update of rosacea · • azelaic acid gel 15%/ 20% lotion/ cream/ foam • benzoyl peroxide/...

15/09/2016

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• Dr Samantha Eisman

• Dermatologist Sinclair Dermatology• MBChB MRCP(UK) FCDerm(SA) FACD

Update of Rosacea

• Sinclair Dermatology • Professor Rod Sinclair

Acknowledgment ‐ photographs

• Chronic skin disorder of vascular origin• Skin of central face (convexities)• Woman• Skin type I and II

• Prevalence 0,5%‐22%• 1,78 Million in Australia• Low self esteem

Rosacea‐ definition

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Pathogenesis

Increased vascularity

InflammationAround vessels

ROSACEA

Clinical Signs



ROSACEA Disrupts barrier/ papules/ pustules

Flush/ erythema/Dilated capillaries

Pathogenesis



genetic

ROSACEA

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Pathogenesis



genetic EnvironmentalDietary triggerDrugs/Disease

ROSACEA

Pathogenesis




infection

ROSACEA

Pathogenesis




infection

ROSACEA

Dysregulation innate immunity‐increase toll‐like R‐2‐increase cathelicidin‐Increase kallikrein 5‐increase MMP

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• Primary Features‐ one or more in central face

• Flushing• Non transient erythema• Papules and pustules (no comedones)• Telangiectasia

Diagnostic Criteria

• Secondary Features‐ one/more may be present

• Burning/ stinging/dryness/scaling• Red plaques/phymatous changes/oedema• Eyes signs• Peripheral location

Diagnostic Criteria

• 1. Erythematotelangiectatic (12%)

• 2. Papulopustular (69%)

• 3. Phymatous (3,7%)

• 4. Ocular (6‐50%)

• 5. Variants

Subtypes

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• Flushing• Persistent central facial erythema (spare periocular)• Burning and stinging• Irritation from topical substances• Minimal inflammatory lesions/scale

1. Erythematotelangiectatic (ETT)

• Redness central face• Telangiectasia• Spare periocular skin• Papules and pustules (transient)• Oedema may be present• Flushing (mild)

2. Papulopustular

• Sebaceous hyperplasia• Skin thickens• Irregular surfaces and nodularities/ prominent pores• Nose/chin/forehead/eyelids

3. Phymatous

rhynophyma

gnatophymametophyma

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• May precede skin signs• 50‐70% patients• Unilateral or asymmetrical • Decrease tear secretion and Meibomian gland dysfunction• 20% present eyes first/ 50% present skin first

4. Ocular/ Eye involvement

injection

• More than 1• Burning/ blurred vision/ stinging/ itching/ light sensitivity/

FB/watery/ bloodshot/ dryness/telangiectasia conjunctiva or lid/ lid and periocular erythema

• Conjunctivitis• Blepharitis• Stye (chalazion)• Meibomian gland inflammation• Rosacea keratitis (5%)‐ corneal involvement

4. Ocular/ Eye involvement

• Granulomatous• Chronic Lymphoedema• Steroid induced• Rosacea fulminans

5. Variants

lymphoedema

Steroid induced

Rosacea fulminans

granulomatous

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• Acne• Perioral dermatitis• Keratosis Pilaris• Seborrhoeic dermatitis• Photodermatitis (seasonal/ extrafacial)• Contact dermatitis (scale/ eczematous/ site application)• Systemic Lupus erythematosis (malar/ photosensitivity)• DLE (follicular plug/ scale /pigmentary changes/ scar)• Sarcoidosis (no skin surface changes/ smooth)• Tinea facei

Differential diagnosis

• Comedones• Not limited face• Younger age onset• No telangiectasia or flushing

• Both‐ papules/ pustules/ erythema

Acne

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• monomorphic papules• Around orifices• Smaller lesions• No telangiectasia/ flush/blush

Peri‐oral dermatitis

• Fixed erythema• Small follicular keratotic plugs• Arms and thighs• Younger patient

Keratosis pilaris

• Eczematous• Greasy scale in scalp and brow/ earparanasal/nasolabial/ extrafacial

• Often co‐ exist

• Both‐ erythema/ blepharitis

Seborrhoeic dermatitis

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• Avoid trigger• Skin care• Disease specific• Maintenance

Treatment of Rosacea


Treatment

• Heat (exercise/ bath/ food/ clothes/ heating home)• Exertion• Emotions (anger/ embarrassment/ stress)• Weather (wind/ heat)• Food (pepper/ coffee/ tea/ citrus/ tomato/choc)• Topical products (cosmetics/ toners/anti‐wrinkle/acne/fragrance)• Drugs (vasodilators/ steroids/ tamoxifen/ erectile dysfunction/

metformin/ nicotinic acid)

Treatment‐ avoid trigger

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Treatment

• Soap Free washes

• Simple emollients (apply after medicated products)

• Sun protection (UVA and UVB)‐ at least SPF 30

• Cosmetics

Treatment‐ Skin care


Treatment

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Pathogenesis



ROSACEA

Treatment of inflammatory component‐Papulopustular

(papules/ pustules/ phymatous)

• Topical• Antibiotics• Anti‐inflammatory

• Systemic (extensive or non‐ responsive)• Antibiotics (off‐label use)• Isotretinoin (off‐label)• ivermectin

• Laser/ Surgery

• Metronidazole 0,5%/ 1%/0,75% / cream/gel/ointment/ lotion

• Erythromycin gel

• Clindamycin lotion

Topical antibiotics

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• Azelaic acid gel 15%/ 20% lotion/ cream/ foam

• Benzoyl peroxide/ +/‐ clindamycin or erythromycin

• Retinoids (adapalene cream/gel and tretinoin cream/gel)

• Calcineurin inhibitors (pimecrolimus and tacrolimus)

• Sulphacetamide 10%/ sulphur 5% lotion/ cream

• Ivermectin 1% cream / permethrin 5% cream

Topical anti‐inflammatory

• First line antibiotics• Doxycycline/ minocycline 50‐100mg daily

• Second line antibiotics• Erythromycin 250mg‐500mg BD/QDS or 400mg BD• Clarithromycin 250mg‐500mg BD/QDS• Azithromycin 250mg 3weekly/ 1000mg 45 days then 500mg 45

days)• Amoxycillin• Bactrim• Metronidazole 200mg BD 6 weeks

• Isotretinoin‐ low dose/ longterm• Ivermectin

Systemic treatment

Pathogenesis



ROSACEA

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Treatment of Vascular Component‐Erythematotelangiectatic

Redness/ telangiectasia/ flushing

Topical vasoconstrictorsSystemicLaser Surgery

• Brimonidine 0,5% gel

• Oxymetazoline 0.05% solution (nasal)

• ‐

Topical vasoconstrictors

• B blockers• Clonidine• Aspirin • Naloxone• Ondansetron• SSRIs• Contraceptive pill• Amitriptyline

• Botox

Systemic treatment for flushing

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• Telangiectasia/ persisting erythema AND symptoms

• Short wavelength Lasers (superficial vessels and persistent erythema)• Pulsed dye laser/ long pulsed dye laser• Long‐pulse KTP laser

• IPL

• Diathermy

Laser/Surgery

• Artificial tears• Eyelid hygiene• Warm compress and massage• Cyclosporine 2% drops/ 0,05% emulsion• Metronidazole eye drops (compounded)• !0% sulphacetamide eye drops • Azithromycin 1,5% drops• Azithromycin and other oral antibiotics

• Ophthalmology review

Treatment Eyes

• High quality evidence• Topical azelaic acid/ ivermectin/ brimonidine• Doxy/ isotretinoin

• Moderate quality evidence• Topical metronidazole• Oral tetracyclines

• Low quality evidence• Low dose minocycline (45mg)• IPL AND laser• Cyclosporine ophthalmic emulsion

Cochrane review 2015

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• Topical serine protease inhibitors/? Cathelicidin blockers

• Topical mast cell stabilisers (cromolyn sodium)

• Nitric oxide inhibitors ( vasoconstrictors)

Future Treatments

• 45 year old woman• C/O 1 year flushing when eats spicy food or drinks red wine• Metronidazole burns• Azelaic acid too drying• Doxy and minocycline 8 weeks each• Uses thick make up to conceal• Many cosmetics sting/ burn

Case 1

• Lifestyle modification• Skin care ( emollient/ sunscreen/ soap free wash/ avoid

toners/ mineral make up)

• Combination• Topical anti‐inflammatory/antibiotic

• pimecrolimus/ azelaic acid/ metronidazole• Topical vasoconstrictor

• Brimonidine® gel• Oral antibiotic‐ doxy 100mg daily 3/12 (if inflammatory)• Laser/ light ( decrease recurrence after ab)

ETT rosacea

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• Reduces moderate to severe erythema• 5 DBPCT confirm effectiveness• TGA 2014

• Onset action 30 min• Lasts 12 hr• SE‐mild and transient worsening erythema/flushing• Expensive

Brimonidine® gel

• Lifestyle modification• Skin care ( emollient/ sunscreen/ soap free wash/ avoid

toners/ mineral make up)

• Combination• Topical anti‐inflammatory/antibiotic

• pimecrolimus/ azelaic acid/ metronidazole• Topical vasoconstrictor

• Brimonidine® gel• Oral antibiotic‐ doxy 100mg daily 3/12 (if inflammatory)• Laser/ light ( decrease recurrence after ab)

ETT rosacea

Pulsed dye laser

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• 68 year old man• Red face• No ETOH• Good skin care• Tried many topicals• Tried Doxy• Tried Laser

Case 2

• Environmental/ trigger factors• Skin Care• Combination

• Topical anti‐inflammatory‐ azelaic acid/ pimecrolimus• Topical antibiotic‐ metronidazole• Topical Ivermectin

• Oral antibiotics

• Isotretinoin (referral)

• Maintenance• Taper antibiotics• Topicals 6‐9 months

Papulopustular rosacea

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• Anti‐parasite and anti‐inflammatory• FDA 2014/ TGA 2015• Inflammatory lesions (mod‐severe PPR rosacea)• Once daily• Superior to vehicle in two DBRCT• 38‐40% clear after 12 weeks (cf 12‐19% vehicle)• Burning

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• As for papulopustular rosacea

• Isotretinoin ( before and or after laser)

• Ablative lasers‐ CO2 and erbium;YAG

• Surgery/ Electrosurgery/ dermabrasion / cryosurgery

• Psyche

Rhynophyma

• Non contagious inflammation of skin of face

• Cause unknown but many new theories (therapeutic targets)

• No cure but options for control

• Avoid triggers and good skin care

• Variety of topicals/ medications and laser‐ subtype

• Non responders/ eye disease – referral

• Online support groups

Take home

update of rosacea · • azelaic acid gel 15%/ 20% lotion/ cream/ foam • benzoyl peroxide/...

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