Hipertermia local para el tratamiento del molusco contagioso.

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News · July 25, 2016

Local Hyperthermia Can Clear Molluscum Contagiosum Lesions

More than half of 21 patients in pilot study had lesions cleared within 12 weeks

FRIDAY, July 22, 2016 (HealthDay News) -- For patients with molluscum contagiosum (MC) lesions, local hyperthermia with a targeted device is successful for lesion clearance, according to a research letter published online July 5 in the British Journal of Dermatology.

Y-Li Gao, from the No. 1 Hospital of China Medical University in Shenyang, and colleagues conducted a prospective trial involving 21 patients who were clinically diagnosed with MC. A hyperthermia device was targeted to the biggest lesion or the one in the region where it was convenient for the heating probe to the placed. After resolution of the first targeted lesion, the device was shifted to a new target. Treatment lasted 30 minutes, and lesions received local hyperthermia at a skin surface temperature of 44 degrees Celsius once a week. Treatment was stopped when there were no lesions left.

The researchers found that two, seven, and three patients had their lesions cleared within four weeks, four to eight weeks, and eight to 12 weeks, respectively. By 12 weeks, 57.14 percent of patients (12 patients) were cured. No obvious correlation was seen between lesions clearance and size or number of lesions. No significant difference of cure rate was seen between childhood and young sexually active patients. Seven of the 12 cured patients had all lesions almost simultaneously cleared by local hyperthermia for one targeted site.

"Based on this preliminary outcome, reasonably designed controlled clinical trials that follow will most probably consolidate the efficacy of local hyperthermia to treat MC," the authors write.

Clinical Evaluation of Local Hyperthermia at 44°C for Mollusca Contagiosa: Pilot study with 21 patients

1. Y-Li Gao^1,*, 
2. X-Hua Gao¹, 
3. R-Qun Qi¹, 
4. J-Lu Xu², 
5. W. Huo¹, 
6. J. Tang¹, 
7. Y. Ren¹, 
8. S. Zheng¹, 
9. Y-Xiao Hong¹, 
10. B. Song^1,3 and
11. H-Duo Chen¹

DOI: 10.1111/bjd.14849

British Journal of Dermatology

Accepted Article (Accepted, unedited articles published online and citable. The final edited and typeset version of record will appear in future.)

Revisiones de piel entre parejas mejora la detección del cancer de piel!

Enseñar a las parejas a revisarse la piel y hacerlo con refuerzos incrementa la detección temprana delCancer de piel.
Skin Self-Exams with Partner Aids Early Detection

JAMA Dermatol; ePub 2016 Jun 29; Robinson et al.

07-13-2016

07-13-2016

Patients with melanoma and their partners reliably performed skin self-examination (SSE) after participating in a structured skills training program lasting approximately 30 minutes, with reinforcement every 4 months by a dermatologist, a recent study found. Researchers conducted a randomized clinical trial with 24-month follow-up assessments. The study cohort comprised of 494 participants, 51% (253 of 494) female, with a mean age of 55 (10) years. They found:

• Patients in the intervention arms had significantly increased SSEs with their partners at 4, 12, and 24 months, compared with the control group (mean differences, 1.57, 0.72, and 0.94, respectively.

• Patients in the intervention arms identified new melanomas more than those in the control group and did not increase physician visits.

• Accurate SSE by those at risk to develop melanoma may enhance early detection and relieve some of the burden on health services.

Citation: Robinson JK, Wayne JD, Martini MC, Hultgren BA, et al. Early detection of new melanomas by patients with melanoma and their partners using a structured skin self-examination skills training intervention. [Published online ahead of print June 29, 2016]. JAMA Dermatol. doi:10.1001/jamadermatol.2016.1985.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Para tratar la porexia.

Enlarged Facial Pores: An Update on Treatments

Joanna Dong, BA; Julien Lanoue, MD; Gary Goldenberg, MD

June 29, 2016 

Enlarged facial pores remain a common dermatologic and cosmetic concern from acne and rosacea, among other conditions, that is difficult to treat due to the multifactorial nature of their pathogenesis and negative impact on patients' quality of life. Enlarged facial pores are primarily treated through addressing associative factors, such as increased sebum production and cutaneous aging. We review the current treatment modalities for enlarged or dense facial pores, including topical retinoids, chemical peels, oral antiandrogens, and lasers and devices, with a focus on newer therapies. 

Cutis. 2016 July;98(1):33-36.

Joanna Dong, BA; Julien Lanoue, MD; Gary Goldenberg, MD

From the Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York. 

The authors report no conflict of interest. Correspondence: Gary Goldenberg, MD, Department of Dermatology, 5 E 98th St, 5th Floor, New York, NY 10029 (garygoldenbergmd@gmail.com). 

    Practice Points 

• The pathogenesis of enlarged facial pores is speculated to be associated with sebum production, skin aging and photodamage, and hair follicle size, among other factors.
• Current treatment modalities for enlarged facial pores target these factors and include topical retinoids, chemical peels, oral antiandrogens, lasers, radiofrequency, and ultrasound devices, with the latter devices offering the most novel and robust choices.
• New botanically derived topical treatments, specifically copper chlorophyllin complex sodium salt and tetra-hydro-jasmonic acid, are in development with initial positive results, though studies are still limited.

Enlarged facial pores are superficial skin structures that are visualized as small openings on the skin corresponding to the openings of the pilosebaceous apparatus. These openings may be impacted with horny follicular plugs consisting of sebaceous debris that appear as open comedones.¹ Skin pores is a lay term that is poorly defined in the medical literature and often is categorized in terms of arbitrary circular diameters determined through cosmetic skin analyzers.² The term refers to pilosebaceous follicular enlargements (with or without open comedonal horny impactions) that can be visualized by the naked eye, most commonly occurring on the face and scalp. These enlarged pores remain a pervasive cosmetic concern that impacts patient quality of life. Enlarged pores are difficult to treat, in part due to lack of knowledge of the pathophysiology; thus, we review the currently proposed causes of enlarged pilosebaceous openings and the treatments in the scope of this pathogenesis with a focus on therapeutic efficacy.

Pathogenesis of Enlarged Facial Pores

It is now thought that seborrhea, loss of skin elasticity and tension, and hair follicle size are most clinically relevant to the pathogenesis of enlarged pores.² Other potential associated and causative factors include genetic predisposition, acne, comedogenic xenobiotics, chronic photodamage, chronic radiodermatitis, and vitamin A deficiency.^1,3

The direct relationship between sebum output and pore size has been well established, particularly in men who generally have higher sebum output levels than women, which likely is testosterone driven.^4,5 However, there are contradictory data on whether sex affects pore size, as females also exhibit contributory hormonal factors. Sebum output and pore size increase substantially during the ovulation phase of the female menstrual cycle, likely secondary to increased progesterone affecting sebaceous gland activity.^2,4

The presence of acne also is associated with enlarged facial pores, though the extent of seborrhea as a confounding factor is unclear. Furthermore, acne severity does not correlate with increased pore size.⁵ However, the processes of acne and facial pores are interlinked, given the frequent occurrence of open comedones within the pores. 

Skin elasticity and tensile strength when defined visually and mechanically has shown a negative correlation with facial pore size and density.⁵ It is well known that cutaneous aging and chronic photodamage cause perturbation in the collagen and elastin framework that allows for the skin to maintain its resilient properties.⁶ Aged and photodamaged skin also demonstrates decreased expression of microfibril-associated glycoprotein-1 (MAGP-1), a crucial component in elastic fiber assembly and skin elasticity in the dermis and perifollicular/pore areas.⁷

Pore density and size appears to range diversely across ethnicities, though Chinese women exhibit notably lower pore size and density across all ages as compared to other ethnicities.⁸ Black individuals have aberrant epidermal architecture, defined as the presence of stalagmitelike structures at the dermoepidermal junction, correlating with enlarged pore size compared to other ethnicities.^2,8

Treating Enlarged Facial Pores

Treatments for enlarged facial pores primarily aim to decrease sebum production, rejuvenate skin, remove hair, and/or decrease follicular size. Evidence-based studies are limited, and many currently used therapies have not been studied with enlarged facial pores as a primary investigative outcome. Here, we include studies that report efficacy in decreasing pore size specifically. It is important to note the lack of a uniform and objective modality with which to report skin pore size. Studies use a wide range of techniques including patient self-reporting, physician observation, and software image analyzers. 

Topical Therapies

Topical retinoids are vitamin A derivatives, and they are first-line therapies in reversing the aberrant collagen and elastin-associated epidermal and dermal changes that occur with chronological aging and photoaging. Tretinoin, isotretinoin, and tazarotene have shown efficacy in multiple parameters of skin rejuvenation, including facial pores, skin wrinkling, hyperpigmentation, skin laxity, and sebum production.⁹ However, it is important to note that retinoids treat keratinocyte atypia in acne, and efficacy in facial pores is confounded by improvement in follicular keratinization. Because studies have not distinctly uncoupled this association, it is erroneous to conclude that retinoids reduce facial pore size and density irrespective of concomitant acne vulgaris. 

Tazarotene has been evaluated for use in reducing facial pore size. In one investigation, 568 patients with moderate wrinkling or hyperpigmentation were randomized to receive tazarotene cream 0.1% or placebo once daily for 24 weeks and were evaluated for enlarged facial pores as a secondary outcome using a double-blinded physician 5-point scale.¹⁰ At week 24, 42% of tazarotene-treated patients achieved improvement of at least 1 point compared to 20% of placebo-treated patients (P<.001). Adverse events were dermatitic, as can be expected of retinoids, leading to a 4% discontinuation rate in the tazarotene group compared to 1% in the placebo group.¹⁰

Tretinoin has long been used off label for antiaging treatments but has only recently shown efficacy for facial pores. In one study, 60 women who had previously sought antiaging procedures were treated with tretinoin cream 0.025% once daily and no other antiaging products or procedures for 90 days.¹¹ Facial pore evaluations were determined by a modified dermatoscope with a polarized analyzer for clinical scoring using a photonumeric scale. Patients improved from a baseline average score of 3.2 in facial pores to a posttreatment average score of 2.0 (P<.05) at day 84. This improvement was sustained from day 28 of treatment and corresponded to patient self-perception. Adverse events included xerosis, desquamation, burning, and erythema, which led to 3 premature discontinuations.¹¹

Various chemical peel formulations are used in skin rejuvenation and have shown application in enlarged facial pores. Chemical peels act at the epidermal or dermal level to induce temporary breakdown and regeneration of healthier cells and improved skin matrix.¹² Twenty-two Japanese women applied glycolic acid (30% solution) every 2 weeks for a total of 5 treatments and exhibited reduced appearance of conspicuous, open, and dark pores, defined by surface area and shading as determined through dermatoscopic and software analysis, with mean improvement rates of 34.6%, 11%, and 34.3%, respectively. More than 70% of participants exhibited improvement in enlarged facial pores.¹³ A study involving a 40% glycolic acid and vitamin C formulation demonstrated significant improvement in facial pores (28.3%; P<.001).¹⁴

The newest topical therapies studied for use in minimizing facial pilosebaceous openings are natural plant-derived copper chlorophyllin complex sodium salt (CHLcu) and tetra-hydro-jasmonic acid (LR2412). Clinical trials of these botanicals are limited with small sample sizes but are included here as novel treatments requiring further investigation. 

Chlorophyllin copper complex sodium salt is derived from chlorophyll, a green pigment found in plants, and has been investigated as a topical gel in liposomal dispersions for application in photodamaged and aged skin. Chlorophyllin copper complex sodium salt exerts in vitro hyaluronidase inhibitory activity to maintain hyaluronic acid in the extracellular matrix and counteract the structural breakdown of cutaneous aging.¹⁵ Two small single-center pilot trials enrolled 10 participants each in a 3-week study of CHLcu 0.1% twice daily and an 8-week study of CHLcu 0.066% twice daily.^16,17 After 3 weeks, patients treated with CHLcu 0.1% exhibited a 22.2% improvement in facial pores by clinical assessment grading, though this improvement was not significant on software imaging analysis. Patients improved the most on parameters of facial seborrhea by clinical assessment.¹⁶ After 8 weeks, patients treated with CHLcu 0.066% exhibited 25.3% improvement in facial pores by clinical assessment grading.¹⁷ Treatments were reported to be well tolerated without noted adverse events in both studies. 

Tetra-hydro-jasmonic acid is an analogue of jasmonic acid, a plant hormone derived from linoleic acid. Due to its favorable safety profile and bioavailability, penetration into epidermal and dermal layers, and potential effects in rejuvenating desquamation, LR2412 is currently being assessed for treatment of skin wrinkles, texture, and pores.¹⁸ Its effect is thought to relate to stimulation of laminin-5, collagen IV, and fibrillin deposition at the dermoepidermal junction.¹⁹ In an open-label trial of a topical preparation of LR2412, 15 participants were treated twice daily for 6 weeks and assessed through investigator clinical assessment scoring.²⁰Investigator scoring of pores improved by 25.2% from baseline (P<.05) after 6 weeks of treatment. Improvement in pores was seen as early as days 1 and 3. No serious adverse events were reported, though 2 participants developed acne on follow-up.²⁰

Tetra-hydro-jasmonic acid also is formulated with retinol (retinol 0.2%/LR2412 2.0%) and demonstrated cosmetic efficacy in a noninferiority trial with tretinoin cream 0.025%.¹¹ Sixty patients each were randomized to retinol/LR2412 or tretinoin at bedtime and treated for 90 days. At day 84, participants in the retinol/LR2412 group exhibited an improvement in investigator clinical assessment scoring from a baseline of 3.6 to 2.5 (P<.05). There were no significant differences in investigator-assessed efficacy between the treatment arms. Participants reported similar or better results and fewer side effects with retinol/LR2412 on self-questionnaires. Eight participants treated with retinol/LR2412 and 15 participants treated with tretinoin reported various incidences of skin irritation, burning, and desquamation.¹¹

Oral Therapies

The most commonly used oral therapies for enlarged pores are antiandrogens, such as combined oral contraceptives, spironolactone, and cyproterone acetate, which modulate sebum production due to the presence of androgen receptors within sebaceous glands.²¹ Forty-four white women in an open-label, phase 4 study were treated with combined oral contraceptives containing chlormadinone acetate–ethinyl estradiol for 6 menstrual cycles, with standardized photography taken before and after the treatment period for software analysis. After 6 treatment cycles, 9.1% (4/44) of participants had visibly enlarged pores of the forehead and cheeks compared to 43.2% (19/44) of participants at baseline (P<.0001).²² The effects of other antiandrogens on facial pores have not been studied in this capacity. 

Lasers, Radiofrequency, and Ultrasound Devices

The development of various devices that can deliver targeted thermal or ultrasound energy to the skin offers the newest and most robust modality in cosmetic therapy. The mechanism of their efficacy may be due to a combination of induced remodeling of collagen fibers near pilosebaceous openings to increase skin elasticity and decrease sebum production.^2,23

Devices with established antiaging effects have been extensively reviewed and include the gold particle 800-nm diode laser, 1450-nm diode laser, microneedle apparatuses, fractional radiofrequency devices, 2790-nm erbium:YAG laser, nonablative 1410-nm fractionated erbium-doped fiber laser, and nonablative 1440-nm fractional laser.²

Literature on the use of these devices for minimizing facial pore size is limited. One treatment of intense focused ultrasound using a 3-mm transducer successfully improved overall pore appearance in 91% of sites at 6-week follow-up on a clinical grading scale.²⁴ Three sessions of nonablative 1410-nm fractionated erbium-doped fiber laser treatments yielded facial skin pore minimization of greater than 51% in 14 of 15 participants.²⁵

The nonablative 1440-nm diode fractional laser received 510(k) clearance by the US Food and Drug Administration in 2011 for aesthetic use in chronologically aged and photoaged skin. Twenty participants treated for 2 weeks and a total of 6 facial treatments with this laser system showed a 17% average improvement in facial pore score on software analysis (P≤.002). Adverse events were mild and included erythema and xerosis.²⁶

Conclusion

The reliability of available literature on efficacy of various treatments in diminishing facial skin pores has been challenging given that most studies are low in power, lack control groups, use nonuniform methods of reporting outcomes, and do not report complete adverse events. Thus, all results should be interpreted with caution. 

Overall, it is clear that the pathogenesis of enlarged facial pores is multifactorial and complex, necessitating a similar approach to therapeutics. Topical treatments offer a range of diverse therapies with proven benefit in facial pore reduction. The advent of lasers and devices offers constantly evolving therapeutic options with diffuse antiaging effects. Despite the numerous topical, oral, and device-oriented options, enlarged facial pores remain a challenging cosmetic concern. More robust efficacy studies on new treatments are necessary. 

Rosacea Pediatrica...

Pediatric Rosacea

Roselyn Kellen, BA; Nanette B. Silverberg, MD

July 5, 2016 

Because rosacea is uncommon in the pediatric population, care must be taken to exclude other papulopustular disorders. Children can present with vascular, papulopustular, and/or ocular findings. Importantly, ocular symptoms can appear before the cutaneous symptoms of rosacea, leading to misdiagnosis. Rosacea is a clinical diagnosis, but histopathologic examination typically reveals dilated vessels, perivascular lymphohistiocytic infiltrates in the upper dermis, elastosis, and disorganization of the upper dermal connective tissue. Treatment involves avoiding known triggers and utilizing topical and/or systemic therapies. Although treatment can control flares, pediatric rosacea often persists into adulthood. 

Cutis. 2016 July;98(7):49-53.

Roselyn Kellen, BA; Nanette B. Silverberg, MD

Ms. Kellen is from the Department of Dermatology, Mount Sinai Hospital, New York, New York. Dr. Silverberg is from Mount Sinai St. Luke's-Roosevelt Hospital and Beth Israel Medical Centers of the Icahn School of Medicine at Mount Sinai, New York. 

The authors report no conflict of interest.

Correspondence: Nanette B. Silverberg, MD, 1090 Amsterdam Ave, Ste 11B, New York, NY 10025 (nsilverb@chpnet.org).

    Practice Points

• Although rosacea is largely a diagnosis of adults, it also can begin in childhood and adolescence.
• Ocular rosacea and papulopustular disease are common clinical findings in younger patients.
• Usage of topical metronidazole and age-appropriate oral antibiotics are the mainstay of management.

Rosacea is a chronic skin disease characterized by flushing, erythema, telangiectasia, papules, and pustules in the central face region.¹ It most often affects middle-aged women (age range, 30–50 years).² Rosacea is rare in the pediatric population, especially before puberty.³ There are 3 subtypes of pediatric rosacea: vascular, papulopustular, and ocular. Phymatous/rhinophymatous rosacea is only seen in the adult population.³ Recommendations for the management of pediatric rosacea heavily rely on data from retrospective chart reviews and case series.

Etiology of Pediatric Rosacea

Rosacea is thought to be a consequence of vasomotor instability in both adults and children. A family history of rosacea is sometimes reported in patients with pediatric rosacea.⁴ Patients often are sensitive to heat, sunlight, topical corticosteroids, spicy foods, hot liquids, and certain soaps and cleansers.^1,3,4 In a review of the literature by Vemuri et al,⁵ the various reported triggers of rosacea include harsh climates that damage the blood vessels and dermal connective tissue, defects in the endothelium and dermal matrix, perivascular inflammation, orally ingested chemicals, changes in the flora of the hair follicles, excessive antimicrobial peptides, and the presence of free radicals. Overall, it is unclear which of these factors are triggers of pediatric rosacea.

The molecular basis of rosacea has been elucidated. It is well known that rosacea patients have higher levels of cathelicidins in the facial skin. Furthermore, they appear to have different processed forms of cathelicidin peptides compared to adults without rosacea, possibly due to changes in posttranslational processing.⁶ One such peptide, cathelicidin LL-37, also has been implicated in atopic dermatitis⁷ and psoriasis.⁸ Its role in rosacea appears to be multifaceted. Cathelicidin LL-37 helps to attract neutrophils, monocytes, and T lymphocytes, and also has antimicrobial properties; therefore, it plays a role in both the innate and adaptive immune systems.⁹ Cathelicidin LL-37 also has been implicated in inducing angiogenesis¹⁰ and suppressing dermal fibroblasts.¹¹

Muto et al¹² found that there is an increased number of mast cells in the dermis of patients with rosacea. Mast cells contribute to vasodilation, angiogenesis, and the recruitment of other inflammatory cells.¹² Importantly, human mast cells are a source of cathelicidins including cathelicidin LL-37; these proteins play a vital role in the antimicrobial capabilities of mast cells.¹³

Clinical Presentation and Comorbidities

Vascular rosacea presents with characteristic flushing and erythema, which lasts more than a few minutes as compared to physiologic erythema,¹ and sometimes telangiectasia is seen.³ The cheeks, chin, and nasolabial folds are most commonly involved.² In papulopustular rosacea, papules and pustules are seen overlying the erythema.^1,3 Open and closed comedones also have been documented in case reports but are not commonly seen.² Pediatric rosacea often begins with flushing of the face and then progresses to the development of papules and pustules.⁴

Ocular rosacea can occur with or without cutaneous findings. In a retrospective study of 20 pediatric patients (aged 1–15 years), 11 (55%) patients had both ocular and cutaneous rosacea, 3 (15%) only had ocular symptoms, and 6 (30%) only had cutaneous symptoms. The most common form of rosacea in this study was papulopustular rosacea.¹⁴ Ocular symptoms often are bilateral¹⁵ and can include blepharitis, conjunctival injection, recurrent chalazion, conjunctivitis,² and less commonly corneal ulceration and scarring.¹⁶ Patients also may report photophobia or a foreign body sensation.¹⁷ Importantly, ocular symptoms often precede the cutaneous symptoms and can delay the diagnosis of rosacea,^14,16,18 as these symptoms often are misdiagnosed as viral or bacterial infections.¹⁵ Fortunately, ocular disease responds well to treatment if diagnosed early. 

Weston and Morelli¹⁹ conducted a retrospective study of 106 children (46 males; 60 females) 13 years and younger with steroid rosacea; 29 children were younger than 3 years. A family history of rosacea was present in 20% of participants, and prior use of class 7 steroids was reported in 54%, whereas only 3% had used class 1 topical steroids. Ninety-eight participants had perinasal involvement, 94 had perioral involvement, and 44 had periorbital involvement of the lower eyelids.¹⁹

Rosacea fulminans (also known as pyoderma faciale) is a rare acute-onset eruption typically found in young women in their 20s and 30s.²⁰ Rosacea fulminans is characterized by papules, pustules, nodules, cysts, draining sinuses, communicating sinus tracts, and less commonly comedones.^20,21 The skin can appear erythematous, cyanotic, or dull red.²¹ Most of the lesions are found on the face, particularly on the forehead, cheeks, nose, and chin,²¹ but lesions on the chest and back have been documented in adult patients.²⁰ In an examination of prior case series, most patients were otherwise healthy. There are case reports documenting rosacea fulminans in teenagers,²⁰ but the youngest patient recorded was an otherwise healthy 3-year-old girl who developed a sudden onset of erythematous papules, pustules, cysts, and purulent discharging sinuses on the cheeks that spread to the chin, perioral, and paranasal areas.²¹

Differential Diagnosis

Rosacea is rare in children, so other papulopustular disorders must be ruled out, including acne vulgaris, periorificial/perioral dermatitis, sarcoidosis, systemic lupus erythematosus, steroid-induced rosacea, ataxia telangiectasia, and demodicosis.

Acne vulgaris commonly presents in older adolescents and teenagers with open and closed comedones, inflammatory papules, and pustules.² Intense facial flushing and telangiectasia usually is not seen. 

In perioral dermatitis, skin lesions often are clustered around the mouth, nose, and eyes. Typically there are no telangiectases or ocular complications.³ Facial flushing and telangiectases are uncommon, except in steroid-induced perioral dermatitis.²

The cutaneous findings of sarcoidosis include red-brown papules on the face and lips, and patients also may have ocular involvement such as uveitis and iritis.³However, there are typically other systemic findings such as pulmonary symptoms, weight loss, fatigue, lethargy, fever, and erythema nodosum.^2,3 Chest radiograph findings (eg, bilateral hilar lym-phadenopathy), ophthalmologic examination, and laboratory data (eg, elevated alkaline phosphate and/or elevated angiotensin-converting enzyme) can help confirm or rule out the diagnosis of sarcoidosis.^2,3

Unlike systemic lupus erythematosus, patients with rosacea will have involvement of sun-protected areas of the skin. Patients with systemic lupus erythematosus typically report arthralgia and severe photosensitivity and will have elevated antinuclear antibody titers. Skin biopsies and immunofluorescence can help confirm the diagnosis.³ Importantly, some patients with rosacea will have a positive lupus band test.^22,23

Steroid-induced rosacea typically occurs 2 weeks after discontinuing therapy with topical fluorinated glucocorticosteroids.²⁴ Children present with monomorphic papules, pustules, and telangiectases⁴ on the eyelids and lateral face as opposed to the central face regions.²⁴

Ataxia telangiectasia can present with telangiectases, skin atrophy, café au lait spots, and premature graying.²⁵ A 15-year-old adolescent girl with ataxia telangiectasia presented with granulomatous acne rosacea that improved after 4 weeks of treatment with isotretinoin 0.5 mg/kg daily. The lesions cleared almost completely after 5 months.²⁵

Demodicosis is a disorder of the pilosebaceous units caused by the human Demodex mite.²⁶ It typically involves the periorificial regions in adults and the elderly population. Patients can present with fine, white-yellow, scaly changes of the sebaceous hair follicles, with minimal erythema and inflammation. Papules and pustules also can be present.²⁶

Diagnosis and Histopathology

Because rosacea is rare in children, it is important to thoroughly evaluate other possible diagnoses. The diagnosis of pediatric rosacea is clinical and biopsies are rarely performed. Laboratory tests such as cultures generally are not useful.

Marks and Harcourt-Webster²⁷ reviewed the biopsies of 108 adult patients with rosacea. The biopsies of patients with predominantly erythema and telangiectasia showed evidence of vascular dilatation with a perivascular infiltrate composed predominantly of lymphocytes and 39 specimens that were compared to controls showed more solar elastosis. Biopsies of papular rosacea contained inflammatory infiltrates in the upper and mid dermis composed primarily of lymphocytes and histiocytes. In some patients, neutrophils, plasma cells, and giant cells also were observed. Hair follicle abnormalities were present in 20% of the biopsies, with 19% showing evidence of the Demodex mite. Vascular dilatation also was common. Overall, common findings included lymphohistiocytic infiltrates around the blood vessels of the upper dermis, dilated vessels, edema, elastosis, and disorganization of connective tissue in the upper dermis.

Helm et al²⁸ reviewed histopathologic patterns from 53 patients with granulomatous rosacea. Findings included a mixed lymphohistiocytic infiltrate (predominantly lymphocytic in 40% of patients and predominantly histiocytic with occasional giant cells in 34% of patients), epithelioid granulomas (11% of patients), and epithelioid granulomas with caseation necrosis (11% of patients). 

The histopathology of rosacea fulminans is characterized by dense perivascular and periadnexal infiltrates composed of granulocytes, eosinophils, and epithelioid granulomas, as well as panniculitis.²⁰

Treatment and Clinical Outcomes

Certain lifestyle recommendations are integral components of disease management, including avoidance of triggers such as extreme temperatures, hot drinks, spicy food, and topical agents that could be irritating (especially topical corticosteroids).²⁹ Patients should be advised to use daily sunscreen containing physical blockers such as titanium dioxide or zinc oxide. Teenagers should avoid the use of cosmetics and makeup, especially products containing sodium lauryl sulfate, menthol, and camphor. Daily use of emollients can help some patients.²⁹

There are both topical and systemic therapies available for pediatric rosacea; however, most of the data are based on the use of these treatments in the adult population. Patients with mild to moderate disease often can be managed using topical agents. Metronidazole (0.75% cream, 1% gel, or 0.75% lotion) has been studied extensively in adult patients, and when used once daily for 12 weeks, it has been able to control moderate to severe disease.^30,31 In one study conducted in adult patients, topical metronidazole was able to maintain remission in adults who had previously been treated with a combination of oral tetracycline and metronidazole gel.³¹ Sodium sulfacetamide 10%–sulfur 5% (cleanser or lotion) has been successful in adult patients and often is used in combination with other therapies such as topical metronidazole.^32-34 Azelaic acid cream 20%,³⁵ benzoyl peroxide (wash or gel),²⁹ topical clindamycin,³⁶ topical erythromycin,^29,37tacrolimus ointment 0.1%,³⁸ and tretinoin cream also have been studied in adults.^3,39 Several of these topical agents can cause irritation on application (eg, metronidazole, sulfur-based agents, azelaic acid, benzoyl peroxide, erythromycin, tretinoin).³

The use of systemic treatments in pediatric patients is heavily based on case reports and case series.^2,14,16,40 Therapies have included tetracycline (500 mg twice daily tapered to 250 mg daily),²⁹ minocycline (50–100 mg twice daily), doxycycline (50–100 mg twice daily or 4 times daily), erythromycin (30–50 mg/kg daily), clarithromycin (15 mg/kg twice daily for 4 weeks and then daily for 4 weeks), and azithromycin (5–10 mg/kg daily).³ Tetracycline antibiotics should not be used in children 8 years or younger.

In a case series by Drolet and Paller,² an 11-year-old girl was treated with tetracycline 500 mg (later tapered to 250 mg daily) and metronidazole gel 0.75%, both used twice daily. Previously, she had not responded to topical steroids, tretinoin cream 0.05%, benzoyl peroxide 5%, or systemic prednisone. After 6 weeks of treatment, the pustules and chalazion had resolved and she had only minimal erythema of the skin and conjunctiva. Sixteen months after the start of treatment, a regimen of tetracycline 250 mg daily and metronidazole gel resulted in disease clearance on the face.²

A 9-year-old girl with concurrent systemic lupus erythematosus was treated with tetracycline 250 mg and topical erythromycin 2%, both used twice daily.² After 4 weeks her face was clear. Four months later she developed new telangiectases and topical erythromycin was replaced with topical metronidazole. Eventually the dose of tetracycline was reduced to 250 mg daily.²

An 11-year-old boy with likely granulomatous rosacea was treated with erythromycin 250 mg 4 times daily, alclometasone dipropionate cream 0.05% twice daily, and topical clindamycin twice daily.² Marked improvement was noticed after 3 weeks of treatment. Metronidazole gel 0.75% was added and 3 months later the patient's face was clear, without evidence of scarring. The dose of erythromycin was later reduced to 500 mg daily, and eventually the patient experienced clearance with the use of metronidazole gel daily.²

In another case series, 4 female patients (age range, 4–12 years) were treated with systemic erythromycin 20 mg/kg daily (ocular involvement only) or doxycycline 2.2 mg/kg daily used in two 12-year-old patients with ocular and cutaneous involvement for at least 12 months. All 4 patients showed considerable improvement within 1 month and remained free of disease throughout a mean follow-up period of 25.5 months.⁴⁰

As evidenced by these case reports, there is a wide array of treatments that have been used for pediatric rosacea. Although there are no formal evidence-based guidelines, there are certain considerations that must be taken into account when choosing treatment plans. Doxycycline and minocycline are known to cause less gastrointestinal upset than tetracycline with similar efficacy.⁴¹ Importantly, the tetracyclines are contraindicated in children younger than 9 years, as they can cause teeth staining and possibly affect skeletal growth.^3,4 When used in older children (age range, 9–12 years), patients must be advised not to take their medication with calcium or antacids.³ Clarithromycin and azithromycin tend to have fewer gastrointestinal side effects than erythromycin. Erythromycin and other macrolides can be used in children of all ages and in patients who are allergic to tetracyclines.³

Children with mild ocular symptoms often can control their disease with bacitracin and topical ocular antibiotics such as erythromycin.^2,15 For patients who require systemic antibiotics, various tetracyclines and macrolides have been used with success.^2,14-16,40

Adults with rosacea fulminans can require treatment with isotretinoin, oral antibiotics, and topical or even systemic corticosteroids.⁴² The 3-year-old girl with rosacea fulminans initially was treated with oral erythromycin (250 mg 4 times daily), oral prednisolone (0.5 mg/kg daily tapered over 2 weeks), fluocinolone acetonide cream 0.025%, and warm compresses with only moderate improvement.²¹ She was then started on oral isotretinoin (0.75 mg/kg daily) and within 4 weeks marked improvement was noted. After 8 weeks, the lesions had disappeared completely with only a few pitted scars remaining. Isotretinoin was continued for 24 weeks. One year after completion of treatment, she was still disease free.²¹

Weston and Morelli¹⁹ recommended the following treatment regimen for children with steroid rosacea: abrupt cessation of topical steroid use (as opposed to gradual withdrawal) and initiation of oral erythromycin stearate (30 mg/kg daily) in 2 daily doses for 4 weeks. Children who were unable to tolerate erythromycin (n=6) were told to use topical clindamycin phosphate twice daily for 4 weeks. Within 3 weeks 22% of patients had resolution, while 86% had resolution within 4 weeks. All of the patients cleared within 8 weeks. Importantly, there was no significant difference in duration of time until clearance between children who used the oral antibiotic or topical antibiotic.¹⁹

Conclusion

We know that the skin of rosacea patients contains higher levels of cathelicidins, which have been implicated in amplifying and contributing to the inflammatory response in several ways. Mast cells, which are a source of cathelicidins, also are increased in the skin of these patients. Children can present with vascular rosacea (characterized by flushing, erythema, and/or telangiectasia), papulopustular rosacea, or ocular rosacea. Common ocular symptoms include blepharitis, conjunctivitis, and recurrent chalazion. It is important to refer pediatric rosacea patients with ocular symptoms to an ophthalmologist to prevent ocular sequelae. 

Rosacea is a clinical diagnosis but biopsy can be performed to rule out other diagnoses. Treatment consists of lifestyle modifications such as avoiding known triggers and the use of topical and/or oral agents. Common topical therapies include metronidazole and erythromycin. Systemic antibiotics include tetracycline, doxycycline, minocycline, azithromycin, and erythromycin. Some children are able to taper systemic agents and maintain disease control with topical therapy, while others may need to continue a low-dose antibiotic. Although flares can be controlled within weeks to months, rosacea is a chronic disorder and childhood rosacea tends to persist into adulthood.

Estudio de Tratamiento de Onicomicosis con Laser ND Yag.

A 24 semanas porcentajes de curación dependieron de la presentación, agente y factores del paciente. Los pacientes diabéticos, inmunocomprometidos y adultos mayores están en mayor riesgo de desarrollar complicaciones secundarías a la presencia de onicomicosis. Los mohos y agentes no tradicionales hacen la respuesta a tratamiento más difícil, y las candidas no albicans también son más resistentes a tratamiento, es por esto que el cultivo de la uña es importante para el paciente, ya que le da una idea sobre su pronóstico y dificultad de respuesta satisfactoria al tratamiento. Los tipos que menos responden a tratamientos tradicionales, son las distrofias totales, presencia de tricofitomas, mientras que las que mejor responden son la onicomicosis distal y lateral y la blanca superficial. Existen otros tratamientos como los medicamentos orales, al avulsión o ablación química de la uña, tratamientos tópicos y otros "naturales". Ninguno a demostrados excelencia terapéutica y todos pueden presentar efectos adversos.  Es por esto que la incorporación del Laser como tratamiento sustitutivo y/o coadyuvante ha ganado un lugar en el armamento actual, pero no es la pomada canaria. Protocolo: Pulso de Energía 200 mj, Ancho del Pulso: 0.1ms, Tamaño del Punto 1.5mm, Frecuencia 30 Hz, alcanzando temperaturas e 40 a 60 grados celsius. Se realiza un patrón de disparos en forma de espiral cubriendo toda la uña. Luego se esperan 2 minutos y se repiten dos veces más.  Las sesiones se separan cada 4 semanas, ya que puede deformarse la uña, si la uña era más gruesa de 2 mm se desgastaba la uña (¿DremmelMR?). Un grupo tratamiento tópico hidrocloruro de naftitina en spray cada día en todas las areas cercanas a la uña y debajo, sólo laser y laser más tratamiento tópico. 15,2 y 22.5% en Laser y Laser más tratamiento tópico experimentaron cura a las 24 semanas.

A randomised comparative study of 1064 nm Neodymium-doped yttrium aluminium garnet (Nd:YAG) laser and topical antifungal treatment of onychomycosis Tae In Kim, Min Kyung Shin, Ki-Heon Jeong, Dong Hye Suh, Sang Jun Lee, In-Hwan Oh and Mu-Hyoung Lee Version of Record online: 12 JUL 2016 | DOI: 10.1111/myc.12534

Hilos con sensores para cicatrización.

Researchers Developing Surgical Thread That Integrates Wireless Diagnostic Sensors.

The Wall Street Journal (7/18, Hotz, Subscription Publication) reports researchers at Tufts University are developing thread that integrates wireless diagnostic sensors. In animal studies, the thread was able to transmit readings of tissue strain, stress, acidity, temperature as well as glucose levels, to monitor healing, infection, and body chemistry.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Inmunoterapia desensibilizante no efectiva en Dermatitis Atópica.

Review Finds Lack Of Consistent Evidence On Effectiveness Of Specific Allergen Immunotherapy For Atopic Eczema.

Healio (7/18, Thiel) reports, "There was a lack of consistent evidence that specific allergen immunotherapy is effective for treating atopic eczema," research suggests. The findings of the 12-study review were published online in Allergy.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Mis sospechas y luego afirmaciones... Confirmadas!

Hormonal Contraceptives May Have Different Effects On Acne, Study Suggests.

MedPage Today (7/16, Jenkins) reported that research suggests "not all hormonal contraceptives are...equal" with regard to "their effects on acne." Investigators found that "on average, depot injections, subdermal implants, and hormonal intrauterine devices worsened acne while the vaginal ring and combined oral contraceptives (COCs) tended to improve it." The study indicated that "there were no other statistically significant differences among contraceptive classes." The findings were published online in the Journal of Drugs in Dermatology.

Benjamin Hidalgo-Matlock

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Laser a base de diodos: laser de baja potencia es útil en el tratamiento de la alopecia androgenetica.

Laser Therapy May Prove Effective for Alopecia Lasers Surg Med; ePub 2016 Apr 25; Afifi, et al
May 11, 2016

The use of low-level laser therapy (LLLT) may serve as an effective alternative for persons with androgenetic alopecia (AGA) unwilling to use medical therapy or undergo surgical options, according to a recent review of several studies. Researchers evaluated 11 studies, published between 1960 and 2015, which investigated 680 patients, consisting of 444 males and 236 females. They found:

• 9 out of 11 studies assessing hair count/hair density found statistically significant improvements in both males and females following LLLT treatment.

• Hair thickness and tensile strength significantly improved in 2 out of 4 studies.

• Patient satisfaction was investigated in 5 studies and was overall positive, though not as profound as the objective outcomes.

Citation: Afifi L, Maranda, EL, Zarei M, Delcanto, GM, et al. Low-level laser therapy as a treatment for androgenetic alopecia. [Published online ahead of print April 25, 2016]. Lasers Surg Med. doi:10.1002/lsm.22512. 

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Adverse Events in Infants Treated With Topical Timolol for Infantile Hemangioma | PracticeUpdate

 FEATURED

Published in Dermatology

Journal Scan / Research · July 11, 2016

Adverse Events in Infants Treated With Topical Timolol for Infantile Hemangioma

Pediatric Dermatology

 TAKE-HOME MESSAGE

• This retrospective study evaluated 22 infants with infantile hemangiomas treated with topical timolol who were assessed for bradycardia using Holter monitoring. For this study, infants were classified as high risk if they received more than 2 drops of timolol per day, began therapy before 44 weeks' postmenstrual age, or received therapy applied to a site with a relatively high risk of systemic absorption. Episodic, asymptomatic bradycardia (heart rate <80 beats per minute) was detected by the Holter monitor in 2 infants and was unrelated to the timing of the timolol doses. These episodes are commonly seen in infants and are considered normal. Another 2 infants had symptomatic bradycardia; these infants both weighted less than 2500 g, were young at initiation of therapy, were preterm, had eyelid hemangiomas, and had a timolol dose above the median exposure for the cohort.

• Topical timolol was safe for the treatment of infantile hemangiomas in this at-risk group. Infants weighing less than 2500 g or aged less than 44 weeks' postmenstrual age may be at risk for symptomatic bradycardia, including hypotension, apnea, and hypothermia, and should be monitored closely if timolol therapy is initiated.

– Sarah Churton, MD

 Dermatology

Written by

 

 

Sarah L Chamlin MD

Since the first report of the efficacy of propranolol for infantile hemangioma (IH) treatment, the literature has exploded with case series of oral and topical beta-blocker use for this indication. Off-label use of topical maleate solution and gel-forming solution (GFS; 0.25% or 0.5%) has become commonplace for IH, with little or no available prospective pharmacokinetic or toxicity data. Timolol maleate GFS was approved in 2007 for pediatric glaucoma therapy, and systemic effects of bradycardia, hypotension, apnea, hypoglycemia, and bronchial reactivity are observed with pediatric intraocular use. In this study, Holter monitoring was performed in 22 infants at high risk for complications (ie, young infants, those using more than 2 drops, those with IH on mucosal sites, ulcerated IH, or IH under occlusion).

Dosing of timolol ranged from 2 to 6 drops per 24 hours divided into 2 doses. In total, 4 infants were noted to have bradycardia, and 2 of these were asymptomatic; the bradycardia seemed unrelated to the timing of application. The 2 infants who experienced symptomatic bradycardia were preterm, young, and had application doses higher than the median exposure. Of note, these infants had eyelid IH and bradycardia before timolol exposure and with later propranolol administration.

While topical timolol is a great option for small and non–function threatening IH, caution should be used in very young, small, and premature infants. No adverse events were noted in this study in infants receiving less than 0.2 mg/kg/day, and it would be worthwhile and reassuring to calculate dosing in infants prior to use. The timolol 0.5% GFS bottle dispenses 0.05 mL/drop and each drop contains 0.25 mg of timolol.

• For a 3-kg infant: 1 drops twice daily = 0.17 mg/kg/day.
• For a 4-kg infant: 1 drop three times daily = 0.19 mg/kg/day.
• For a 5-kg infant: 2 drops twice daily = 0.20 mg/kg/day.

Of note, in my practice, I use timolol in a 1 drop twice daily or 1 drop three times daily routine, with efficacy noted after several weeks of use. Efficacy often includes lack of continued hemangioma growth and decreased redness and thickness.

---

Abstract

BACKGROUND

The success of oral propranolol for treatment of infantile hemangiomas (IHs) has led practitioners to use topical β-blockers. In preterm infants, clinicians frequently turn to topical timolol, with the presumption that topical application will result in less systemic absorption. We used Holter monitoring to assess for drug-induced bradycardia in high-risk infants.

METHODS

We retrospectively reviewed the charts of 22 at-risk infants who received a Holter monitor to assess for association between timolol administration and development of significant bradycardia.

RESULTS

Four infants had episodic bradycardia detected by Holter monitoring. Two of these infants were full term; weighed more than 3,000 g; and had rare, brief, asymptomatic episodes unrelated to the timing of the timolol application. The other two infants had symptomatic bradycardia while on timolol and were the only two babies that weighed less than 2,500 g at initiation of therapy. Both were young (postmenstrual age [PMA] 34 and 37 wks) at initiation and had a timolol dose above the average exposure for the cohort.

CONCLUSION

In this cohort of at-risk infants, topical timolol appeared to provide safe treatment for IHs in full-term infants receiving a dose of less than 0.2 mg/kg/day, but infants with a PMA of less than 44 weeks and weight at treatment initiation of less than 2,500 g may be at risk of adverse events, including bradycardia, hypotension, apnea, and hypothermia. We recommend close monitoring of temperature, blood pressure, and heart rate in premature and low-birthweight infants with IHs at initiation of and during therapy with topical timolol.

Copyright © 2016 Elsevier Inc. All rights reserved.

Pediatric Dermatology

Adverse Events in Young and Preterm Infants Receiving Topical Timolol for Infantile Hemangioma

Pediatr Dermatol 2016 May 31;[EPub Ahead of Print], P Frommelt, A Juern, D Siegel, K Holland, M Seefeldt, J Yu, M Uhing, K Wade, B Drolet 

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Infecciones en atletas de colegio, son mas frecuentes las bacterias, luego hongos y luego los virus...

Ashack KA, Burton KA, Johnson TR, et al. Skin Infections Among US High School Athletes: A National Survey. J Am Acad Dermatol. 2016;74(4):679-684.

Take-home message

This study used a convenience sample of data from the High School Reporting Information Online injury surveillance database, which contains information provided by athletic trainers, to assess the epidemiology of skin infections in US high school athletes. During the study period, 2.27 skin infections per 100,000 athlete exposures were reported (474 skin infections among 20,858,781 athlete exposures). The most common infection type was bacterial, followed by tinea (60.6% and 28.4% of infections, respectively). Infections most commonly occurred on the head/face (25.3% of infections). Wrestling presented the greatest risk, resulting in substantially more infections than the next highest–risk sport of football (73.6% and 17.9% of infections, respectively). This study suggests that sports-related skin infections are common in student athletes and that prevention efforts are needed.

Dr. Heymann's commentary

This study identified 474 skin infections among 20,858,781 athlete exposures, a rate of 2.27 per 100,000 athlete exposures. Skin infections were most common in wrestling (73.6%), followed by football (17.9%). Bacterial infections were the most common (60.6%), followed by tinea infections (28.4%). The head/face (25.3%) and forearm (12.7%) were the body parts affected the most.

I usually do not comment on epidemiological studies; however, I was compelled to because of a recent case of facial herpes gladiatorum that I diagnosed in a high school wrestler. In thinking about prevention, please see the abstract in the journal article by Anderson et al.

Anderson BJ, McGuire DP, Reed M, et al. Prophylactic Valacyclovir to Prevent Outbreaks of Primary Herpes Gladitorium at a 28-Day Wrestling Camp: A 10-Year Review [published online November 4, 2015]. Clin J Sport Med. doi: 10.1097/JSM.0000000000000255.

Benjamin Hidalgo-Matlock

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Nuevo medicamento topico para la Dermatitis Atopica.

Novel Compound Promising Topical Treatment For Mild To Moderate Atopic Dermatitis.

HCP Live (7/14) reports that "a novel compound has emerged from two phase III clinical trials as a promising topical treatment for mild to moderate atopic dermatitis (AD)." Researchers found that "crisaborole (Anacor Pharmaceuticals), a nonsteroidal phosphodiesterase 4 (PDE4) inhibitor, showed safety and efficacy in two identically designed, vehicle-controlled double-blind studies." The findings were published online in the Journal of the American Academy of Dermatology.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Cuidado con el humo que se libera durante la depilacion laser...

Deben de tener cuartos bien ventilados y/o un evacuador se humo, ya que el humo fue analizado y tiene 13 toxinas y 13 sustancias sospechosasde producir cancer.

Smoke Released During Laser Hair Removal May Be A Health Hazard, Researchers Say.

Reuters (7/13, Larkin) reports that "smoke released during laser hair removal could be a health hazard, especially for people with heavy exposure to it, researchers report" in a study published online July 6 in JAMA Dermatology. Investigators found "377 chemical compounds in the smoke, including 20 that are known environmental toxins...and 13 that are known or suspected to cause cancer."

Benjamin Hidalgo-Matlock

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Importancia de las tetraciclinas, en particular doxiciclina en Rosacea.

SCOTTSDALE, ARIZ. – Doxycycline significantly reduced the amount of cathelicidin in the skin of adults with papulopustular rosacea, and levels of this antimicrobial peptide correlated with treatment response, according to a double-blind, placebo-controlled trial.

Patients who improved the most on doxycycline also had the lowest activity of serine protease and matrix metalloprotease (MMP) in their skin, said Anna Di Nardo, MD, PhD, of the University of California San Diego in La Jolla. Doxycycline seems to work in rosacea by targeting the cathelicidin pathway, and measuring relevant biomarkers could one day help guide treatment selection, she concluded during an oral presentation at the annual meeting of the Society for Investigative Dermatology.

Skin inflammation in rosacea is associated with high cathelicidin levels and increased activity of serine protease and MMP, but none of these biomarkers are well understood with regard to doxycycline. Therefore, Dr. Di Nardo and her associates randomly assigned 170 adults with papulopustular rosacea to once-daily modified-release doxycycline (40 mg; 84 patients) or placebo (86 patients) for 12 weeks. They assessed disease severity by counting inflammatory lesions and performing Investigator Global Assessments (IGA) of disease activity. They assessed cathelicidin and serine protease by analyzing stratum corneum samples obtained with adhesive tape, and quantified expression of the cathelicidin antimicrobial peptide (CAMP) gene, the matrix metallopeptidase 9 (MMP9) gene, and the serine protease-encoding KLK5 gene by studying small skin biopsies.

As expected, significantly more patients achieved an IGA score of 0 or 1 (clear or near-clear) with doxycycline than with placebo, beginning at week 4 and continuing at weeks 8 and 12 (P less than .05). Likewise, average lesion counts dropped by 45% in the doxycycline group by week 12, but only by 25% in the placebo group (P = .02). Notably, while cathelicidin levels dropped over time in both groups, they were significantly lower for the doxycycline group than for placebo at weeks 2, 4, 8, and 12. At week 12, doxycycline patients also had significantly lower expression of the associated CAMP gene than at baseline or compared with the placebo group. The same trends occurred for KLK5 and MMP9 expression. Furthermore, doxycycline led to a significant drop in serine protease activity by week 8 compared with baseline and with the placebo group.

Treatment response also correlated with lower CAMP expression and with lower serine protease and MMP activity among doxycycline patients, Dr. Di Nardo reported. At week 12, patients with IGA scores of 0 or 1 (clear or near-clear) had the lowest levels of all three biomarkers, while patients with moderate or severe disease had substantially higher levels of all three biomarkers. 

Finally, baseline levels of two of the biomarkers significantly predicted treatment response (P less than .05). 

"Patients who reached success at 12 weeks were those who started with lower baseline levels of matrix metalloprotease, or lower or intermediate baseline levels of serine protease," Dr. Di Nardo said. Patients who did not respond to doxycycline may simply have needed a higher dose, she added.

Galderma Laboratories and the National Rosacea Society funded the study. Dr. Di Nardo had no disclosures.

VITALS

Key clinical point: Doxycycline significantly reduced disease activity and levels of cathelicidin in the skin of patients with papulopustular rosacea.

Major finding: Average cathelicidin levels dropped over time in both groups, but were significantly lower for the doxycycline group compared with placebo at weeks 2, 4, 8, and 12.

Data source: A randomized, double-blind, placebo-controlled study of 170 adults with papulopustular rosacea.

Disclosures: Galderma Laboratories and the National Rosacea Society funded the study. Dr. Di Nardo had no disclosures.

 

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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