Download PDF - The Dermatologist
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FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S FIGURE 1. DEMODEX DERMATITIS: AT BASELINE (LEFT) AND AFTER 2 WEEKS OF TREATMENT WITH PER- METHRIN TWICE DAILY (RIGHT). BASELINE AFTER 2 WEEKS U S U A L THERAPIES FOR ROSACEA van Zuuren et al 1 conducted a literature review of 71 randomized, controlled studies of rosacea therapy. Of the 71 studies, 29 met their inclusion criteria, but the quality in general of these studies was not considered very good. The conclusions were that topical metronidazole and azelaic acid a re effective therapies for rosacea. There was some evidence that oral metronidazole and tetracycline including doxycycline and minocycline are effective, but the take-away message was that there is a great need for randomized, cont rolled trials examining the efficacy of present medications for the treatment of ro s a c e a . Del Rosso et al 2 conducted two such randomized, Phase III clinical trials evaluating the anti-inflammatory doxycycline 40 mg a day administered once daily for the treatment of rosacea. They concluded that once-daily anti-inflammatory dose doxycycline appears to be effective and safe for the t reatment of ro s a c e a . U N U S U A L T R E ATMENTS FOR ROSACEA Skin care. The skin of the rosacea patient can be either oily or dry. Certainly, it can be extremely sensitive in some cases. There can be altered cutaneous vascular reactivity and, most importantly, skin barrier dysfunction, which is defined as increased transepidermal water loss, increased susceptibility to irritants, allergens and pathogens, and increased skin inflammation through cytokine-mediated lipogenesis. Skin barrier dysfunction exists in most inflammatory diseases, including atopic dermatitis, psoriasis, acne and aged, actinicly damaged skin. The stratum corneum is a “bricks” and “mortar” structure. Corneocytes are the bricks, and sitting between the corneocytes is the mortar, the lipid matrix, which has a certain constitution that needs to be re s t o red. Ceramides a re most important, constituting about 40% to 50% of the lipid matrix. In addition to the ceramides, the lipid matrix contains f ree sterols and free fatty acid. There are also lipid bilayers, which become a moisture barrier for the stratum corn e u m . S U P P L E M E N T T O S K I N & A G I N G • M A R C H 2 0 0 8 • 9
FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S FIGURE 2. STEROID USE/ABUSE/MISUSE DER- MATITIS: A 26-YEAR-OLD WOMAN WITH A 6-MONTH HISTORY OF AN ERYTHE- MATOUS, PAPULAR, SCALY, INTENSELY PRURITIC FACIAL ERUPTION. A d d i t i o n a l l y, inside the corneocytes is natural moisturizing fact o r. All of these can be disrupted in inflammatory diseases, so restoring them as part of skin care and treatment for ro s a c e a and other inflammatory diseases is most important. Products that can restore the skin barrier are available over the counter and soon by prescription. CeraVe is available over the counter as a cleanser and a moisturizer. Another over-thecounter product is Triceram from Osmotics, and Elizabeth Arden also has a line of products available over the counter. Patients being treated for inflammatory skin disease, especially rosacea, should be encouraged to purchase one of these products as a cleanser and a moisturizer. THERE IS AN INCREASED INCIDENCE OF ROSACEA PATIENTS WITH MIGRAINE HEADACHES. BOTH ROSACEA AND MIGRAINES ARE VASCULAR DILATATION PHENOMENA. FIGURE 3. PLAQUE ROSACEA: A 48-YEAR-OLD MAN WITH A 2-YEAR HISTORY OF AN EDEMATOUS, ERYTHEMATOUS PAPULE AND PUSTULE STUDDED LESION OF THE LEFT CHEEK. I s o t re t i n o i n . I s o t retinoin is effective in the treatment of the facial edema that can be associated with acne, and it also is an e ffective treatment for rosacea. Isotretinoin 30 mg twice daily for the treatment of rosacea is an off-label indication, but it is something to consider. A s p i r i n . While papules and pustules are not much of a challenge, erythema can be. There is an increased incidence of rosacea patients with migraine headaches. Both rosacea and migraines are vascular dilatation phenomena. The re p e a t e d flushing associated with rosacea leaves one with persistent erythema. Neurologists recommend aspirin 81 mg long acting as p rophylaxis against migraine headaches. It also works for rosacea flushing and blushing. If patients are asked to keep track of their flushing and blushing episodes with a calendar diary for 30 days after starting on 81 mg of aspirin daily it becomes evident that the episodes of flushing decrease in s e v e r i t y, intensity and rates of occurrence. Wa t e r-based emulsion or nonsteroidal cre a m . O t h e r options for treating the erythema of rosacea are water- b a s e d emulsions or nonsteroidal creams. In a patient who has persistent erythema in whom D e m o d e x dermatitis has been ruled out, use of Mimyx or Atopiclair may be effective (F i g u re 4). A D VANCES IN BASIC RESEARCH Yamasaki and colleagues 3 at the University of C a l i f o rnia, San Diego, have been studying cathelicidin 1 0 • M A R C H 2 0 0 8 • S U P P L E M E N T T O S K I N & A G I N G
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FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S<br />
FIGURE 2. STEROID USE/ABUSE/MISUSE DER-<br />
MATITIS: A 26-YEAR-OLD WOMAN WITH<br />
A 6-MONTH HISTORY OF AN ERYTHE-<br />
MATOUS, PAPULAR, SCALY, INTENSELY<br />
PRURITIC FACIAL ERUPTION.<br />
A d d i t i o n a l l y, inside the corneocytes is natural moisturizing fact<br />
o r. All of these can be disrupted in inflammatory diseases, so<br />
restoring them as part of skin care and treatment for ro s a c e a<br />
and other inflammatory diseases is most important.<br />
Products that can restore the skin barrier are available over<br />
the counter and soon by prescription. CeraVe is available over<br />
the counter as a cleanser and a moisturizer. Another over-thecounter<br />
product is Triceram from Osmotics, and Elizabeth<br />
Arden also has a line of products available over the counter.<br />
Patients being treated for inflammatory skin disease, especially<br />
rosacea, should be encouraged to purchase one of<br />
these products as a cleanser and a moisturizer.<br />
THERE IS AN INCREASED INCIDENCE<br />
OF ROSACEA PATIENTS WITH<br />
MIGRAINE HEADACHES. BOTH<br />
ROSACEA AND MIGRAINES ARE<br />
VASCULAR DILATATION PHENOMENA.<br />
FIGURE 3. PLAQUE ROSACEA: A 48-YEAR-OLD<br />
MAN WITH A 2-YEAR HISTORY OF AN<br />
EDEMATOUS, ERYTHEMATOUS PAPULE<br />
AND PUSTULE STUDDED LESION OF<br />
THE LEFT CHEEK.<br />
I s o t re t i n o i n . I s o t retinoin is effective in the treatment of the<br />
facial edema that can be associated with acne, and it also is an<br />
e ffective treatment for rosacea. Isotretinoin 30 mg twice daily<br />
for the treatment of rosacea is an off-label indication, but it is<br />
something to consider.<br />
A s p i r i n . While papules and pustules are not much of a challenge,<br />
erythema can be. <strong>The</strong>re is an increased incidence of<br />
rosacea patients with migraine headaches. Both rosacea and<br />
migraines are vascular dilatation phenomena. <strong>The</strong> re p e a t e d<br />
flushing associated with rosacea leaves one with persistent erythema.<br />
Neurologists recommend aspirin 81 mg long acting as<br />
p rophylaxis against migraine headaches. It also works for<br />
rosacea flushing and blushing. If patients are asked to keep<br />
track of their flushing and blushing episodes with a calendar<br />
diary for 30 days after starting on 81 mg of aspirin daily it<br />
becomes evident that the episodes of flushing decrease in<br />
s e v e r i t y, intensity and rates of occurrence.<br />
Wa t e r-based emulsion or nonsteroidal cre a m . O t h e r<br />
options for treating the erythema of rosacea are water- b a s e d<br />
emulsions or nonsteroidal creams. In a patient who has persistent<br />
erythema in whom D e m o d e x dermatitis has been ruled<br />
out, use of Mimyx or Atopiclair may be effective (F i g u re 4).<br />
A D VANCES IN BASIC RESEARCH<br />
Yamasaki and colleagues 3 at the University of<br />
C a l i f o rnia, San Diego, have been studying cathelicidin<br />
1 0 • M A R C H 2 0 0 8 • S U P P L E M E N T T O S K I N & A G I N G
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