acne and rosacea update

Acne and Acne and Rosacea UpdateRosacea Update

Assistant Professor of Dermatology, Assistant Professor of Dermatology, University of Miami, Miller School of University of Miami, Miller School of

Medicine Medicine Chief, Dermatology Service, Miami VA Chief, Dermatology Service, Miami VA

HospitalHospital

AcneAcne

Prevalence of AcnePrevalence of Acne In the US, more than 50 million are affected by In the US, more than 50 million are affected by

some form of acne, and over 17 million have acne some form of acne, and over 17 million have acne vulgarisvulgaris11

Women more than men Women more than men 79-95% of all teens are affected79-95% of all teens are affected22

May also begin in 20’s or 30’s and persist in adults for May also begin in 20’s or 30’s and persist in adults for many yearsmany years22

12% of women until age 4412% of women until age 44 3% of men until age 443% of men until age 44

Most patients are mild to moderate in severityMost patients are mild to moderate in severity

1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: http://www.niams.nih.gov/hi/topics/acne/acne.htm. 2. Cordain L, Lindeberg S, Hurtado M, et al. Arch Dermatol. 2002;138:1584-1590.

4 Key Components of Acne 4 Key Components of Acne DevelopmentDevelopment

Follicular plugging and excessive sebum Follicular plugging and excessive sebum productionproduction

Enlargement of sebaceous glands and Enlargement of sebaceous glands and development of microcomedonesdevelopment of microcomedones

Propionobacterium acnesPropionobacterium acnes in in microcomedones triggers inflammatory microcomedones triggers inflammatory processprocess

Release of cytotoxic and chemotactic Release of cytotoxic and chemotactic agents leads to further inflammationagents leads to further inflammation

Who gets treated?Who gets treated?

Acne and Socioeconomic Acne and Socioeconomic StatusStatus

Ontario, CanadaOntario, Canada 295,469 patients 295,469 patients Given diagnosis of acne by Primary Given diagnosis of acne by Primary

Care physicianCare physician Measured outcome was visit to Measured outcome was visit to

Dermatologist within 2 years of Dermatologist within 2 years of initial diagnosisinitial diagnosis

Acne and Socioeconomic Acne and Socioeconomic StatusStatus

Lowest income level (by neighborhood, Lowest income level (by neighborhood, not individual) – 17% referrednot individual) – 17% referred

Highest income level (same as above) – Highest income level (same as above) – 24% referred24% referred

When comparing urban to rural areas, When comparing urban to rural areas, urban patients were 43% more likely to urban patients were 43% more likely to be referred to a dermatologist for acnebe referred to a dermatologist for acne

Antibiotics as treatmentAntibiotics as treatment

Systemic Systemic AntibioticsAntibiotics

Conventional and Conventional and Unconventional ApproachesUnconventional Approaches

Systemic AntibioticsSystemic Antibiotics

Doxycycline - 100mg BIDDoxycycline - 100mg BID Minocycline - 100mg BIDMinocycline - 100mg BID Tetracycline - 500mg BIDTetracycline - 500mg BID Trimethoprim/sulfamethoxazole - a Trimethoprim/sulfamethoxazole - a

tab BIDtab BID Erythromycin - 500mg BIDErythromycin - 500mg BID Azithromycin 250-500mg QD Azithromycin 250-500mg QD

(pulses)(pulses)

Pulse dosing of antibiotics Pulse dosing of antibiotics for acnefor acne

Azithromycin most often used in this Azithromycin most often used in this settingsetting

Various dosing regimensVarious dosing regimens Comparable efficacy with daily Comparable efficacy with daily

dosing of antibioticsdosing of antibiotics44

44Parsad, D., Pandhi, R., Hagpal, R., Negi, K.S. Journal of Dermatology. 28(1):1-4, Parsad, D., Pandhi, R., Hagpal, R., Negi, K.S. Journal of Dermatology. 28(1):1-4, 2001 Jan.2001 Jan.

Newer formulations of Newer formulations of antibioticsantibiotics

OraceaOracea (Doxycycline)(Doxycycline) 30mg immediate release30mg immediate release 10mg delayed release10mg delayed release

FDA Approved for treatment of rosaceaFDA Approved for treatment of rosacea


PeriostatPeriostat Doxycycline 20mg po BIDDoxycycline 20mg po BID


SolodyneSolodyne MinocyclineMinocycline Dosing is WEIGHT BASED Dosing is WEIGHT BASED

Not the same dosing as standard Not the same dosing as standard minocyclineminocycline

Daily dosingDaily dosing 45, 90, 135mg daily doses45, 90, 135mg daily doses Approved for 12 weeks of useApproved for 12 weeks of use

Antibiotics and UTIs?Antibiotics and UTIs?

Antibiotics and URTIs?Antibiotics and URTIs?

Acne patients on oral antibiotics are Acne patients on oral antibiotics are about 2 times more likely to develop about 2 times more likely to develop an upper respiratory tract infections an upper respiratory tract infections (URTI)(URTI)

Their household contacts do not Their household contacts do not appear to be at increased riskappear to be at increased risk

Dermatology. 215(3):213-8. 2007.Dermatology. 215(3):213-8. 2007.

Antibiotics and the risk of Breast Antibiotics and the risk of Breast CancerCancer

9 year follow up9 year follow up 2.1 million women2.1 million women

Observed associations between, antibiotics Observed associations between, antibiotics overall, tetracyclines, and macrolides with overall, tetracyclines, and macrolides with breast cancer were WEAK and could be breast cancer were WEAK and could be explained uncontrolled confounding by explained uncontrolled confounding by other diseases or other factorsother diseases or other factors

Cancer Epidemiology, Biomarkers & Prevention. 15(11):2102-6, 2006 Nov.Cancer Epidemiology, Biomarkers & Prevention. 15(11):2102-6, 2006 Nov.

Prostate Cancer and Prostate Cancer and Acne?Acne?

Prostatectomy specimens which grew P. Prostatectomy specimens which grew P. acnes were more likely to have acnes were more likely to have inflammation that specimens that had inflammation that specimens that had negative cultures or grew other bacterianegative cultures or grew other bacteria

Retrospective analysis asking men if they Retrospective analysis asking men if they had taken antibiotics for acne for 4 or had taken antibiotics for acne for 4 or more years.more years.

Those that did had a higher rate of Those that did had a higher rate of prostate cancerprostate cancer

Sutcliffe S. Giovannucci E. Isaacs WB. Willett WC. Platz EA. Sutcliffe S. Giovannucci E. Isaacs WB. Willett WC. Platz EA. Acne and risk of prostate cancer.Acne and risk of prostate cancer. [Journal Article. Research Support, [Journal Article. Research Support, N.I.H., Extramural] N.I.H., Extramural] International Journal of International Journal of CancerCancer. 121(12):2688-92, 2007 Dec 15.. 121(12):2688-92, 2007 Dec 15.

Prostate Cancer and Prostate Cancer and Acne?Acne?

View with cautionView with caution Acne is a complex condition, not Acne is a complex condition, not

solely caused by solely caused by P. acnesP. acnes Need more data Need more data

Cephalexin to treat acne?Cephalexin to treat acne?

retrospective chart review of 93 acne retrospective chart review of 93 acne patientspatients

4% of patients cleared4% of patients cleared 45% were much improved45% were much improved 29% were somewhat improved29% were somewhat improved 16% experienced no change16% experienced no change 6% worsened at first follow-up visit.6% worsened at first follow-up visit.

Fenner JA, Wiss K, Levin NA. Oral cephalexin for acne vulgaris: clinical experience with 93 Fenner JA, Wiss K, Levin NA. Oral cephalexin for acne vulgaris: clinical experience with 93 patients. Pediatric Dermatology./ Vol. 25. NO. 2 179-83, 2008.patients. Pediatric Dermatology./ Vol. 25. NO. 2 179-83, 2008.

Cephalexin for acne?Cephalexin for acne? Median treatment length was 6 months.Median treatment length was 6 months.

Eighty-four percent of patients had Eighty-four percent of patients had previously used a systemic antibiotic(s) previously used a systemic antibiotic(s) for for acneacne

Drawbacks: small retrospective Drawbacks: small retrospective analysis without a comparison group analysis without a comparison group and is limited by the number of patients and is limited by the number of patients and nonstandardized treatment lengths and nonstandardized treatment lengths and charting proceduresand charting procedures

Diet and Diet and AcneAcne

Beliefs about acneBeliefs about acne

Multiple studies from various areas Multiple studies from various areas around the worldaround the world

Patient around the world list diet as Patient around the world list diet as a cause or aggravator or acnea cause or aggravator or acne

Diet and acneDiet and acne

For the last thirty plus years most For the last thirty plus years most dermatologists have told patients that dermatologists have told patients that acne is not caused by what they eat. acne is not caused by what they eat. These concepts came from two studies These concepts came from two studies evaluating chocolateevaluating chocolate11 and chocolate and chocolate bars, milk, peanuts, and Coca-Colabars, milk, peanuts, and Coca-ColaTMTM,,22 and their role in causing acneand their role in causing acne

1. Fulton, J.E.Jr., Plewig, G., Kligman, A.M. Effect of chocolate on acne vulgaris. 1. Fulton, J.E.Jr., Plewig, G., Kligman, A.M. Effect of chocolate on acne vulgaris. JAMA. 1969;210:2071-4.JAMA. 1969;210:2071-4.

2. Anderson,P.C. Foods as the cause of acne. Am Fam Physician. 1971;3:102-2. Anderson,P.C. Foods as the cause of acne. Am Fam Physician. 1971;3:102-

103.103.

Chocolate and AcneChocolate and Acne

Study is frequently misinterpretedStudy is frequently misinterpreted Chocolate bars with cacao solids Chocolate bars with cacao solids

(cacao paste and cocoa butter) (cacao paste and cocoa butter) versus bars without cacao solidsversus bars without cacao solids

There was no difference between the There was no difference between the sugar and fat content in the barssugar and fat content in the bars

There was no milk in the barsThere was no milk in the bars

Role of Diet Role of Diet and Acneand Acne

In 2002, Cordain, et al. In 2002, Cordain, et al. reported the prevalence of acne reported the prevalence of acne

in 2 nonwesternized in 2 nonwesternized populationspopulations

Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002; 138:1584-90.Dermatol 2002; 138:1584-90.

Ache hunter-gatherers of Ache hunter-gatherers of ParaguayParaguay

Kitavan Islanders of Papua Kitavan Islanders of Papua New GuineaNew Guinea

Role of Diet and AcneRole of Diet and Acne These populations had no These populations had no

evidence of acneevidence of acne Hypothesized these people had Hypothesized these people had

low glycemic loadslow glycemic loads

Controversy with this study is Controversy with this study is how much of their condition is how much of their condition is related to related to geneticsgenetics versus versus environmentenvironment??

Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002; 138:1584-90.Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002; 138:1584-90.

Diet and AcneDiet and Acne

Young men with acne have also been Young men with acne have also been studied studied

Forty-three (43) men aged 15-25 with Forty-three (43) men aged 15-25 with acne, acne,

control versus low glycemic load diet control versus low glycemic load diet groups for 12 weeks. groups for 12 weeks.

Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. controlled trial. J Am Acad Dermatol.J Am Acad Dermatol. 57(2), 247-56 (2007). 57(2), 247-56 (2007).

Diet and AcneDiet and Acne

Low glycemic load groupLow glycemic load group Lost WeightLost Weight Reduced Free Androgen IndexReduced Free Androgen Index Increase in Insulin-like Growth Factor Increase in Insulin-like Growth Factor

Binding Protein – 1 (IGFBP-1) – known Binding Protein – 1 (IGFBP-1) – known to be correlated with insulin levelsto be correlated with insulin levels

Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. 57(2), 247-56 (2007).

Glycemic Index vs Glycemic Glycemic Index vs Glycemic LoadLoad

Glycemic indexGlycemic index is a relative comparison of the potential is a relative comparison of the potential of various foods to increase blood glucose given there is of various foods to increase blood glucose given there is an equal amount of carbohydrate in the food an equal amount of carbohydrate in the food

Glycemic indexGlycemic index is a measure of carbohydrate quality is a measure of carbohydrate quality (i.e. nature or source) but (i.e. nature or source) but not quantitynot quantity

Glycemic loadGlycemic load assesses the potential of a food to assesses the potential of a food to increase blood glucose and is defined as glycemic index increase blood glucose and is defined as glycemic index * carbohydrate content* carbohydrate content

Glycemic loadGlycemic load relates carbohydrate relates carbohydrate quantity and quantity and qualityquality

Values Values Glycemic index:Glycemic index:

Low 1-55Low 1-55 moderate 56-69moderate 56-69 high 70-100high 70-100

Glycemic load:Glycemic load:

Low 1-10Low 1-10 Moderate, 11-19 Moderate, 11-19 High 20 and upHigh 20 and up

www.glycemicindex.comwww.glycemicindex.com

Glycemic Glycemic IndexIndex

Glycemic Glycemic LoadLoad

Glycemic Glycemic IndexIndex

Glycemic Glycemic LoadLoad

MuffinMuffin 5959 1717 DoughnutDoughnut 7676 1717

Coca ColaCoca Cola11 6363 1616 GatoradeGatorade22 7878 1212

Multigrain breadMultigrain bread 4343 66 White breadWhite bread 7070 1010

All –Bran CerealAll –Bran Cereal33 3838 99 Cornflakes CerealCornflakes Cereal33 9292 2424

Sweet cornSweet corn 6060 2020 ChickpeasChickpeas 3131 99

Brown riceBrown rice 5050 1616 White riceWhite rice 5656 2323

Skim MilkSkim Milk 3232 44 Whole MilkWhole Milk 4040 33

Ice creamIce cream 6262 88 Low-fat yogurtLow-fat yogurt 1414 22

AppleApple 4040 66 BananaBanana 5151 1313

GrapesGrapes 4343 77 MangoMango 4141 88

WatermelonWatermelon 7272 44 PeachPeach 2828 44

Macaroni and cheeseMacaroni and cheese44 6464 3232 SpaghettiSpaghetti 3232 1515

Corn ChipsCorn Chips55 4242 1111 Kudos BarKudos Bar66 6262 2020

M &M’s peanutM &M’s peanut77 3333 66 Cashew nutsCashew nuts88 2222 33

PopcornPopcorn99 5555 66 PretzelsPretzels1010 8383 1616

CarrotsCarrots 4747 33 Baked PotatoBaked Potato 6060 1818

Sweet PotatoSweet Potato 4848 1616 TaroTaro 5454 44

References to previous References to previous slideslide

Glycemic reference is glucose with a glycemic index Glycemic reference is glucose with a glycemic index of 100. Data adapted from Foster-Powell et al. [5]of 100. Data adapted from Foster-Powell et al. [5]

1Atlanta, GA, USA1Atlanta, GA, USA 2Spring Valley Beverages Pty Ltd, Cheltenham, 2Spring Valley Beverages Pty Ltd, Cheltenham,

AustraliaAustralia 3Kellogg’s, Battle Creek, MI, USA3Kellogg’s, Battle Creek, MI, USA 4Kraft General Foods Canada Inc, Don Mills, 4Kraft General Foods Canada Inc, Don Mills,

CanadaCanada 5Smith’s Snack Food Co., Australia5Smith’s Snack Food Co., Australia 6M &M/Mars, Hackettstown, NJ, USA6M &M/Mars, Hackettstown, NJ, USA 7Mars Confectionery, Australia7Mars Confectionery, Australia 8Coles Supermarkets, Australia8Coles Supermarkets, Australia 9Green’s Foods, Australia9Green’s Foods, Australia 10Parker’s, Smith’s Snack Food Co., Australia10Parker’s, Smith’s Snack Food Co., Australia

Foods with a high glycemic loadFoods with a high glycemic load

HIGH GLYCEMIC DIET

INCREASE IN INSULIN

HIGH GLYCEMIC DIET

INCREASE IN INSULIN LIKE GROWTH FACTOR 1

HIGH GLYCEMIC DIET

INCREASE IN INSULIN

Cappel. M., Arch Dermatol. Cappel. M., Arch Dermatol. 2005;141:333/8.2005;141:333/8.

Insulin-like growth factor 1 Insulin-like growth factor 1 (IGF-1)(IGF-1)

IGF-1 may promote acne by inducing IGF-1 may promote acne by inducing hyperkeratosishyperkeratosis and and epidermal epidermal hyperplasiahyperplasia

AA first step in the follicular plug first step in the follicular plug

IGF-1 can stimulate IGF-1 can stimulate androgensandrogens, well , well known to cause an increase in sebumknown to cause an increase in sebum

Bol, K.K., Kiguchi, K., Gimenez-Conti, I., Rupp, T., DiGiovanni, J. Overexpression of insulin-like growth Bol, K.K., Kiguchi, K., Gimenez-Conti, I., Rupp, T., DiGiovanni, J. Overexpression of insulin-like growth factor-1 induces hyperplasia, dermal abnormalities, and spontaneous tumor formation in transgenic factor-1 induces hyperplasia, dermal abnormalities, and spontaneous tumor formation in transgenic mice. Oncogene. 1997;14:1725-1734mice. Oncogene. 1997;14:1725-1734..

INCREASE IN IGF 1

HIGH GLYCEMIC DIET

INCREASE IN INSULIN

INCREASE IN ANDROGENS

POSITIVELY INFLUENCE EACH OTHER

IGF-1 in patientsIGF-1 in patients Post-adolescent women (20-25 Post-adolescent women (20-25

years)years)

Those with acne had higher levels Those with acne had higher levels of IGF-1of IGF-1

Cappel, M., Mauger, D., Thiboutot, D. Correlation between serum levels of insulin-like growth factor Cappel, M., Mauger, D., Thiboutot, D. Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. Arch Dermatol. 2005;141:333-338.Arch Dermatol. 2005;141:333-338.

Food and AcneFood and Acne

Recent study implicates milkRecent study implicates milk 47,355 women from the Nurses Health 47,355 women from the Nurses Health

Study II retrospectively assessedStudy II retrospectively assessed Completed questionnaires regarding diet Completed questionnaires regarding diet

and teenage acneand teenage acne Found positive association between milk Found positive association between milk

and teenage acneand teenage acne

Adebamowo, C.A., JAAD 2005;52:207-14.Adebamowo, C.A., JAAD 2005;52:207-14.

Second study implicating Second study implicating MilkMilk

Boys in the Growing Up Today Study Boys in the Growing Up Today Study (GUTS)(GUTS)

Offspring of the women in the Offspring of the women in the Nurses Health Study II listed aboveNurses Health Study II listed above

Positive association between the Positive association between the intake of skim milk and acneintake of skim milk and acne

Genetic association relating to acne Genetic association relating to acne is not discussed is not discussed

Adebamowo CA, Spiegelman D, Berkey CS, Adebamowo CA, Spiegelman D, Berkey CS, et alet al. . Milk consumption and acne in teenaged boys. Milk consumption and acne in teenaged boys. J J Am Acad Dermatol. Am Acad Dermatol. (2008) [Epub ahead of print].(2008) [Epub ahead of print].

Further data implicating Further data implicating dietdiet Tape stripping of skin of acne patientsTape stripping of skin of acne patients

Looked at composition of surface lipids Looked at composition of surface lipids of those on low glycemic load diet of those on low glycemic load diet versus control dietversus control diet

Difference in patients based on the dietDifference in patients based on the diet ? Does this suggest that what we eat ? Does this suggest that what we eat

may play a role at the skin surfacemay play a role at the skin surface Early but interesting dataEarly but interesting data Smith, Et al. The effect of a low glycemic load diet on acne vulgaris and the fatty acid composition of the skin surface Smith, Et al. The effect of a low glycemic load diet on acne vulgaris and the fatty acid composition of the skin surface

triglycerides. Jour. Derm Science. 50: 41-52. 2008.triglycerides. Jour. Derm Science. 50: 41-52. 2008.

Factors to considerFactors to consider

LGL group also lost weightLGL group also lost weight Was weight loss the factor and not the Was weight loss the factor and not the

actual LGL diet?actual LGL diet? Sebum production is largely under Sebum production is largely under

genetic controlgenetic control First study to look at the surface First study to look at the surface

lipids during a dietary interventionlipids during a dietary intervention

Food and AcneFood and Acne

Milk has been associated Milk has been associated with increased IGF-1 with increased IGF-1 levelslevels

Holmes, M.D., Cancer Epidem. Biomarkers Prev 2002;11:1228-Holmes, M.D., Cancer Epidem. Biomarkers Prev 2002;11:1228-12331233

In clinical In clinical practice how practice how

can we can we connect IGF-connect IGF-1 and acne?1 and acne?

Polycystic Ovarian Polycystic Ovarian SyndromeSyndrome

Best evidenceBest evidence for a role for a role of diet and acneof diet and acne


AcneAcne Irregular mensesIrregular menses Overweight, but not necessarily soOverweight, but not necessarily so AlopeciaAlopecia HirsuitismHirsuitism InfertilityInfertility


Increased levels of insulinIncreased levels of insulin Increased levels of IGF-1Increased levels of IGF-1 Increased androgensIncreased androgens


Acne improvesAcne improves with medications with medications which which improve insulin improve insulin metabolismmetabolism::

MetforminMetformin TolbutamideTolbutamide PioglitazonePioglitazone

What do we tell our What do we tell our patients?patients?

The jury is still out on the role of diet The jury is still out on the role of diet causing acne.causing acne.

Emphasize that the pathogenesis is Emphasize that the pathogenesis is multifactorialmultifactorial, so no single treatment , so no single treatment or habit change will rid them of the or habit change will rid them of the disease.disease.

Should not dismiss the patient those Should not dismiss the patient those swears that a certain food is a trigger. swears that a certain food is a trigger. Have patients avoid the offending food, if Have patients avoid the offending food, if they feel it is a trigger.they feel it is a trigger.

RosaceaRosacea

Prevalence of RosaceaPrevalence of Rosacea

Common facial disorder affecting 13 Common facial disorder affecting 13 million in the USmillion in the US11

All races and both sexes affectedAll races and both sexes affected Most commonly seen in CaucasiansMost commonly seen in Caucasians Higher overall prevalence in women with Higher overall prevalence in women with

phymas more common in menphymas more common in men

1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: http://www.niams.nih.gov/hi/topics/rosacea/rosacea.htm.

Treatments for RosaceaTreatments for Rosacea

Topical AntibioticsTopical Antibiotics Systemic AntibioticsSystemic Antibiotics Topical SulfurTopical Sulfur Systemic IsotretinoinSystemic Isotretinoin

Avoidance of trigger factorsAvoidance of trigger factors

RosaceaRosacea randomized vehicle-controlled double-blind randomized vehicle-controlled double-blind

trial trial 40 patients40 patients 4-8 weeks4-8 weeks

pimecrolimus cream 1% was not more pimecrolimus cream 1% was not more efficacious than treatment with the vehicle efficacious than treatment with the vehicle cream.cream.

British Journal of Dermatology. 156(4):728-32, 2007 Apr.British Journal of Dermatology. 156(4):728-32, 2007 Apr.

Z-pak for Rosacea?Z-pak for Rosacea? Reactice oxygen species (ROS) where measured in Reactice oxygen species (ROS) where measured in

patients with rosacea and healthy controlspatients with rosacea and healthy controls

Skin biopsiesSkin biopsies were taken before treatment with were taken before treatment with azithromycin (500mg 3 days of each week) and after azithromycin (500mg 3 days of each week) and after 4 weeks on this regimen4 weeks on this regimen

ROS were greater before treatment in the rosacea ROS were greater before treatment in the rosacea patientspatients

ROS decreased in rosacea patients after this ROS decreased in rosacea patients after this treatmenttreatment

Clinical & Experimental Dermatology. 32(2):197-200, 2007 Mar.Clinical & Experimental Dermatology. 32(2):197-200, 2007 Mar.

Cetaphil and RosaceaCetaphil and Rosacea 20 patients20 patients Split face studySplit face study Entire face received Metronidazole 0.75%Entire face received Metronidazole 0.75% One half of the face got Cetaphil creamOne half of the face got Cetaphil cream Restoration of skin barrier and less skin Restoration of skin barrier and less skin

sensitivity, sensitivity, (electrical capacitance, transepidermal water loss (electrical capacitance, transepidermal water loss

(TEWL), and lactic acid stinging test(TEWL), and lactic acid stinging test))

Concluded that a basic therapeutic moisturizer Concluded that a basic therapeutic moisturizer will help patients with rosaceawill help patients with rosacea

Journal of Dermatological Treatment. 18(3):158-62, 2007.Journal of Dermatological Treatment. 18(3):158-62, 2007.

Heat the known culpritHeat the known culprit Guzman-Sanchez et al. Guzman-Sanchez et al. quantitativelyquantitatively evaluated heat sensitivity evaluated heat sensitivity

of the skin of rosacea patients of the skin of rosacea patients

They found that the heat pain threshold was lower in the skin They found that the heat pain threshold was lower in the skin involved with rosaceainvolved with rosacea

More prominent in the papulopustular rosacea subtypeMore prominent in the papulopustular rosacea subtype

For years patients have been told to avoid hot caffeinated For years patients have been told to avoid hot caffeinated beverages such as coffee and tea, and although caffeine may beverages such as coffee and tea, and although caffeine may aggravate rosacea, there is now quantitative evidence that heat is aggravate rosacea, there is now quantitative evidence that heat is a true culprit. a true culprit.

Therefore, for many patients an iced coffee or tea may be less of Therefore, for many patients an iced coffee or tea may be less of an aggravator than originally thought an aggravator than originally thought

Guzman-Sanchez DA, Ishiuji Y, Patel T, et al. Enhanced skin blood flow and sensitivity to noxious heat stimuli in Guzman-Sanchez DA, Ishiuji Y, Patel T, et al. Enhanced skin blood flow and sensitivity to noxious heat stimuli in papulopustular rosacea. J Am Acad Dermatol 2007;57(5):800-5 papulopustular rosacea. J Am Acad Dermatol 2007;57(5):800-5

Alternative therapies for Alternative therapies for RosaceaRosacea

Omega-3 and omega-6 fatty acidsOmega-3 and omega-6 fatty acids Ophthalmology literature suggests such Ophthalmology literature suggests such

supplements or foods that contain such fatty supplements or foods that contain such fatty acids, may help with dry eyesacids, may help with dry eyes

Flax seed oil supplements, containing high Flax seed oil supplements, containing high levels of omega-3 fatty acid, may help levels of omega-3 fatty acid, may help combat ocular rosaceacombat ocular rosacea

Flax seed oil 1000mg orally twice dailyFlax seed oil 1000mg orally twice daily

Rashid S, Jin Y, Ecoiffier T, et al. Topical omega-3 and omega-6 fatty acids for treatment of dry eye. Arch. Ophthalmol Rashid S, Jin Y, Ecoiffier T, et al. Topical omega-3 and omega-6 fatty acids for treatment of dry eye. Arch. Ophthalmol

2008;162(2):219-25.2008;162(2):219-25.

Commonly Commonly asked asked

questionsquestions

Face washing in acneFace washing in acne Single-blinded, randomized, controlled trialSingle-blinded, randomized, controlled trial MalesMales Subjects divided into frequency groups of 1, 2, Subjects divided into frequency groups of 1, 2,

and 4 times a dayand 4 times a day 6 weeks – no statistically significant differences 6 weeks – no statistically significant differences

were noted between groupswere noted between groups Twice daily had noticeable improvements in Twice daily had noticeable improvements in

comedones and noninflammatory lesionscomedones and noninflammatory lesions Slight evidence that twice daily washing is Slight evidence that twice daily washing is

supported.supported.

Pediatric Dermatology. 23(5):421-7, 2006 Sept-Oct.Pediatric Dermatology. 23(5):421-7, 2006 Sept-Oct.

Makeup and AcneMakeup and Acne Make-up improves the quality of life in Make-up improves the quality of life in

acne patientsacne patients Can be done without aggravating acneCan be done without aggravating acne 18 females18 females Trained by a makeup artist and applied Trained by a makeup artist and applied

acne-designed cosmetics for 2-4 weeks acne-designed cosmetics for 2-4 weeks while their acne was being treatedwhile their acne was being treated

Improvement in their quality of life was Improvement in their quality of life was noted with three quality of life indexes, noted with three quality of life indexes, Skindex-16, GHQ30 and anxiety state indexSkindex-16, GHQ30 and anxiety state index

European Journal of Dermatology. 15(4):284-7, 2005 Jul-Aug.European Journal of Dermatology. 15(4):284-7, 2005 Jul-Aug.

Hypnosis and Acne?Hypnosis and Acne?

Case report Case report Pregnant womanPregnant woman 15 year history of “picking face”15 year history of “picking face” Topical Antibiotics were used to Topical Antibiotics were used to

acneacne Hypnotic suggestions alleviated her Hypnotic suggestions alleviated her

picking acneiform lesionspicking acneiform lesions

American Journal of Clinical Hypnosis. 46(3):239-45; Jan 2004American Journal of Clinical Hypnosis. 46(3):239-45; Jan 2004..

Acne ScarringAcne Scarring 27 Korean patients27 Korean patients Fitzpatrick Skin type IV to VFitzpatrick Skin type IV to V 1550-nm erbium-doped Fractional photothermolysis 1550-nm erbium-doped Fractional photothermolysis 3 month follow up; patient perspective3 month follow up; patient perspective

excellent improvement in eight patients (30%), excellent improvement in eight patients (30%), significant improvement in 16 patients (59%), significant improvement in 16 patients (59%), moderate improvement in three patients (11%)moderate improvement in three patients (11%)

Fractional photothermolysis for the treatment of acne scars: a report of 27 Korean patients.Fractional photothermolysis for the treatment of acne scars: a report of 27 Korean patients.Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, Chung JHLee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, Chung JH

Bone Density and Bone Density and IsotretinoinIsotretinoin

36 patients (16 male, 20 female)36 patients (16 male, 20 female)

120mg/kg cummulative dose of isotretinoin120mg/kg cummulative dose of isotretinoin

Bone mineral density in the lumbar spine and femur was Bone mineral density in the lumbar spine and femur was measured at baseline and at the end of therapymeasured at baseline and at the end of therapy

Serum calcium, phosphate, parathormone, total alkaline Serum calcium, phosphate, parathormone, total alkaline phosphatase, osteocalcin, free deoxypyridinoline, and phosphatase, osteocalcin, free deoxypyridinoline, and urinary calcium were also measured before and at the end urinary calcium were also measured before and at the end of treatmentof treatment..

Bone mineral density and bone turnover markers in patients receiving a single course of isotretinoin for nodulocystic acne.Tekin Bone mineral density and bone turnover markers in patients receiving a single course of isotretinoin for nodulocystic acne.Tekin NS, Ozdolap S, Sarikaya S, Keskin SINS, Ozdolap S, Sarikaya S, Keskin SI

Bone Density and Bone Density and IsotretinoinIsotretinoin

RESULTS:RESULTS: no statistically significant difference no statistically significant difference was observed between the BMD values in was observed between the BMD values in patients at the beginning vs. the end of patients at the beginning vs. the end of treatment (P > 0.05). treatment (P > 0.05).

no statistically significant changes in bone no statistically significant changes in bone turnover markers were observed in patients at turnover markers were observed in patients at the beginning vs. the end of treatment (P > the beginning vs. the end of treatment (P > 0.05).0.05).

CONCLUSION:CONCLUSION: A single course of isotretinoin A single course of isotretinoin therapy has no clinically significant effect on therapy has no clinically significant effect on bone metabolismbone metabolism

Thank YouThank You

acne and rosacea update

Health & Medicine