Acne and Rosacea Update

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Acne and Rosacea Update

  1. 1. Acne and RosaceaAcne and Rosacea UpdateUpdate Assistant Professor of Dermatology, University ofAssistant Professor of Dermatology, University of Miami, Miller School of MedicineMiami, Miller School of Medicine Chief, Dermatology Service, Miami VA HospitalChief, Dermatology Service, Miami VA Hospital
  2. 2. AcneAcne
  3. 3. Prevalence of AcnePrevalence of Acne  In the US, more than 50 million are affected by some form of acne,In the US, more than 50 million are affected by some form of acne, and over 17 million have acne vulgarisand over 17 million have acne vulgaris11  Women more than menWomen 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 many yearsMay also begin in 20’s or 30’s and persist in adults for many 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. 4. 4 Key Components of Acne4 Key Components of Acne DevelopmentDevelopment  Follicular plugging and excessive sebumFollicular plugging and excessive sebum productionproduction  Enlargement of sebaceous glands andEnlargement of sebaceous glands and development of microcomedonesdevelopment of microcomedones  Propionobacterium acnesPropionobacterium acnes in microcomedonesin microcomedones triggers inflammatory processtriggers inflammatory process  Release of cytotoxic and chemotactic agentsRelease of cytotoxic and chemotactic agents leads to further inflammationleads to further inflammation
  5. 5. Who gets treated?Who gets treated?
  6. 6. Acne and Socioeconomic StatusAcne and Socioeconomic Status  Ontario, CanadaOntario, Canada  295,469 patients295,469 patients  Given diagnosis of acne by Primary CareGiven diagnosis of acne by Primary Care physicianphysician  Measured outcome was visit to DermatologistMeasured outcome was visit to Dermatologist within 2 years of initial diagnosiswithin 2 years of initial diagnosis
  7. 7. Acne and Socioeconomic StatusAcne and Socioeconomic Status  Lowest income level (by neighborhood, notLowest income level (by neighborhood, not individual) – 17% referredindividual) – 17% referred  Highest income level (same as above) – 24%Highest income level (same as above) – 24% referredreferred  When comparing urban to rural areas, urbanWhen comparing urban to rural areas, urban patients were 43% more likely to be referred to apatients were 43% more likely to be referred to a dermatologist for acnedermatologist for acne
  8. 8. Antibiotics as treatmentAntibiotics as treatment
  9. 9. SystemicSystemic AntibioticsAntibioticsConventional and UnconventionalConventional and Unconventional ApproachesApproaches
  10. 10. Systemic AntibioticsSystemic Antibiotics  Doxycycline - 100mg BIDDoxycycline - 100mg BID  Minocycline - 100mg BIDMinocycline - 100mg BID  Tetracycline - 500mg BIDTetracycline - 500mg BID  Trimethoprim/sulfamethoxazole - a tab BIDTrimethoprim/sulfamethoxazole - a tab BID  Erythromycin - 500mg BIDErythromycin - 500mg BID  Azithromycin 250-500mg QD (pulses)Azithromycin 250-500mg QD (pulses)
  11. 11. Pulse dosing of antibiotics for acnePulse dosing of antibiotics for acne  Azithromycin most often used in this settingAzithromycin most often used in this setting  Various dosing regimensVarious dosing regimens  Comparable efficacy with daily dosing ofComparable efficacy with daily dosing of antibioticsantibiotics44  44 Parsad, D., Pandhi, R., Hagpal, R., Negi, K.S. Journal of Dermatology. 28(1):1-4, 2001 Jan.Parsad, D., Pandhi, R., Hagpal, R., Negi, K.S. Journal of Dermatology. 28(1):1-4, 2001 Jan.
  12. 12. Newer formulations of antibioticsNewer formulations of antibiotics  OraceaOracea (Doxycycline)(Doxycycline)  30mg immediate release30mg immediate release  10mg delayed release10mg delayed release  FDA Approved for treatment of rosaceaFDA Approved for treatment of rosacea
  13. 13. Newer formulations of antibioticsNewer formulations of antibiotics  PeriostatPeriostat  Doxycycline 20mg po BIDDoxycycline 20mg po BID
  14. 14. Newer formulations of antibioticsNewer formulations of antibiotics  SolodyneSolodyne  MinocyclineMinocycline  Dosing is WEIGHT BASEDDosing is WEIGHT BASED  Not the same dosing as standard minocyclineNot the same dosing as standard minocycline  Daily dosingDaily dosing  45, 90, 135mg daily doses45, 90, 135mg daily doses  Approved for 12 weeks of useApproved for 12 weeks of use
  15. 15. Antibiotics and UTIs?Antibiotics and UTIs?
  16. 16. Antibiotics and URTIs?Antibiotics and URTIs?  Acne patients on oral antibiotics are about 2Acne patients on oral antibiotics are about 2 times more likely to develop an uppertimes more likely to develop an upper respiratory tract infections (URTI)respiratory tract infections (URTI)  Their household contacts do not appear to be atTheir household contacts do not appear to be at increased riskincreased risk  Dermatology. 215(3):213-8. 2007.Dermatology. 215(3):213-8. 2007.
  17. 17. Antibiotics and URTIs?Antibiotics and URTIs?  Acne patients on oral antibiotics are about 2Acne patients on oral antibiotics are about 2 times more likely to develop an uppertimes more likely to develop an upper respiratory tract infections (URTI)respiratory tract infections (URTI)  Their household contacts do not appear to be atTheir household contacts do not appear to be at increased riskincreased risk  Dermatology. 215(3):213-8. 2007.Dermatology. 215(3):213-8. 2007.
  18. 18. Antibiotics and the risk of Breast CancerAntibiotics and the risk of Breast Cancer  9 year follow up9 year follow up  2.1 million women2.1 million women  Observed associations between, antibiotics overall,Observed associations between, antibiotics overall, tetracyclines, and macrolides with breast cancer weretetracyclines, and macrolides with breast cancer were WEAK and could be explained uncontrolledWEAK and could be explained uncontrolled confounding by other diseases or other factorsconfounding by other diseases or other factors  Cancer Epidemiology, Biomarkers & Prevention. 15(11):2102-6, 2006 Nov.Cancer Epidemiology, Biomarkers & Prevention. 15(11):2102-6, 2006 Nov.
  19. 19. Prostate Cancer and Acne?Prostate Cancer and Acne?  Prostatectomy specimens which grew P. acnesProstatectomy specimens which grew P. acnes were more likely to have inflammation thatwere more likely to have inflammation that specimens that had negative cultures or grewspecimens that had negative cultures or grew other bacteriaother bacteria  Retrospective analysis asking men if they hadRetrospective analysis asking men if they had taken antibiotics for acne for 4 or more years.taken antibiotics for acne for 4 or more years.  Those that did had a higher rate of prostateThose that did had a higher rate of prostate cancercancer  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, N.I.H., Extramural][Journal Article. Research Support, N.I.H., Extramural] International Journal ofInternational Journal of CancerCancer. 121(12):2688-92, 2007 Dec 15.. 121(12):2688-92, 2007 Dec 15.
  20. 20. Prostate Cancer and Acne?Prostate Cancer and Acne?  View with cautionView with caution  Acne is a complex condition, not solely causedAcne is a complex condition, not solely caused byby P. acnesP. acnes  Need more dataNeed more data
  21. 21. Cephalexin to treat acne?Cephalexin to treat acne?  retrospective chart review of 93 acne patientsretrospective chart review of 93 acne patients  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 patients. Pediatric Dermatology./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.Vol. 25. NO. 2 179-83, 2008.
  22. 22. Cephalexin for acne?Cephalexin for acne?  Median treatment length was 6 months.Median treatment length was 6 months.  Eighty-four percent of patients had previouslyEighty-four percent of patients had previously used a systemic antibiotic(s) forused a systemic antibiotic(s) for acneacne  Drawbacks: small retrospective analysis withoutDrawbacks: small retrospective analysis without a comparison group and is limited by thea comparison group and is limited by the number of patients and nonstandardizednumber of patients and nonstandardized treatment lengths and charting procedurestreatment lengths and charting procedures
  23. 23. Diet and AcneDiet and Acne
  24. 24. Beliefs about acneBeliefs about acne  Multiple studies from various areas around theMultiple studies from various areas around the worldworld  Patient around the world list diet as a cause orPatient around the world list diet as a cause or aggravator or acneaggravator or acne
  25. 25. Diet and acneDiet and acne  For the last thirty plus years most dermatologistsFor the last thirty plus years most dermatologists have told patients that acne is not caused byhave told patients that acne is not caused by what they eat. These concepts came from twowhat they eat. These concepts came from two studies evaluating chocolatestudies evaluating chocolate11 and chocolate bars,and chocolate bars, milk, peanuts, and Coca-Colamilk, peanuts, and Coca-ColaTMTM ,,22 and their role inand their role in causing acnecausing acne 1. Fulton, J.E.Jr., Plewig, G., Kligman, A.M. Effect of chocolate on acne vulgaris. JAMA.1. Fulton, J.E.Jr., Plewig, G., Kligman, A.M. Effect of chocolate on acne vulgaris. JAMA. 1969;210:2071-4.1969;210:2071-4. 2. Anderson,P.C. Foods as the cause of acne. Am Fam Physician. 1971;3:102-103.2. Anderson,P.C. Foods as the cause of acne. Am Fam Physician. 1971;3:102-103.
  26. 26. Chocolate and AcneChocolate and Acne  Study is frequently misinterpretedStudy is frequently misinterpreted  Chocolate bars with cacao solids (cacao pasteChocolate bars with cacao solids (cacao paste and cocoa butter) versus bars without cacaoand cocoa butter) versus bars without cacao solidssolids  There was no difference between the sugar andThere was no difference between the sugar and fat content in the barsfat content in the bars  There was no milk in the barsThere was no milk in the bars
  27. 27. Role of Diet andRole of Diet and AcneAcneIn 2002, Cordain, et al. reported theIn 2002, Cordain, et al. reported the prevalence of acne in 2 nonwesternizedprevalence of acne in 2 nonwesternized populationspopulations Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002;Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002; 138:1584-90.138:1584-90.
  28. 28. Ache hunter-gatherers of ParaguayAche hunter-gatherers of Paraguay
  29. 29. Kitavan Islanders of Papua New GuineaKitavan Islanders of Papua New Guinea
  30. 30. Role of Diet and AcneRole of Diet and Acne  These populations had no evidence of acneThese populations had no evidence of acne  Hypothesized these people had lowHypothesized these people had low glycemic loadsglycemic loads  Controversy with this study is how muchControversy with this study is how much of their condition is related toof their condition is related to geneticsgenetics versusversus 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.
  31. 31. Diet and AcneDiet and Acne  Young men with acne have also been studiedYoung men with acne have also been studied  Forty-three (43) men aged 15-25 with acne,Forty-three (43) men aged 15-25 with acne,  control versus low glycemic load diet groupscontrol versus low glycemic load diet groups for 12 weeks.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, high glycemic-load diet onThe 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.biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol.J Am Acad Dermatol. 57(2), 247-56 (2007).57(2), 247-56 (2007).
  32. 32. 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 BindingIncrease in Insulin-like Growth Factor Binding Protein – 1 (IGFBP-1) – known to be correlatedProtein – 1 (IGFBP-1) – known to be correlated with insulin levelswith 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).
  33. 33. Glycemic Index vs Glycemic LoadGlycemic Index vs Glycemic Load Glycemic indexGlycemic index is a relative comparison of the potential ofis a relative comparison of the potential of various foods to increase blood glucose given there is an equalvarious foods to increase blood glucose given there is an equal amount of carbohydrate in the foodamount of carbohydrate in the food Glycemic indexGlycemic index is a measure of carbohydrate quality (i.e. natureis a measure of carbohydrate quality (i.e. nature or source) butor source) but not quantitynot quantity Glycemic loadGlycemic load assesses the potential of a food to increase bloodassesses the potential of a food to increase blood glucose and is defined as glycemic index * carbohydrate contentglucose and is defined as glycemic index * carbohydrate content Glycemic loadGlycemic load relates carbohydraterelates carbohydrate quantity and qualityquantity and quality
  34. 34. ValuesValues  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, 11-19Moderate, 11-19  High 20 and upHigh 20 and up  www.glycemicindex.comwww.glycemicindex.com
  35. 35. GlycemicGlycemic IndexIndex GlycemicGlycemic LoadLoad GlycemicGlycemic IndexIndex GlycemicGlycemic 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
  36. 36. References to previous slideReferences to previous slide  Glycemic reference is glucose with a glycemic index of 100. DataGlycemic reference is glucose with a glycemic index of 100. Data adapted from Foster-Powell et al. [5]adapted from Foster-Powell et al. [5]  1Atlanta, GA, USA1Atlanta, GA, USA  2Spring Valley Beverages Pty Ltd, Cheltenham, Australia2Spring Valley Beverages Pty Ltd, Cheltenham, Australia  3Kellogg’s, Battle Creek, MI, USA3Kellogg’s, Battle Creek, MI, USA  4Kraft General Foods Canada Inc, Don Mills, Canada4Kraft General Foods Canada Inc, Don Mills, Canada  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
  37. 37. Foods with a high glycemic loadFoods with a high glycemic load HIGH GLYCEMIC DIET
  38. 38. INCREASE IN INSULIN HIGH GLYCEMIC DIET
  39. 39. 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.
  40. 40. Insulin-like growth factor 1 (IGF-1)Insulin-like growth factor 1 (IGF-1)  IGF-1 may promote acne by inducingIGF-1 may promote acne by inducing hyperkeratosishyperkeratosis andand epidermal hyperplasiaepidermal hyperplasia  AA first step in the follicular plugfirst step in the follicular plug  IGF-1 can stimulateIGF-1 can stimulate androgensandrogens, well known to, well known to cause an increase in sebumcause an increase in sebum Bol, K.K., Kiguchi, K., Gimenez-Conti, I., Rupp, T., DiGiovanni, J. Overexpression of insulin-like growth factor-1 inducesBol, 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 mice. Oncogene. 1997;14:1725-1734hyperplasia, dermal abnormalities, and spontaneous tumor formation in transgenic mice. Oncogene. 1997;14:1725-1734..
  41. 41. INCREASE IN IGF 1 HIGH GLYCEMIC DIET INCREASE IN INSULIN INCREASE IN ANDROGENS POSITIVELY INFLUENCE EACH OTHER
  42. 42. IGF-1 in patientsIGF-1 in patients  Post-adolescent women (20-25 years)Post-adolescent women (20-25 years)  Those with acne had higher levels of IGF-Those with acne had higher levels of IGF- 11 Cappel, M., Mauger, D., Thiboutot, D. Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosteroneCappel, 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. Arch Dermatol. 2005;141:333-338.sulfate, and dihydrotestosterone and acne lesion counts in adult women. Arch Dermatol. 2005;141:333-338.
  43. 43. Food and AcneFood and Acne  Recent study implicates milkRecent study implicates milk  47,355 women from the Nurses Health Study II47,355 women from the Nurses Health Study II retrospectively assessedretrospectively assessed  Completed questionnaires regarding diet and teenageCompleted questionnaires regarding diet and teenage acneacne  Found positive association between milk and teenageFound positive association between milk and teenage acneacne  Adebamowo, C.A., JAAD 2005;52:207-14.Adebamowo, C.A., JAAD 2005;52:207-14.
  44. 44. Second study implicating MilkSecond study implicating Milk  Boys in the Growing Up Today Study (GUTS)Boys in the Growing Up Today Study (GUTS)  Offspring of the women in the Nurses HealthOffspring of the women in the Nurses Health Study II listed aboveStudy II listed above  Positive association between the intake of skimPositive association between the intake of skim milk and acnemilk and acne  Genetic association relating to acne is notGenetic association relating to acne is not discusseddiscussed 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 Am Acad Dermatol.J Am Acad Dermatol. (2008)(2008) [Epub ahead of print].[Epub ahead of print].
  45. 45. Further data implicating dietFurther data implicating diet  Tape stripping of skin of acne patientsTape stripping of skin of acne patients  Looked at composition of surface lipids of thoseLooked at composition of surface lipids of those on low glycemic load diet versus control dieton low glycemic load diet versus control diet  Difference in patients based on the dietDifference in patients based on the diet  ? Does this suggest that what we eat may play a? Does this suggest that what we eat may play a role at the skin surfacerole 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 triglycerides. Jour. Derm Science.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. 2008.50: 41-52. 2008.
  46. 46. Factors to considerFactors to consider  LGL group also lost weightLGL group also lost weight  Was weight loss the factor and not the actual LGLWas weight loss the factor and not the actual LGL diet?diet?  Sebum production is largely under geneticSebum production is largely under genetic controlcontrol  First study to look at the surface lipids during aFirst study to look at the surface lipids during a dietary interventiondietary intervention
  47. 47. Food and AcneFood and Acne  Milk has been associated withMilk has been associated with increased IGF-1 levelsincreased IGF-1 levels Holmes, M.D., Cancer Epidem. Biomarkers Prev 2002;11:1228-1233Holmes, M.D., Cancer Epidem. Biomarkers Prev 2002;11:1228-1233
  48. 48. In clinicalIn clinical practice how canpractice how can we connect IGF-we connect IGF- 1 and acne?1 and acne?
  49. 49. Polycystic Ovarian SyndromePolycystic Ovarian Syndrome  Best evidenceBest evidence for a role of dietfor a role of diet and acneand acne
  50. 50. Polycystic Ovarian SyndromePolycystic Ovarian Syndrome  AcneAcne  Irregular mensesIrregular menses  Overweight, but not necessarily soOverweight, but not necessarily so  AlopeciaAlopecia  HirsuitismHirsuitism  InfertilityInfertility
  51. 51. Polycystic Ovarian SyndromePolycystic Ovarian Syndrome  Increased levels of insulinIncreased levels of insulin  Increased levels of IGF-1Increased levels of IGF-1  Increased androgensIncreased androgens
  52. 52. Polycystic Ovarian SyndromePolycystic Ovarian Syndrome  Acne improvesAcne improves with medications whichwith medications which improve insulin metabolismimprove insulin metabolism::  MetforminMetformin  TolbutamideTolbutamide  PioglitazonePioglitazone
  53. 53. What do we tell our patients?What do we tell our patients?  The jury is still out on the role of diet causingThe jury is still out on the role of diet causing acne.acne.  Emphasize that the pathogenesis isEmphasize that the pathogenesis is multifactorialmultifactorial, so no single treatment or habit, so no single treatment or habit change will rid them of the disease.change will rid them of the disease.  Should not dismiss the patient those swears thatShould not dismiss the patient those swears that a certain food is a trigger. Have patients avoida certain food is a trigger. Have patients avoid the offending food, if they feel it is a trigger.the offending food, if they feel it is a trigger.
  54. 54. RosaceaRosacea
  55. 55. Prevalence of RosaceaPrevalence of Rosacea  Common facial disorder affecting 13 million inCommon facial disorder affecting 13 million in the USthe 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 phymas moreHigher overall prevalence in women with phymas more common in mencommon in men 1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: http://www.niams.nih.gov/hi/topics/rosacea/rosacea.htm.
  56. 56. Treatments for RosaceaTreatments for Rosacea  Topical AntibioticsTopical Antibiotics  Systemic AntibioticsSystemic Antibiotics  Topical SulfurTopical Sulfur  Systemic IsotretinoinSystemic Isotretinoin  Avoidance of trigger factorsAvoidance of trigger factors
  57. 57. RosaceaRosacea  randomized vehicle-controlled double-blind trialrandomized vehicle-controlled double-blind trial  40 patients40 patients  4-8 weeks4-8 weeks  pimecrolimus cream 1% was not more efficacious thanpimecrolimus cream 1% was not more efficacious than treatment with the vehicle cream.treatment with the vehicle cream.  British Journal of Dermatology. 156(4):728-32, 2007 Apr.British Journal of Dermatology. 156(4):728-32, 2007 Apr.
  58. 58. Z-pak for Rosacea?Z-pak for Rosacea?  Reactice oxygen species (ROS) where measured in patients withReactice oxygen species (ROS) where measured in patients with rosacea and healthy controlsrosacea and healthy controls  Skin biopsiesSkin biopsies were taken before treatment with azithromycinwere taken before treatment with azithromycin (500mg 3 days of each week) and after 4 weeks on this regimen(500mg 3 days of each week) and after 4 weeks on this regimen  ROS were greater before treatment in the rosacea patientsROS were greater before treatment in the rosacea patients  ROS decreased in rosacea patients after this treatmentROS decreased in rosacea patients after this treatment  Clinical & Experimental Dermatology. 32(2):197-200, 2007 Mar.Clinical & Experimental Dermatology. 32(2):197-200, 2007 Mar.
  59. 59. 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 sensitivity,Restoration of skin barrier and less skin sensitivity, (electrical(electrical capacitance, transepidermal water loss (TEWL), and lactic acid stinging testcapacitance, transepidermal water loss (TEWL), and lactic acid stinging test))  Concluded that a basic therapeutic moisturizer will help patientsConcluded that a basic therapeutic moisturizer will help patients with rosaceawith rosacea  Journal of Dermatological Treatment. 18(3):158-62, 2007.Journal of Dermatological Treatment. 18(3):158-62, 2007.
  60. 60. Heat the known culpritHeat the known culprit  Guzman-Sanchez et al.Guzman-Sanchez et al. quantitativelyquantitatively evaluated heat sensitivity of the skin of rosaceaevaluated heat sensitivity of the skin of rosacea patientspatients  They found that the heat pain threshold was lower in the skin involved with rosaceaThey found that the heat pain threshold was lower in the skin involved 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 beverages such as coffeeFor years patients have been told to avoid hot caffeinated beverages such as coffee and tea, and although caffeine may aggravate rosacea, there is now quantitativeand tea, and although caffeine may aggravate rosacea, there is now quantitative evidence that heat is a true culprit.evidence that heat is a true culprit.  Therefore, for many patients an iced coffee or tea may be less of an aggravator thanTherefore, for many patients an iced coffee or tea may be less of an aggravator than originally thoughtoriginally thought  Guzman-Sanchez DA, Ishiuji Y, Patel T, et al. Enhanced skin blood flow and sensitivity to noxious heat stimuli in papulopustular rosacea. J Am AcadGuzman-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):800-5Dermatol 2007;57(5):800-5
  61. 61. Alternative therapies for RosaceaAlternative therapies for Rosacea  Omega-3 and omega-6 fatty acidsOmega-3 and omega-6 fatty acids  Ophthalmology literature suggests such supplements orOphthalmology literature suggests such supplements or foods that contain such fatty acids, may help with dryfoods that contain such fatty acids, may help with dry eyeseyes  Flax seed oil supplements, containing high levels ofFlax seed oil supplements, containing high levels of omega-3 fatty acid, may help combat ocular rosaceaomega-3 fatty acid, may help combat 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 2008;162(2):219-25.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.
  62. 62. Commonly askedCommonly asked questionsquestions
  63. 63. 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, and 4 times a daySubjects divided into frequency groups of 1, 2, and 4 times a day  6 weeks – no statistically significant differences were noted6 weeks – no statistically significant differences were noted between groupsbetween groups  Twice daily had noticeable improvements in comedones andTwice daily had noticeable improvements in comedones and noninflammatory lesionsnoninflammatory lesions  Slight evidence that twice daily washing is supported.Slight evidence that twice daily washing is supported.  Pediatric Dermatology. 23(5):421-7, 2006 Sept-Oct.Pediatric Dermatology. 23(5):421-7, 2006 Sept-Oct.
  64. 64. Makeup and AcneMakeup and Acne  Make-up improves the quality of life in acne patientsMake-up improves the quality of life in acne patients  Can be done without aggravating acneCan be done without aggravating acne  18 females18 females  Trained by a makeup artist and applied acne-designedTrained by a makeup artist and applied acne-designed cosmetics for 2-4 weeks while their acne was beingcosmetics for 2-4 weeks while their acne was being treatedtreated  Improvement in their quality of life was noted withImprovement in their quality of life was noted with three quality of life indexes, Skindex-16, GHQ30 andthree quality of life indexes, Skindex-16, GHQ30 and anxiety state indexanxiety state index  European Journal of Dermatology. 15(4):284-7, 2005 Jul-Aug.European Journal of Dermatology. 15(4):284-7, 2005 Jul-Aug.
  65. 65. Hypnosis and Acne?Hypnosis and Acne?  Case reportCase report  Pregnant womanPregnant woman  15 year history of “picking face”15 year history of “picking face”  Topical Antibiotics were used to acneTopical Antibiotics were used to acne  Hypnotic suggestions alleviated her pickingHypnotic suggestions alleviated her picking acneiform lesionsacneiform lesions  American Journal of Clinical Hypnosis. 46(3):239-45; Jan 2004American Journal of Clinical Hypnosis. 46(3):239-45; Jan 2004 ..
  66. 66. Acne ScarringAcne Scarring  27 Korean patients27 Korean patients  Fitzpatrick Skin type IV to VFitzpatrick Skin type IV to V  1550-nm erbium-doped Fractional photothermolysis1550-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
  67. 67. Bone Density and IsotretinoinBone Density and Isotretinoin  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 measured at baselineBone mineral density in the lumbar spine and femur was measured at baseline and at the end of therapyand at the end of therapy  Serum calcium, phosphate, parathormone, total alkaline phosphatase,Serum calcium, phosphate, parathormone, total alkaline phosphatase, osteocalcin, free deoxypyridinoline, and urinary calcium were also measuredosteocalcin, free deoxypyridinoline, and urinary calcium were also measured before and at the end of treatmentbefore and at the end of treatment..  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 SIBone mineral density and bone turnover markers in patients receiving a single course of isotretinoin for nodulocystic acne.Tekin NS, Ozdolap S, Sarikaya S, Keskin SI
  68. 68. Bone Density and IsotretinoinBone Density and Isotretinoin  RESULTS:RESULTS: no statistically significant difference was observedno statistically significant difference was observed between the BMD values in patients at the beginning vs. the endbetween the BMD values in patients at the beginning vs. the end of treatment (P > 0.05).of treatment (P > 0.05).  no statistically significant changes in bone turnover markers wereno statistically significant changes in bone turnover markers were observed in patients at the beginning vs. the end of treatment (Pobserved in patients at the beginning vs. the end of treatment (P > 0.05).> 0.05). CONCLUSION:CONCLUSION: A single course of isotretinoin therapy has noA single course of isotretinoin therapy has no clinically significant effect on bone metabolismclinically significant effect on bone metabolism
  69. 69. Thank YouThank You

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