacea. Bose SK. J Dermatol. 1996 Dec;23(12):902-4.

A rare case of Melkersson-Rosenthal syndrome with all the cardinal signs of the
triad, including facial swelling, facial nerve palsy and glossitis, is described.
The additional feature of this case was an association with rosacea.

Cutaneous applications of lasers. Ries WR, Speyer MT. Otolaryngol Clin North Am. 1996 Dec;29(6):915-29.

The cutaneous application of lasers today includes more selective and less
damaging devices. Carbon dioxide, neodymium:yttrium-aluminum-garnet, potassium
titanyl phosphate, argon, and yellow lasers are most prevalent in treating
cutaneous lesions. Specific techniques in skin resurfacing, keloid excision,
rhinophyma, actinic cheilitis ablation, and excision of superficial cutaneous
tumors are discussed. Proper management of cutaneous vascular lesions is also
presented.

[Detection of Helicobacter pylori in dermatoses. Clinical incidental finding or pathogenetic association?] [Article in German] Tebbe B, Geilen CC, Orfanos CE. Hautarzt. 1996 Aug;47(8):587-90.

Recently, several reports have been describing a possible relation between
Helicobacter pylori infection of the gastric mucosa and dermatological diseases.
Associations have been reported for urticaria, roascea, Sjögren’s syndrome and
Schönlein-Henoch purpura. In this paper we review the current knowledge on
Helicobacter pylori infection and its relevance for skin diseases, especially its
clinical and pathophysiological aspects.

[Pharma-clinics. How I treat... rosacea] [Article in French] Piérard-Franchimont C, Arrese JE, Piérard GE. Rev Med Liege. 1996 Jun;51(6):393-5.

Meibomian gland dysfunction. Driver PJ, Lemp MA. Surv Ophthalmol. 1996 Mar-Apr;40(5):343-67.

Blepharitis is probably the most common disease entity seen in the general
ophthalmologist’s office. A significant proportion of these cases are secondary
to meibomian gland disease. This review outlines our knowledge of the
histopathology, lipid abnormalities and role of microorganisms in meibomian gland
dysfunction. We will also review the physiology of meibomian gland secretion and
present models of meibomian gland dysfunction which have enhanced our knowledge
of this condition. The importance of diagnosing associated conditions such as
aqueous tear deficiency, contact lens intolerance, rosacea, and seborrheic
dermatitis is emphasized. Although this condition causes significant morbidity in
the population, there are effective treatments available and these will be
discussed.

Rosacea-like demodicosis in an HIV-positive child. Barrio J, Lecona M, Hernanz JM, Sánchez M, Gurbindo MD, Lázaro P, Barrio JL. Dermatology. 1996;192(2):143-5.

A second case of rosacea-like demodicosis in an HIV-positive child was seen at
our center. No such cases have previously been published. The present case is a
2-year-old boy, the son of an HIV-positive mother, who responded well to oral
erythromycin and topical metronidazole. The frequency of rosacea-like eruptions
in HIV-negative children is very low. However, the incidence of these eruptions
in HIV-positive children may have been underestimated. The pathogenic role of
Demodex mites is discussed as well as the possible mechanisms for an exaggerated
reaction.

Dermatologic diagnosis and treatment of itchy red eyelids. Zug KA, Palay DA, Rock B. Surv Ophthalmol. 1996 Jan-Feb;40(4):293-306.

Distinguishing the cause of itching, red eyelids is often difficult. Pruritic,
inflamed eyelids can reflect various etiologies and are a common clinical
presentation to the office of a dermatologist or ophthalmologist. In this
article, five of the more common causes of eyelid dermatitis (atopic dermatitis,
contact dermatitis, contact urticaria, rosacea, seborrhea, and psoriasis) are
reviewed in detail, with particular emphasis on the ocular and periocular
features. Clinical clues, historical features, and patch testing in cases of
eczematous eyelid dermatitis aid in differential diagnosis. In addition,
pathogenesis and treatment are reviewed.

Efficacy and safety of topical azelaic acid (20 percent cream): an overview of results from European clinical trials and experimental reports. Graupe K, Cunliffe WJ, Gollnick HP, Zaumseil RP. Cutis. 1996 Jan;57(1 Suppl):20-35.

Azelaic acid cream (20 percent) is a new topical treatment for acne with an
additional therapeutic potential in rosacea and hyperpigmentation disorders.
Azelaic acid (AzA; HOOC-(CH2)7-COOH) is a naturally occurring compound that
interferes with acne pathogenesis by virtue of its antikeratinizing,
antibacterial, and anti-inflammatory properties. Vehicle-controlled studies have
verified that AzA exercises a significant and clinically relevant effect on both
non-inflammatory and inflammatory acne lesions. Comparisons with clinically
proven therapies have shown that 20 percent AzA cream is an effective monotherapy
in mild to moderate forms of acne, with an overall efficacy comparable to that of
tretinoin (0.05 percent), benzoyl peroxide (5 percent), and topical erythromycin
(2 percent). In the treatment of moderate to severe acne, 20 percent AzA cream
may be favorably combined with minocycline (90 percent good and excellent
results), and may contribute towards reducing recurrences following
discontinuation of systemic therapy (maintenance therapy with AzA cream).
Particular advantages of AzA therapy include its favorable safety and side effect
profile. It is non-teratogenic, is not associated with systemic adverse events or
photodynamic reactions, exhibits excellent local tolerability, and does not
induce resistance in Propionibacterium acnes.

[The oral treatment of rosacea with isotretinoin] [Article in German] Jansen T, Plewig G. Dtsch Med Wochenschr. 1995 Dec 15;120(50):1745-7.

[Draining sinus in acne and rosacea. A clinical, histopathologic and experimental study] [Article in German] Jansen T, Lindner A, Plewig G. Hautarzt. 1995 Jun;46(6):417-20.

The draining sinus is an unpleasant complication of acne conglobata, acne
fulminans, acne inversa, rosacea conglobata and rosacea fulminans (pyoderma
faciale). It is most common on the face, especially in the nasolabial folds, and
on the neck below the mandibular line. Clinically, it is an elongated (2-5 cm
long), elevated, periodically inflamed lesion, which sporadically discharges pus.
The lesion persists with no tendency to spontaneous regression.
Histopathologically, it consists of elaborate, epithelialized galleries connected
to the skin surface at multiple points. It contains corneocytes, hairs, bacteria,
serum, inflammatory cells and epitheloid granulomas. A surgical thread placed
into the skin provides a model in which the generation of sinus tracts can be
studied. Therapy is difficult. Intralesional corticosteroid injection,
cryosurgery and isotretinoin are not always very effective. Sometimes complete
excision of the lesion is necessary. The draining sinus is a special form of scar
analogous to the pilonidal cyst.

Acne rosacea and Helicobacter pylori betrothed. Parish LC, Witkowski JA. Int J Dermatol. 1995 Apr;34(4):236-7.

Cosmetic use of lasers. Wheeland RG. Dermatol Clin. 1995 Apr;13(2):447-59.

During the 35 years of their existence, lasers have assumed an ever-expanding
role in cosmetic surgery due to their reproducible precision in effectively
managing a number of cutaneous conditions and disorders for which no acceptable
form of treatment has been developed. Current medical lasers can be used to fade
or remove many vascular and pigmented birthmarks, decorative and traumatic
tattoos, solar and rosacea telangiectasia, and many acquired pigmentary
disorders, without a visible scar or change in texture. In order to provide their
patients with the best possible aesthetic result, cosmetic surgeons should be
familiar with the advantages, disadvantages, and potential complications of
lasers.

May Helicobacter pylori be important for dermatologists? Rebora A, Drago F, Parodi A. Dermatology. 1995;191(1):6-8.

Helicobacter pylori, a microaerophilic gram-negative bacterium, is the major
cause of gastritis, plays a key role in the etiology of peptic ulcer and is a
risk factor for gastric cancer. Although 50% of the population is affected,
dermatologist seem to be unaware of the impact H. pylori may have on cutaneous
pathology. Among skin diseases, H. pylori has been related so far only with
chronic urticaria and rosacea. In rosacea, histology of the stomach mucosa
revealed tht 84% of 31 patients were H. pylori positive. Twenty percent of them
were serologically negative, but, overall, 100% of the 20 patients with both
histology and serology were H. pylori positive with either test. The consistency
between clinical success with metronidazole and abatement of H. pylori isolates
and serology after treatment was an additional evidence suggesting an etiologic
relationship between rosacea and H. pylori infection. Rosacea has often been
linked with gastrointestinal disturbances. H. pylori, therefore, may link them to
the well-known beneficial activity of metronidazole on rosacea lesions. The role
of H. pylori is more probable in erythrotic rosacea than in its papulopustular
and granulomatous stages. As in Bacillus subtilis intoxication, a flush-inducing
toxin cannot be excluded. Despite the difficulty to find patients accepting
bioptic gastroscopies, large case-control studies should be done before a causal
relationship with urticaria and rosacea is firmly established.

Perioral dermatitis. Hogan DJ. Curr Probl Dermatol. 1995;22:98-104.

Acne rosacea. Thiboutot DM. Am Fam Physician. 1994 Dec;50(8):1691-7, 1701-2.

Rosacea is a multifactorial skin disorder that usually affects middle-aged
persons. Little is known about the etiology of rosacea, although the disease most
likely represents a vascular anomaly occurring in patients with fair skin. The
mainstay of treatment for inflammatory lesions has been oral antibiotics, but
topical metronidazole also may be effective. Because recurrences are common after
discontinuation of therapy, doses should be tapered as tolerated. Antibiotics are
more effective for inflammatory lesions than for erythema and telangiectasia.
Isotretinoin may be effective for inflammatory lesions, edema and rhinophyma in
some resistant cases, but its use is limited by its side effects and
teratogenicity. Ablation of telangiectasia with the tunable dye laser and various
surgical approaches to rhinophyma are effective newer treatments but are more
expensive and less available than conventional therapy.

Rosacea. Pathophysiology and treatment. Wilkin JK. Arch Dermatol. 1994 Mar;130(3):359-62.

Diagnosis and treatment of rosacea fulminans. Jansen T, Plewig G, Kligman AM. Dermatology. 1994;188(4):251-4.

Rosacea fulminans is a rare disease of unknown cause which occurs exclusively in
women well past adolescence. It was previously called pyoderma faciale because of
its confinement to the face covering most of the surface with innumerable
fluctuant inflammatory nodules and papules which frequently fuse and form
monstrosities. Seborrhea prior to onset is typical. It is not a pyoderma; neither
it is infectious or a variant of acne conglobata. The patients respond well to a
therapeutic regimen including isotretinoin in combination with topical and
systemic corticosteroids. The response is superior and much more rapid than in
patients treated with oral antibiotics. Rosacea fulminans is the only indication
for topical or systemic corticosteroids in the treatment of rosacea. Scarring is
often minimal when the lesions clear. No recurrence is seen.

Rhinophyma in Japan. Furukawa M, Kanetou K, Hamada T. Int J Dermatol. 1994 Jan;33(1):35-7.

BACKGROUND. Rhinophyma is an end stage of acne rosacea. It results in a large
nose due to a proliferation of sebaceous glands and fibrous tissue. Many cases of
rhinophyma have been reported in the Western world; however, in Japan, rhinophyma
has been an uncommon disease. METHODS. We present two patients associated with
rhinophyma who were treated by cross-shaped full-thickness excision followed by
direct closure and compare the rhinophyma in Japan with that in the West.
RESULTS. To date, only 20 rhinophyma cases including our 2 cases have been
reported in Japan. Epidemiologic factors of rhinophyma between the West and Japan
do not differ except for location, malignancy and surgical treatment.
CONCLUSIONS. In Japan, almost all cases are located on the lower half of the
nose, treated by full-thickness excision followed by application of either skin
grafts or direct closure. None have been malignant.

Cutaneous disease and alcohol misuse. Higgins EM, du Vivier AW. Br Med Bull. 1994 Jan;50(1):85-98.

Certain skin disorders have now been demonstrated to be affected by alcohol
misuse, in particular psoriasis and discoid eczema. The pattern of involvement in
psoriasis differs from psoriasis vulgaris in character and distribution, and
tends to be more difficult to treat. Discoid eczema appears to be specifically
related to alcohol excess and is associated with deranged liver function tests.
Rosacea, post-adolescent acne, superficial infections and porphyria cutanea tarda
may also be markers of alcohol misuse. These disorders occur early and are quite
distinct from the traditional cutaneous stigmata of established liver disease.
The association between alcohol and skin disease is under-reported, as alcohol
misuse may go undetected in a general clinic unless specifically sought. Alcohol
has a profound influence on immune function and induces changes in the cutaneous
vasculature. The relevance of these effects to the pathophysiology of
alcohol-related skin disease is discussed.

Steroid-induced rosacea. Litt JZ. Am Fam Physician. 1993 Jul;48(1):67-71.

The excessive, regular use of topical fluorinated corticosteroids on the face
often produces an array of skin complications, including an eruption clinically
indistinguishable from rosacea (“iatrosacea”). Treatment involves discontinuation
of the steroid and administration of oral tetracycline and nonsteroidal topical
preparations. Once therapy is begun, clearing of the lesions may take several
months.

Common dermatoses in the elderly. Beacham BE. Am Fam Physician. 1993 May 1;47(6):1445-50.

Common dermatoses in the elderly include xerosis, pruritus, contact dermatitis,
acne rosacea, stasis dermatitis, bullous pemphigoid and herpes zoster. Physicians
must be able to recognize these pathologic changes superimposed on the intrinsic
and extrinsic effects of aging. Diagnosis is dependent on clinical appearance and
supportive laboratory studies. Management is based on correct diagnosis.

The red face: rosacea. Rebora A. Clin Dermatol. 1993 Apr-Jun;11(2):225-34.

Acne rosacea with keratitis in childhood. Erzurum SA, Feder RS, Greenwald MJ. Arch Ophthalmol. 1993 Feb;111(2):228-30.

We present three cases of acne rosacea keratitis that developed in childhood. All
three children were prepubescent and demonstrated characteristic dermatologic
findings involving the nose, cheeks, and/or chin. The patients had complained of
ocular irritation for at least 6 months, and in one case symptoms were reported
by the family to have occurred intermittently since age 4 years. All three
children showed evidence of meibomian gland inflammation; two patients
demonstrated bilateral keratitis, the third had only unilateral involvement. In
each case, oral tetracycline hydrochloride or doxycycline hyclate was necessary
to relieve symptoms. Rosacea keratitis should be considered in the differential
diagnosis of chronic keratoconjunctivitis during childhood.

Pyoderma faciale. A review and report of 20 additional cases: is it rosacea? Plewig G, Jansen T, Kligman AM. Arch Dermatol. 1992 Dec;128(12):1611-7.

BACKGROUND AND DESIGN–Pyoderma faciale was originally described by O’Leary and
Kierland in 1940. It is characterized by the sudden onset of monstrous coalescent
nodules and confluent draining sinuses confined to the face of young women in
their early 20s. This report summarizes our results in 20 cases. The women were
15 to 46 years old (mean, 25 years). RESULTS–All women were flushers and
blushers. Histopathologic examination revealed a dense perivascular and
periadnexial infiltrate, including granulocytes, eosinophils with epithelioid
granulomas, and septal and lobular panniculitis. No consistent laboratory
abnormalities were found. After much therapeutic experimentation, we developed an
effective treatment plan, based on a combination of oral isotretinoin and
corticosteroids. CONCLUSION–We regard it as an extreme form of rosacea and
suggest it be renamed rosacea fulminans in analogy with its counterpart, acne
fulminans.

Inflammatory and papulosquamous disorders of the skin and eye. Donshik PC, Hoss DM, Ehlers WH. Dermatol Clin. 1992 Jul;10(3):533-47.

We have discussed herein the dermatologic and ocular manifestations of several
inflammatory diseases. Cooperation between ophthalmologists and dermatologists
can significantly enhance patient care and comfort. It is hoped that this review
will stimulate increased awareness of the prevalence of ocular findings in these
diseases and encourage cooperation between these specialties for the benefit of
our patients.

[Skin diseases with photosensitivity] [Article in French] Amblard P, Leccia MT. Rev Prat. 1992 Jun 1;42(11):1365-8.

Skin diseases associated with photosensitivity are numerous and may be divided
into three main groups: photo-aggravated dermatoses, genophotodermatoses and
metabolic photodermatoses. Photo-aggravated dermatoses are autonomous skin
diseases in which exposure to sunlight may make the disease worse or precipitate
its onset and/or its progressiveness; this group includes lupus erythematosus,
autoimmune bullous diseases, acantolytic dyskeratoses, acne vulgaris, rosacea and
cutaneous lymphoid infiltrates. To these must be added photosensitive forms of
autonomous dermatoses such as atopic dermatitis, psoriasis, herpes labialis,
erythema multiforme, granuloma and disseminated superficial actinic
porokeratosis. Genophotodermatoses are genodermatoses which are made
photosensitive by a recognized or as yet unidentified deficiency of the natural
photoprotection system. In this group are albinism, vitiligo, xeroderma
pigmentosum and poikiloderma. Metabolic photodermatoses are diseases in which
photosensitization reactions, often revealing, are due to the accumulation in the
skin of an endogenous chromophore as a result of a congenital (porphyria) or
acquired (pellagra) enzymatic disorder.

Follicle mites and their role in disease. Burns DA. Clin Exp Dermatol. 1992 May;17(3):152-5.

[Dermatitis in VDT operators: a review of the literature] [Article in Italian] Pierini F, Piccoli B, Moroni P. Med Lav. 1991 Sep-Oct;82(5):451-7.

The paper reports studies on the relationship between work with VDT’s and
dermatitis in the operators. From the first observation in 1979, numerous studies
have been carried out to try and explain the reason why some forms of dermatitis
like rosacea, eczema seborrhoeic and erythematitis appeared more frequently in
VDT operators compared to the general population. The various authors at present
consider low indoor air humidity associated with a strong electrostatic field to
be essential factors in the occurrence of dermatitis. Laboratory experiments have
shown that the presence of a strong electrostatic field does not seem to be
important in itself. Similarly, it is agreed that X, UV-A or UV-B radiations do
not play any causative role in dermatitis. Further investigations are required to
assess the influence of indoor climatic factors and the presence of irritant
substances in the air of the working environment.

Rosacea-like lesions due to familial Mycobacterium avium-intracellulare infection. Nedorost ST, Elewski B, Tomford JW, Camisa C. Int J Dermatol. 1991 Jul;30(7):491-7.

Mycobacterium avium-intracellulare (MAI) is a non-tuberculous, nonlepromatous or
“atypical” mycobacterium now seen frequently in patients with acquired
immunodeficiency syndrome (AIDS). In the past decade, the incidence appears to
have increased in non-AIDS patients. Although cutaneous involvement is rare, two
brothers without detectable immune defects who both presented with cutaneous MAI
infection are described; the older brother also has disseminated disease. The
cutaneous presentation of MAI, as well as immune and genetic defects that may
predispose to mycobacterial infection, are discussed.

[Rhinophyma] [Article in French] Moulin G, Guillaud V. Ann Dermatol Venereol. 1991;118(4):319-22.

[Rhinophyma. The value of progressive dermabrasion] [Article in French] Labbé D, Kaluzinski E, Ferrand JY, Dompmartin A, Compère JF. Rev Stomatol Chir Maxillofac. 1991;92(6):402-5.

After briefly summing up the nosology of rhinophyma, the authors report their
experience with the surgical correction of this nasal disease, on the basis of
eight cases. They explain their reasons for giving up dermasection and preferring
dermabrasion.

Meibomian gland disease. Classification and grading of lid changes. Bron AJ, Benjamin L, Snibson GR. Eye. 1991;5 ( Pt 4):395-411.

In recent years attention has been paid to meibomian gland dysfunction (MGD) as a
distinct clinical entity responsible for chronic symptoms and signs and occurring
independently or in association with atopy, cicatrising mucosal disorders and
rosacea. Attempts to correlate MGD with microbiological and lipid biochemical
changes are confounded by the absence of a clear descriptive language for the
disorder and its associated changes. Such a language is crucial for the conduct
of cross-sectional and natural history studies and therapeutic clinical trials.
We present a comprehensive classification and grading scheme of meibomian gland
disease, supporting our observations with illustrations.

Treatment of massive rhinophyma with the carbon dioxide laser. Haas A, Wheeland RG. J Dermatol Surg Oncol. 1990 Jul;16(7):645-9.

A case of massive rhinophyma that produced significant functional and cosmetic
difficulties was treated using the carbon dioxide laser. Minimal bleeding
occurred during the operative procedure despite the grotesque enlargement and
high degree of vascularity of the skin and soft tissue. Using this technique,
restoration of normal function and excellent cosmesis was possible without
complication.

Topical metronidazole: a new therapy for rosacea. Schmadel LK, McEvoy GK. Clin Pharm. 1990 Feb;9(2):94-101.

The chemistry, mechanism of action, pharmacokinetics, and adverse effects of
topically applied metronidazole are reviewed, and the drug’s use and efficacy in
the treatment of rosacea and other conditions are discussed. Metronidazole is a
synthetic, nitroimidazole-derivative antibacterial and antiprotozoal agent. For
topical use, metronidazole is available in the United States as an aqueous gel.
Polar reduction products of the drug appear to be responsible for its
antimicrobial effects, which include disruption of DNA. The mechanism by which
metronidazole ameliorates the lesions and erythema of rosacea may be related to
anti-inflammatory or immunosuppressive actions of the drug rather than to
suppression of skin bacteria. Metronidazole does not seem to be appreciably
absorbed after topical application to the skin. Little is known about the
distribution and elimination of topically applied metronidazole. Topical
metronidazole has been designated an orphan drug by the FDA for the treatment of
rosacea. In clinical studies metronidazole 0.75% topical gel or 1% cream resulted
in improvement in inflammatory lesions in 68-96% of patients. Like other
currently available therapies, metronidazole is only palliative; when the drug is
withdrawn, symptoms commonly recur. Topical metronidazole has been used with some
success in the treatment of decubitus and other ulcers and in certain dental
conditions. The drug seems to have low toxicity and generally is well tolerated
when applied topically. The principal adverse effects are local reactions, such
as burning and stinging. Topical metronidazole provides another option for the
treatment of rosacea.

Bifonazole. A review of its antimicrobial activity and therapeutic use in superficial mycoses. Lackner TE, Clissold SP. Drugs. 1989 Aug;38(2):204-25.

Bifonazole is a substituted imidazole antifungal agent structurally related to
other drugs in this group. It possesses a broad spectrum of activity in vitro
against dermatophytes, moulds, yeasts, dimorphic fungi and some Gram-positive
bacteria. Both non-comparative and comparative clinical trials have clearly
demonstrated the efficacy and safety of various formulations of bifonazole 1%
(cream, gel, solution and powder) applied once daily in the treatment of
superficial fungal infections of the skin such as dermatophytoses, cutaneous
candidiasis and pityriasis versicolor. In comparative studies bifonazole was
significantly superior to placebo and at least as effective as alternative
imidazole antifungal drugs including clotrimazole, econazole, miconazole,
oxiconazole and sulconazole. Preliminary studies in other superficial skin and
nail infections/dermatoses suggest that bifonazole may be useful for treating
onychomycoses (in a combination cream; bifonazole 1% plus urea 40%), otomycoses,
erythrasma, sebopsoriasis, seborrhoeic dermatitis and rosacea. However,
controlled trials are needed in each of these clinical settings to assess
accurately its relative place in therapy. Thus, bifonazole is an effective and
well-tolerated treatment for superficial fungal infections of the skin. Compared
with the majority of topical antifungal drugs, which need to be applied at least
twice daily, bifonazole offers the convenience of once daily administration,
which may improve patient compliance.

Common inflammatory skin diseases of the elderly. Fitzpatrick JE. Geriatrics. 1989 Jul;44(7):40-6.

Elderly patients are more likely than the general population to have significant
cutaneous diseases due to structural changes, alteration of immunologic response,
and different environmental influences. This review focuses on the pathogenesis,
diagnosis, and management of the most common inflammatory dermatoses likely to be
encountered in the geriatric population.

Topical antibiotics in dermatology. Hirschmann JV. Arch Dermatol. 1988 Nov;124(11):1691-700.

Topical antibiotics are safe and effective in certain conditions, primarily acne,
rosacea, and nasal carriage of Staphylococcus aureus. They are useful in impetigo
only when it is of limited extent. Their efficacy in other pyodermas is unclear,
although mupirocin is probably effective in many cases. In “infected eczema” that
does not require systemic therapy they seem to add little to what topical
corticosteroids alone achieve. They are ineffective in reducing the incidence of
significant infection with indwelling intravenous catheters. They are safe
preparations, but extensive use, especially in closed populations, may encourage
the emergence of resistant bacteria.

ABC of eyes. General medical disorders and the eye. Elkington AR, Khaw PT. BMJ. 1988 Aug 6;297(6645):412-6.

Basal cell carcinoma mimicking rhinophyma. Case report and literature review. Keefe M, Wakeel RA, McBride DI. Arch Dermatol. 1988 Jul;124(7):1077-9.

An 82-year-old man presented with rapid enlargement of a long-standing
rhinophyma. Following an uncomplicated excision of rhinophyma, histologic
examination showed that the enlargement was entirely due to basal cell carcinoma.
Radiotherapy was administered, and the nose has now healed satisfactorily. There
are few reports of an association between rhinophyma and basal cell carcinoma;
but it is claimed that it occurs more frequently than is expected by chance. The
evidence for this is reviewed. Previous reports were anecdotal or contained
biases that prevent generalization of the results and, in addition, a statistical
analysis was incorrect. There is insufficient evidence to claim an association
between basal cell carcinoma and rhinophyma.

[Rosacea: recent findings on the subject of its etiopathogenesis and therapy] [Article in Italian] Rotoli M, La Parola IL, Ferruzzi F, Zamparelli F, Rusciani L. Recenti Prog Med. 1988 Jun;79(6):271-6.

Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. A review. Goa KL. Drugs. 1988;36 Suppl 5:51-61.

The development of topical corticosteroids since the 1950s has opened new doors
for dermatologists previously faced with treating intractable dermatoses, so that
the pharmacology of topically applied corticosteroids is now reasonably well
described. Manipulation of the steroid molecule has produced compounds with
greater lipophilicity, fewer mineralocorticoid properties and high potency.
Potency is determined through various techniques, notably the vasoconstrictor
assay as well as the mitotic index suppression method and atrophogenic potential
assay. The mechanism of activity of corticosteroids is thought to result, at
least in part, from binding of the drug to steroid receptors, with resultant
effects on the synthesis of proteins responsible for specific effects.
Corticosteroids are proposed to alter the inflammatory response, and thus provide
therapeutic benefits, via actions on mediator release and function, inflammatory
cell function and release of lysosomal enzymes. Disadvantages of corticosteroid
activity include the possibility of adrenal suppression, epidermal and dermal
thinning, and local effects such as purpura, striae, and steroid-induced rosacea
and perioral dermatitis. The cutaneous pharmacokinetics, particularly of
absorption of topical corticosteroids, must be examined in parallel with their
pharmacodynamic effects to gain a more complete understanding of activity. Many
factors can affect percutaneous steroid absorption: drug lipophilicity and
solubility, drug concentration, anatomical site, age of the patient, presence of
skin disease and use of occlusive dressings will each influence the degree to
which topically applied corticosteroids achieve their intended therapeutic
results. Cutaneous metabolism is a poorly understood process at present, but one
which is acknowledged to have some impact on the biotransformation of
corticosteroids applied topically. Thus, although some gaps still persist in
present knowledge of the pharmacology and pharmacokinetics of this important
class of drugs, there can be no denying the contribution of topical
corticosteroids to the therapy of dermatoses.

Is the skin affected by work at visual display terminals? Wahlberg JE, Lidén C. Dermatol Clin. 1988 Jan;6(1):81-5.

According to some reports, mainly from Norway and Sweden, visual display terminal
work is suspected of causing skin rashes. In three different studies, we have
tried to elucidate the question, and the results indicate that there might be a
relation between VDT work and aggravation of some common skin diseases such as
rosacea, seborrheic and atopic dermatitis, and acne. Whether this depends on
physical, chemical, or psychological factors is still unknown.

Metronidazole treatment in rosacea. Nielsen PG. Int J Dermatol. 1988 Jan-Feb;27(1):1-5.

The retinoids. A review of their clinical pharmacology and therapeutic use. Orfanos CE, Ehlert R, Gollnick H. Drugs. 1987 Oct;34(4):459-503.

With the introduction of the synthetic retinoids, oral therapy with an acceptable
risk/benefit ratio became possible for a variety of skin diseases including
severe acne, psoriasis and numerous genodermatoses. This article reviews the
clinical pharmacology, mechanisms of action and therapeutic use of the retinoids,
particularly isotretinoin (13-cis-retinoic acid) and etretinate. The free
aromatic acid of etretinate, etretin, and the new polyaromatic retinoid compounds
(arotinoids) are also discussed. Isotretinoin is used clinically for oral therapy
of severe acne, but is also recommended for severe Gram-negative folliculitis and
rosacea not responding to traditional therapy. The results of several studies
have established that acne therapy should be started with 1.0 mg/kg/day for 2 to
3 months after which the daily dosage should be lowered to 0.2 to 0.5 mg/kg/day
for another 2 to 3 months. This therapeutic regimen of isotretinoin has proven to
be the most successful in preventing relapses. Etretinate is particularly useful
for oral therapy of widespread plaque-like, pustular and erythrodermic psoriasis,
and of generalised lichen planus, Darier’s disease and severe congenital
ichthyoses. Whereas pustular forms of psoriasis require a high daily dosage of
1.0 mg/kg/day, erythrodermic psoriasis should be treated with a lower dosage of
0.25 to 0.35 mg/kg/day. In chronic plaque-like psoriasis, a mean daily dosage of
0.5 mg/kg/day over several weeks to months, usually combined with
photo(chemo)therapy, tar or dithranol, is recommended. Other indications for oral
etretinate therapy are adequately treated with a moderate dosage of 0.4 to 0.75
mg/kg/day. Etretin differs from etretinate in having a much shorter elimination
half-life of 2 to 3 days, in contrast to 80 to 100 days after long term
administration of etretinate. Moreover, it has not been shown to increase serum
cholesterol levels. However, its clinical efficacy is not yet clearly
established. Among the arotinoids, arotinoid ethylester (Ro 13-6298) has revealed
the best anti-psoriatic and anti-inflammatory effects at extremely low dose
levels. Furthermore, no significant elevations of serum lipids have been
observed. Taking its prolonged elimination half-life and its efficacy/side effect
ratio into account, the drug is comparable to etretinate. The free arotinoid
carboxylic acid (Ro 13-7410) is currently undergoing clinical investigation.
Another arotinoid, the parent compound Ro 15-0778, has not demonstrated any
convincing clinical efficacy in acne or psoriasis, but topical anti-inflammatory
effects were evident in some models.(ABSTRACT TRUNCATED AT 400 WORDS)

Rosacea. Rebora A. J Invest Dermatol. 1987 Mar;88(3 Suppl):56s-60s.

Ocular rosacea. Browning DJ, Proia AD. Surv Ophthalmol. 1986 Nov-Dec;31(3):145-58.

The demographic, clinical, and histopathologic characteristics of ocular rosacea
are reviewed, with emphasis on examination of the skin in patients with external
ocular disease. Since no single clinical or pathological hallmark of rosacea
exists, a proposed point system for diagnosis is presented. Studies of
pathogenesis reveal that no single unifying hypothesis accounts for all the
expressions of ocular rosacea. Reports of treatment with tetracycline and other
antibiotics demonstrate efficacy, although the mechanisms of action of these
drugs are not known. More recently, other classes of drugs, including
isotretinoin and hexachlorocyclohexane, have proven to be effective in
dermatologic manifestations of rosacea, but effects on ocular manifestations are
unknown.

[Therapy of rhinophyma] [Article in German] Petres J. Hautarzt. 1985 Aug;36(8):433-5.

Treatment of rhinophyma is successful only with surgical methods. The operative
techniques described in the literature are discussed critically and decortication
is the method of choice. When this technique is applied, the hyperplastic nasal
tissue is removed down to the basal parts of the sebaceous glands. This causes
spontaneous re-epithelization of the skin surface without scarring. Methods using
deeper excision and plastic surgical repair of the defect by skin grafting or
pedicled flaps are cosmetically inferior to the method of decortication. Whatever
the method, however, histopathological examination of the excised rhinophyma
tissue is necessary in order to exclude malignant growths, such as basal cell or
squamous cell carcinomas, which are frequently seen in rhinophyma.

Dermatologic therapy: December 1983 through November 1984. Coskey RJ. J Am Acad Dermatol. 1985 Jun;12(6):1045-71.

Tetracyclines in ophthalmology. Salamon SM. Surv Ophthalmol. 1985 Jan-Feb;29(4):265-75.

Tetracycline and its congeners demonstrate antimicrobial activity against
bacteria, Chlamydiae and Toxoplasma gondii. Ophthalmologists can use these drugs
to treat bacterial and chlamydial infections, and also for ocular rosacea and
similar disorders. Side effects associated with systemic tetracycline use are
most commonly related to the gastrointestinal tract and to signs of yeast
superinfection. Minocycline use may be limited by its vestibular toxicity.
Temporary growth retardation and staining of erupting teeth may occur with oral
use of tetracycline in children under 8 years; these drugs should not be given in
pregnancy or to young children. Topical tetracycline application yields good tear
and aqueous humor concentrations.

Psychosomatic dermatology. Panconesi E. Clin Dermatol. 1984 Oct-Dec;2(4):94-179.

Acquired ichthyosis and related conditions. Aram H. Int J Dermatol. 1984 Sep;23(7):458-61.

Isotretinoin. A review of its pharmacological properties and therapeutic efficacy in acne and other skin disorders. Ward A, Brogden RN, Heel RC, Speight TM, Avery GS. Drugs. 1984 Jul;28(1):6-37.

Isotretinoin is a new orally active retinoic acid derivative for the treatment of
severe refractory nodulocystic acne. The pharmacological profile of isotretinoin
suggests that it acts primarily by reducing sebaceous gland size and sebum
production, and as a result alters skin surface lipid composition. Bacterial skin
microflora is reduced, probably as a result of altered sebaceous factors.
Isotretinoin 1 to 2 mg/kg/day for 3 to 4 months produces 60 to 95% clearance of
inflammatory lesions in patients with severe, recalcitrant nodulocystic acne,
with evidence of continued healing and prolonged remissions in many patients
after treatment withdrawal. Doses as low as 0.1 mg/kg/day have also proven
successful in the clearance of lesions; however, with such low doses the duration
of remission after discontinuation of therapy is usually shorter. Encouraging
results have also been seen in small numbers of patients with rosacea,
Gram-negative folliculitis, Darier’s disease, ichthyosis and pityriasis rubra
pilaris, the response in keratinising disorders resembling that with the related
drug etretinate. While long term follow-up studies in these patients have not
been reported, prolonged remission after withdrawal of isotretinoin in disorders
of keratinisation is unlikely, as with other drugs used in these conditions.
Isotretinoin is only partially effective in psoriasis, in contrast to etretinate
which is very effective in psoriasis but ineffective in severe acne. Some
encouraging results have also been reported with isotretinoin in patients with
squamous and basal cell carcinomas, but isotretinoin has proven unsuccessful in
non-squamous cell epithelial and non-epithelial cancer. Side effects affecting
the mucocutaneous system occur in nearly all patients receiving isotretinoin, but
rarely lead to drug withdrawal. Raised serum triglyceride levels are also
commonly reported. The possibility of long term spinal or skeletal bone toxicity
may restrict the use of isotretinoin in severe disorders of keratinisation
requiring prolonged administration. Isotretinoin is strictly contraindicated in
women of childbearing potential due to its severe teratogenic properties, unless
an effective form of contraception is used. Thus, isotretinoin offers an
effective advance on the treatment options available in a difficult therapeutic
area – those patients with severe, nodulocystic acne not responding to
‘traditional’ therapy.

The skin in alcoholism. Shellow WV. Int J Dermatol. 1983 Nov;22(9):506-10.

Dermatologic disorders. Engels WD. Psychosomatics. 1982 Dec;23(12):1209-11, 1214-9.

Topical corticosteroids. Robertson DB, Maibach HI. Int J Dermatol. 1982 Mar;21(2):59-67.

Flushing reactions: consequences and mechanisms. Wilkin JK. Ann Intern Med. 1981 Oct;95(4):468-76.

The mechanisms of flushing reactions are pharmacologically and physiologically
heterogeneous. Flushing may result from agents acting directly on the vascular
smooth muscle or may be mediated by vasomotor nerves. Vasomotor nerves may lead
to flushing as a result of events at both peripheral and central sites. In
susceptible persons, frequent, intense flushing leads to a cluster of physical
signs (rosacea). Flushing provoked by alcohol has been associated with ethnic
sensitivity, a possible predisposition to alcoholism, various disulfiramlike
agents, one type of diabetes mellitus, and the carcinoid syndrome and other types
of neoplasia. Flushing reactions also occur during the menopause, after glutamate
ingestion, and in response to oral thermal challenges.

Iatrogenic dermatitis. Caro I. Med Clin North Am. 1981 Sep;65(5):1083-8.

The hair follicle mites Demodex folliculorum and Demodex brevis: biology and medical importance. A review. Rufli T, Mumcuoglu Y. Dermatologica. 1981;162(1):1-11.

[Differential diagnosis of facial skin swellings (author's transl)] [Article in German] Hornstein OP. HNO. 1979 Apr;27(4):129-37.

Enlargement of the cheeks may be due to a multitude of disorders, congenital,
neoplastic, and in particular inflammatory. Congenital facial anomalies include
cutaneous (and osseous) hemihypertrophy of the face and unilateral angiomatous
malformations (e.g. Sturge-Weber-Krabbe Syndrome). Buccal enlargement due to
dermal tumours include localized haemangiomas and lymphangiomas, lipomas and
other benign connective tissue neoplasms, generalized disorders of the lymphatic
or reticuloendothelial system including mycosis fungoides, reticulum cell sarcoma
and other soft tissue malignancies, and cutaneous manifestations of malignant
haemoblastoses, in particular chronic lymphatic leukaemia. Within the very large
group of inflammatory skin swellings of the face a review is made of some
bacterial pyodermias, severe forms of acne vulgaris, herpes zoster, lupus
vulgaris, erysipelas, rosacea, steroid dermatitis, lupus erythematosus (discoid
and systemic), toxic dermatitis, allergic eczema, urticaria, Quincke’s oedema,
and the Melkersson-Rosenthal syndrome. The importance of prevention and early
detection of steroid-induced dermatitis is emphasized. This disorder, which is a
pseudo-inflammatory disfiguring complication of prolonged topical steroid abuse,
ranks in frequency with the skin problems most often seen in dermatological
practice.

[Positive side-effects of antibiotic and antimicrobial drugs in therapy (author's transl)] [Article in German] Illig L. Infection. 1979;7 Suppl 6:584-8.

Since about 1950 especially, dermatologists world-wide have been utilizing the
positive side-effects, discovered by chance, of all groups of antibiotic and
antimicrobial drugs. These drugs are used to treat certain non-microbially
induced dermatoses, without any knowledge of the mechanisms involved. A short
history is given and the most important drugs and the indications for their use
are described. The following drugs are undoubtedly effective and sometimes even
the therapy of choice: tetracyclines in acne vulgaris and rosacea (including
rosacea keratitis); penicillin G in acrodermatitis atrophicans and cold
urticaria; dapsone in dermatitis herpetiformis and – as a powerful adjuvant – in
acne vulgaris and rosacea. Before the discovery of the socalled immunodepressive
drugs, tetracycline was the only alternative to – or at least a highly effective
adjuvant of – cortisone in dermatomyositis and chloroquine in localised and
systemic lupus erythematosus. Finally, clioquinole was life-saving in
acrodermatitis continua in children until this condition was recently identified
as a zinc-deficiency syndrome. Therapeutical mechanisms have been found only in
the case of acne, rosacea and dermatitis herpetiformis. In most other diseases
the nature of the therapeutical effectiveness of antibiotic and antimicrobial
drugs still remains a mystery.

Steroid addiction. Kligman AM, Frosch PJ. Int J Dermatol. 1979 Jan-Feb;18(1):23-31.

Dermatology. Greaves MW. Practitioner. 1976 Oct;217(1300 SPEC NO):585-90.

Hydrocortisone 17-butyrate: a new topical corticosteroid preliminary report. Brogden RN, Pinder RM, Sawyer PR, Speight TM, Avery GS. Drugs. 1976;12(4):249-57.

Hydrocortisone 17-butyrate is a new non-fluorinated topical corticosteroid for
use in psoriasis, eczema and other inflammatory dermatoses. In double-blind
paired comparisons with other topical corticosteroids, the efficacy of
hydrocortisone 17-butyrate 0.1% has generally been indistinguishable from that of
triamcinolone acetonide 0.1%, fluocinolone acetonide 0.025% or betamethasone
17-valerate 0.1% in patients with eczema or psoriasis. When applied to the face
of patients with atrophy superimposed on rosacea and perioral dermatitis
resulting from prolonged use of fluorinated topical corticosteroids,
hydrocortisone 17-butyrate 0.1% did not prevent the beneficial effect of systemic
tetracycline nor the disappearance of telangiectasis, and tended to be more
effective than hydrocortisone 1%. This result suggests that hydrocortisone
17-butyrate may be suitable for long-term use on facial lesions, although the
occurrence of moderate rebound eruption in about 10% of patients indicates the
need for caution. The findings suggest that hydrocortisone 17-butyrate may be
less liable to cause skin atrophy and adrenal suppression than some other potent
topical corticosteroids, but trials to date have been too short to allow definite
conclusions regarding possible long-term effects and have not involved infants or
children.

Emotional factors in skin disease. Russell BF. Br J Psychiatry. 1975;Spec No 9:447-52.

Topical corticosteroids. Maibach HI, Stoughton RB. Med Clin North Am. 1973 Sep;57(5):1253-64.

Sunlight and the skin. Belisario JC. Int J Dermatol. 1972 Oct-Dec;11(4):200-10.

[Inflammatory skin changes in the face. Diagnostics and therapy] [Article in German] Steigleder GK. Dtsch Med Wochenschr. 1971 Oct 22;96(43):1688-94 passim.

Advances in the treatment of diseases of the skin. Beare JM. Practitioner. 1971 Oct;207(240):450-9.

[News from American dermatology. 2.] [Article in German] Hollander A. Hautarzt. 1971 Oct;22(10):423-9.

Notable advances in the treatment of skin diseases 1946-1970. Verbov J. Br J Clin Pract. 1971 Mar;25(3):105-17.

[Differential diagnosis of rosacea] [Article in German] Steigleder GK. Hautarzt. 1971 Mar;22(3):91-4.

The gut and the skin. Fry L. Postgrad Med J. 1970 Nov;46(541):664-70.

The scope and limitations of the immunofluorescence method in the diagnosis of lupus erythematosus. Jablonska S, Chorzelski T, Maciejowska E. Br J Dermatol. 1970 Aug;83(2):242-7.

[Treatment of skin diseases in seacoast climate. 1] [Article in German] Schultze EG. Ther Ggw. 1969 Aug;108(8):1125-6 passimc.

Diseases of sweat and sebaceous glands, hair and nails. [No authors listed] Q Med Rev. 1968 Jul;19(1):1-43.

[PROBLEMS AND EXPERIENCE IN THE SUBJECT OF HORMONAL ALLERGY IN ROSACEA.] [Article in Italian] PANCONESI E, GIANNOTTI B. Rass Dermatol Sifilogr. 1964 May-Jun;17:125-69.