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The Recognition, Evaluation, and Treatment of Eczema and Rosacea


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The Recognition, Evaluation, and Treatment of Eczema and Rosacea
Joel Wagner, PharmD

Published in: Health & Medicine
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The Recognition, Evaluation, and Treatment of Eczema and Rosacea

  1. 1. Recognition, Evaluation, and Treatment of Eczema and Rosacea Joel Wagner Pharm. D. Clinical Professor/Emeritus Professor Thomas J. Long School of Pharmacy and Health Sciences
  2. 2. Conflict of Interest Disclosure  No Conflicts of Interest to Disclose
  3. 3. Statement of Need  This presentation will help pharmacists develop a logical, systemic approach for the treatment of atopic dermatitis and rosacea.  The presentation will cover several new drugs for the treatment of atopic dermatitis and rosacea.  Information on the new drugs will include their mode of action, side effects, and consultation points.
  4. 4. Goals and Objectives  The purpose of this presentation is to help pharmacists:  Develop the skills necessary to recognize the skin lesions associated with eczema and rosacea  Recognize the different stages of eczema and rosacea.  Develop a treatment regimen for eczema and rosacea dependent upon the stage of the disease that the patient has developed and the type and severity of the lesions.
  5. 5. Learning Objectives  Describe the lesions and the characteristics of rashes associated with rosacea and eczema  Describe the eczematous process and the 3 stages of eczema  Relate the 3 stages of eczema to their most effective treatment  Describe the 3 types of rosacea  Relate the 3 types of rosacea to their most effective treatment  Provide patient education and counseling for commonly prescribed medications in eczema and rosacea
  6. 6. Question  What is eczema? a. Eczema is an itchy, inflammatory skin disease. b. Eczema is not really a disease in itself, but a term that describes an eczematous rash or eczematous process rather than a specific disease. c. Eczema refers to a number of skin diseases that have similar rashes. d. All of the above
  7. 7. Skin Diseases That Exhibit Eczematous Rashes  Atopic Dermatitis  Contact Dermatitis  Dyshidrotic Eczema  Asteatotic Eczema  Stasis dermatitis  Nummular Eczema  Seborrheic Dermatitis  Scabies
  8. 8. So What is Atopic Dermatitis?  Atopic dermatitis is the most common of the inflammatory skin diseases.  It is an intensely pruritic, chronic inflammatory condition of the skin.  Many people and physicians refer to atopic dermatitis as eczema  Usually occurs in a patient with a personal or family history atopy.
  9. 9. Atopy?  Atopy refers to the genetic tendency to develop allergic diseases such as chronic allergic rhinitis, asthma, and extremely dry, irritated skin.  These three conditions are known as the atopic triad.  Atopy is also typically associated with an heightened allergic response to common inhaled allergens.
  10. 10. What Causes Atopic Dermatitis?  Atopic dermatitis is thought to be caused by a genetic defect in the filaggrin protein in the skin.  This defect is associated with disrupting the epidermis  The epidermal disruption results in contact between immune cells in the dermis and antigens from the external environment leading to inflammation, intense itching, and scratching.
  11. 11. Signs and Symptoms of Atopic Dermatitis  The most common skin lesions are, erythematous, scaly, papules, patches and plaques.  Most common symptom is severe, unrelenting itching which may lead to difficulty in sleeping.  Itching is intensified by the itch-scratch cycle
  12. 12. Itch-Scratch Cycle  Disease stimulates peripheral nerve endings which the brain identifies as itching.  This leads to vigorous scratching or rubbing.  Scratching leads to greater peripheral nerve stimulation which causes even more itching.  Cycle continues until the pain of nail induced skin damage supplants the sensation of itching.  The presence of nighttime scratching usually warrants a diagnosis of atopic dermatitis.
  13. 13. Age Related Presentation  Atopic dermatitis presents differently in infants, children, and adults.
  14. 14. Infantile Atopic Dermatitis  A child may be 2 or 3 months old when atopic dermatitis begins.  Infantile atopic dermatitis is associated with the following characteristics:  Dry, scaly, itchy, skin  Lesions form on the scalp, face, and sometimes on the back.  Lesions, because if intense inflammation, can become wet and oozy.  Causes intense itching that may come and go.
  15. 15. Infantile Atopic Dermatitis
  16. 16. Infantile Atopic Dermatitis
  17. 17. Infantile Atopic Dermatitis
  18. 18. Childhood Atopic Dermatitis  Usually develops in the 2-12 year old age group.  Lesions often begin the antecubital or popliteal fossa.  Other common places include the neck, wrists, ankles and feet.
  19. 19. Childhood Atopic Dermatitis
  20. 20. Childhood Atopic Dermatitis
  21. 21. Childhood Atopic Dermatitis
  22. 22. Childhood Atopic Dermatitis
  23. 23. Childhood Atopic Dermatitis
  24. 24. Adult Atopic Dermatitis  Rash appears in the antecubital or popliteal fossa and nape of neck.  Can be especially noticeable on the neck and face.  Can be especially bad around the eyes.  May cover much of the body.  Non-stop itching is the principal symptom.
  25. 25. Adult Atopic Dermatitis
  26. 26. Adult Atopic Dermatitis
  27. 27. Adult Atopic Dermatitis
  28. 28. Adult Atopic Dermatitis
  29. 29. Stages of Atopic Dermatitis  There are 3 forms or stages of atopic dermatitis.  These stages are  Acute  Subacute  Chronic  Chronic phase occurs if the disease process continues for a relatively long period of time.
  30. 30. Acute Atopic Dermatitis  Acute eczematous rash is characterized by erythematous, weeping vesicles and bulla  Most common symptom is unrelenting itching  Acute stage is usually associated with contact dermatitis rather than atopic dermatitis
  31. 31. Acute Atopic Dermatitis
  32. 32. Acute Contact Dermatitis- Poison Oak
  33. 33. Acute Contact Dermatitis
  34. 34. Subacute Atopic Dermatitis  Primary lesions are erythema, scale, and fissuring  Itching is moderate to severe.
  35. 35. Sub-Acute Atopic Dermatitis
  36. 36. Sub-Acute Atopic Dermatitis
  37. 37. Sub-Acute Atopic Dermatitis
  38. 38. Chronic Atopic Dermatitis  Lichenification is the characteristic lesion of chronic atopic dermatitis  Characterized by scaly and thickened skin with exaggerated skin markings  Lichenification is caused by constant rubbing.  Pigmentation changes may occur which are also caused by constant rubbing.
  39. 39. Chronic Atopic Dermatitis
  40. 40. Chronic Atopic Dermatits
  41. 41. Chronic Atopic Dermatits Pigment Changes
  42. 42. Chronic Atopic Dermatits
  43. 43. Course of Atopic Dermatitis  Course is unpredictable  Usually begins in infancy or childhood and runs frequent courses of exacerbation and remission  May spontaneously remit in childhood but may return in adolescence or adulthood
  44. 44. Case Study 1  A 28-year-old male patient comes into the dermatology clinic wanting treatment for a very itchy rash that the patient has developed on his feet.  The patient shows you the rash.
  45. 45. Fissure Lichenification Excoriation
  46. 46. Patient History  The patient describes the rash as very, very itchy.  The patient states that he unconsciously rubs and scratches the rash.  The patients has had the rash for about 6 months  The patient had a similar problem when he was younger but the problem seemed to resolve only to reappear about 6 months ago.  The patient has a large number of allergies including hay fever and asthma.  The patient has been treating the rash with moisturizers.
  47. 47. Question  What should be the recommended initial treatment for this patient’s rash? a. Application of a low to mid potency topical corticosteroid. b. Application of a super-potent topical corticosteroid. c. Frequent use of moisturizers. d. Oral diphenhydramine at bedtime. e. Topical diphenhydramine
  48. 48. Primary Treatment of Mild Atopic Dermatitis Low to mid potency topical corticosteroids applied for 2 -4 weeks Reassess after 4 weeks Adjunctive Therapy Moisturizing creams and ointments Moisturizing soaps Cetaphil Cleanser Proper bathing and showering Treatment Algorithm for Mild Atopic Dermatitis TEACHING TOOL If improvement, maintenance with moisturizers and intermittent use of low to to mid potency TCS applied on two consecutive days/week
  49. 49. Which Topical Corticosteroid?  Infants and adult patients with involvement of areas of the body where the skin is thin, should be treated with low-potency topical corticosteroids.  In areas of the body where skin is thicker, can be treated with more potent topical corticosteroids.  Cream base is generally preferred because of easy spreading and more cosmetically acceptable to most patients.
  50. 50. Topical Corticosteroid Application  Apply at least 2 times/day for 2-4 weeks.  After lesions appear to have resolved, application should be tapered to once daily then every other day followed by maintenance therapy.  Maintenance therapy is twice-weekly application of topical corticosteroids on consecutive days in conjunction with frequent application of moisturizers.
  51. 51. Question  Why is it necessary to taper down the frequency of application before discontinuing a corticosteroid? a. To prevent HPA access depression. b. To prevent acute adrenal insufficiency. c. To prevent a rebound flare reaction. d. To prevent the development of an infection.
  52. 52. Question  What are the side effects associated with the long-term continuous application of high potency topical corticosteroids? a. Development of HPA axis suppression. b. Development of steroid psychosis. c. Development dermal atrophy. d. Development of osteoporosis. e. Development of cataracts.
  53. 53. Dermal Atrophy Secondary to Continuous Mometasone Application for 6 months Striae Atopic Dermatitis
  54. 54. Moisturizers  Moisturizers help retain and replenish epidermal moisture.  Thick creams, which have a low water content, or ointments which have zero water content, are treatment of choice.  Lotions, which have a high water and low oil content, can worsen xerosis through evaporation.  Should be applied at least two times per day and immediately after bathing or hand-washing.
  55. 55. Bathing and Showering  To avoid xerosis, patients should shower or bathe with warm instead of hot water  After bathing or showering, thick, occlusive, moisturizers should be applied.
  56. 56. Soaps  Washing with a drying soap such as Ivory ® should be avoided.  Washing with moisturizing, super-fatted soaps should be encouraged  The use of Cetaphil® cleanser may be helpful.
  57. 57. Antihistamines  Topical antihistamines should be avoided.  CNS depression is the most important characteristic if antihistamines are to be used for itching secondary to AD.  Diphenhydramine is probably the treatment of choice because it is the most sedative.  Non-sedative antihistamines are ineffective in treating itching associated with atopic dermatitis.
  58. 58. Question  Why should the use of topical diphenhydramine be avoided? a. Topical diphenhydramine is ineffective. b. Topical diphenhydramine may dry the skin. c. Topical diphenhydramine may cause contact dermatitis. d. Topical diphenhydramine may cause rebound erythema and itching.
  59. 59. Case Study 2  A 16-year-old female, is being seen in the dermatology clinic.  Twenty percent of her body is covered by an eczematous rash with extensive involvement of her neck, antecubital and popliteal fossae, feet and arms.  Her chief complaint is extreme itching over all the involved areas.
  60. 60. Case Study 2  The patient states that she is currently seeking medical attention because of persistent, unrelenting, itching.  The patient states that the itching is so severe that she has found herself unconsciously scratching the rash during the night.  The patient says that she has been using moisturizers and topical desonide to treat the itching for the past 4 months.
  61. 61. Treatment of Moderate Atopic Dermatitis Mid to high-potency TCS applied for 4 weeks or for areas at risk for dermal atrophy, low to mid potency TCS or TCI Reassess after 4 weeks Adjunctive Therapy Moisturizing creams and ointments Moisturizing soaps Cetaphil Cleanser Proper bathing and showering Treatment Algorithm for Moderate Atopic Dermatitis TEACHING TOOL If improvement, maintenance with moisturizers and intermittent use of TCS or TCI. If no improvement switch to TCI if not already done or to crisaborole If no response consider dupilumab
  62. 62. Topical Calcineurin Inhibitors (TCIs)  Pimecrolimus (Elidel) and Tacrolimus (Protopic)  For short-term and intermittent long-term treatment of mild to moderate atopic dermatitis in patients who are unresponsive or intolerant of other therapies  They can be used as an alternative to topical corticosteroids for the treatment of mild to moderate atopic dermatitis involving the face, including the eyelids, neck, and skin folds.  Intermittent long-term treatment consists of using TCIs two consecutive days/week.
  63. 63. How Do Calcineurin Inhibitors Work?  Pimecrolimus and tacrolimus inhibit calcineurin which is a calcium- dependent phosphatase.  As a result, pimecrolimus and tacrolimus prevent the release of inflammatory cytokines into the skin thus reducing inflammation.
  64. 64. Are Calcineurin Inhibitors Effective?  Produced relatively good results in about 50% of the patients treated.  Pimecrolimus maybe better tolerated than tacrolimus with less stinging and burning upon application.  Several studies found that tacrolimus ointment was more effective than pimecrolimus cream.
  65. 65. Consultation for Calcineurin Inhibitors  Patient should be warned about sun avoidance and warned to wear protective clothing when out in the sun.  May be applied topically to all skin surfaces including the head, neck, and intertriginous areas.  Wash hands with soap and water before and after application.  If treating the hands, only wash hands before application.
  66. 66. Problems with Calcineurin Inhibitors  8% of the patients using the cream complained of mild to moderate warmth or burning.  Can’t be applied to active viral infections and any infection at the treatment site should be cleared before calcineurin inhibitors are applied.  Must avoid excessive sun exposure and use sunscreens.
  67. 67. Calcineurin Inhibitors and Cancer  Between January 2004 and January 2009, the FDA received 46 reports of cancer cases among children who used topical calcineurin inhibitors.  This led the FDA to issue a black box warning about a possible cancer risk.  No definite causal relationship has been established and two case-control studies did not detect an increased risk of lymphoma among patients treated with topical calcineurin inhibitors.
  68. 68. Recommendations for Use  Use only for patients who have failed with conventional therapy.  Use only for short-term or long-term intermittent treatment.  Long-term safety has not been determined.  Avoid use in children under 2 years of age.
  69. 69. New Drugs for Moderate to Severe Atopic Dermatitis  Crisaborole (Eucrisa)  Dupilumab (Dupixent)
  70. 70. Crisaborole (Eucrisa)  Crisaborole is used topically  It inhibits phosphodiesterase-4 (PDE-4).  By inhibiting the ability of PDE-4 to degrade cAMP, crisaborole suppresses the release of pro-inflammatory cytokines  Can be used in children older than 2 years old.
  71. 71. Is Crisaborle Effective?  In multicenter randomized trials, a total of 1522 patients ≥2 years of age were randomized to receive crisaborole 2% ointment twice daily for 28 days or a vehicle.  At day 29, 50-60% of patients in the crisaborole groups achieved success.  Improvement was noted in pruritus, skin inflammation, excoriation, and lichenification.  Crisaborole-related adverse events occurred in 4.4 percent of patients and were mild and limited to burning or stinging at the site of application.
  72. 72. Dupilumab (Dupixent)  Dupilumab is an interleukin-4 receptor antagonist for the treatment of adult patients with moderate to severe atopic dermatitis not adequately controlled with topical prescription therapies.  May be used in conjunction with topical corticosteroids.  Recommended for adults and children over 12 years of age
  73. 73. Is Dupilumab Effective?  The efficacy of dupilumab 300mg or placebo given by subcutaneous injection weekly or every other week was evaluated in adult patients with long-standing moderate to severe atopic dermatitis not controlled by topical treatments.  At week 16, 50-60% of patients in the dupilumab group were considered to have a successful outcome vs 10 % in the placebo group.
  74. 74. Question  What are the most common side effects associated with the administration of dupilumab? a. Injection-site reactions b. Conjunctivitis c. Increased incidence of infections d. Increased rate of malignancy development e. All of the above
  75. 75. Adverse Reactions  Serious adverse events were rare in all groups.  Injection-site reactions and conjunctivitis occurred more frequently in the dupilumab groups than in the placebo group.
  76. 76. Adverse Reactions  What about an increased infection rate and the development of malignancies as is the case with many other monoclonal antibodies?  Increase infection rate and the development of malignancies, as of yet, have not been reported.  Company states that laboratory monitoring of the medication is not needed
  77. 77. Rescue Treatment  Patients with severe and extensive disease may require a “burst” of oral prednisone.  40mg to 60mg of prednisone are given as a single dose early in the AM daily for 7-10 days.  In most cases the dose is rapidly tapered to avoid the development of a “flare” reaction.  This therapy is very safe and serious side effects are almost unheard of
  78. 78. Systemic Corticosteroids  Therapy must be followed by a good topical program  Failure to recognize this point will result in a rapid exacerbation of the disease  One problem with this therapy is the possibility of precipitating a “flare” reaction.  This can be avoided by tapering prednisone dosage  Long term administration of oral corticosteroids have no place in the treatment of atopic dermatitis
  79. 79. Other Treatments  What about treatment with systemic immunosupressants?  Cyclosporine  Methotrexate  Azathioprine
  80. 80. Rosacea
  81. 81. What is Acne Rosacea?  Rosacea is an acne-like facial eruption sometimes called “middle-age acne”  It is characterized by marked involvement of the central face with transient or persistent erythema, telangiectasia, inflammatory papules and pustules, or hyperplasia of the connective tissue.
  82. 82. Differences Between Acne and Rosacea  “True” acne always begins with the following three lesions:  Microcomedo  Closed comedo  Open comedo  Frequently closed comedones develop into into inflammatory papules, pustules, and nodules.
  83. 83. Lesions Associated with Rosacea  Rosacea is not associated with  Microcomedones  Closed Comedones  Open Comedones  Rosacea is associated with  Erythema  Telangiectasia  Papules  Pustules
  84. 84. Rosacea Persistent Erythema
  85. 85. Rosacea Telangiectasia
  86. 86. Rosacea
  87. 87. Rosacea
  88. 88. Rosacea
  89. 89. Rosacea
  90. 90. What’s The Cause?  Don’t know  Flaw in the autonomic innervation of the cutaneous vasculature?  Aberration in endothelial growth factor, substance P, serotonin, bradykinins, histamine, neuropeptides, endorphins, gastrin, and cytokines.  Perhaps involvement of demodex folliculorum
  91. 91. Demodex Folliculorum?  Demodex folliculorum is a species of face mite.  The mites live in human hair follicles.  Found in greater numbers around the cheeks, nose, eyebrows, eyelashes, and forehead.  Not harmful, and classified as commensals  80% of adults are “infected” with demodex folliculorum
  92. 92. Demodex Folliculorum
  93. 93. Demodex Folliculorum
  94. 94. Demodex and Rosacea  A study found a significant association between the increased presence of demodex folliculorum and the development of rosacea,  The study authors also proposed that increased mite density in skin might trigger inflammatory responses, leading to signs and symptoms of rosacea.
  95. 95. Classification of Rosacea  Important because helps select optimal therapy.  Important because can help to predict therapeutic outcomes.
  96. 96. Classification of Rosacea  Subtype 1-Erythematotelangiectatic  Subtype 2-Papulopsustular  Subtype 3-Rhinophyma
  97. 97. Erythematotelangiectatic Rosacea (Subtype I) Clinical Features Comments Persistent erythema of the face Most difficult subtype to treat Prolonged Flushing Certain topical therapy can be irritating thus making erythema worse. Presence of telangiectasia Burning and stinging often present
  98. 98. Erythematotelangiectatic Rosacea
  99. 99. Erythematotelangiectatic Rosacea
  100. 100. Erythematotelangiectatic Rosacea
  101. 101. Erythematotelangiectatic Rosacea
  102. 102. Erythematotelangiectatic Rosacea Treatment  Responds poorly to treatment.  Best treatment is probably non-pharmacological therapy along with proper skin care and avoiding triggers which cause flushing.  In moderate to severe disease ablation of superficial facial blood vessels by lasers can be helpful.  There is little evidence that the use of topical or systemic antibiotics has any effect on erythematotelangiectatic rosacea.
  103. 103. Trigger Factor Percentage of Patients Affected Sun Exposure 81% Emotional Stress 79% Hot Weather 75% Brisk Wind 57% Strenuous Exercise 56% Alcohol Consumption 52% Spicy Foods 45% Use of Alpha Hydroxy Containing Cosmetics 41% Excessive Indoor Heat 41% Common Trigger Factors for Rosacea
  104. 104. Proper Skin Care  Frequent Moisturization.  Gentle skin cleansing.  Avoidance of irritating cosmetic products.  Frequent use of sunscreens.  Use of a soap-free cleanser such as Cetaphil.  Cosmetic coverage of excess redness with matte-finish, water-soluble, facial powder containing inert green pigment.
  105. 105. New Drugs for Treatment of Erythematotelangiectatic Rosacea  Brimonidine (Mirvaso)  Oxymetazoline (RhoFade)
  106. 106. New Drugs for Treatment of Erythematotelangiectatic Rosacea  Brimonidine is a selective alpha-2 agonist available as a 0.33% gel.  Oxymetazoline is an alpha receptor agonist available as a 1% cream.  Topical application reduces erythema by direct vasoconstriction of facial blood vessels.  Both are used to treat persistent facial erythema in rosacea.  Applied one time/day
  107. 107. Results with Brimonidine
  108. 108. Results with Oxymetazoline
  109. 109. Results with Oxymetazoline
  110. 110. Question  Based on your knowledge of using vasoconstrictors in the eye and in the nose, what side effects do you think the topical facial application of oxymetazoline and brimonidine causes? a. Skin irritation b. Skin pain c. Rebound erythema d. Systemic absorption resulting in hypertension e. No side effects reported
  111. 111. Rebound Erythema
  112. 112. Statement By a Physician Treating Rosacea “I will tell my rosacea patients about RhoFade is what I tell my red eye patients about Visine”: “Feel free to use it once or twice a month before taking important pictures or going out on an important date, but other than that, leave it in your medicine cabinet.”
  113. 113. Papulopustular Rosacea (Subtype II) Clinical Features Comments Erythema with papules and pustules Easiest subtype to treat Burning and stinging possible Usually good response to topical therapy May resemble acne vulgaris but without comedones May be associated with facial edema
  114. 114. Papulopustular Rosacea
  115. 115. Papulopustular Rosacea
  116. 116. Papulopustular Rosacea
  117. 117. Papulopustular Rosacea
  118. 118. Papulopustular Rosacea
  119. 119. Papulopustular Rosacea Treatment  Usually responds well to treatment  For mild cases, topical therapy can be used alone  For more severe cases systemic therapy is given for 6-12 weeks and followed with maintenance topical therapy.  Maintenance topical therapy usually required to maintain remission.  No real evidence that use of combined topical and systemic treatment for severe disease has any increased benefits although combination therapy is commonly used.
  120. 120. Topical Therapy  Metronidazole Gel 0.75% and 1% (Metrogel)  Metronidazole Cream 1% (Noritate)  Ivermectin 1% Cream (Soolantra)  Azelaic Acid 15% gel (Finacea)  Erythromycin 2% and clindamycin 1% solution.
  121. 121. Topical Metronidazole (Metrogel,Metrocream)  Applied 1-2 times/day  Well tolerated with few adverse reactions.  Does not seem to work by killing bacteria or demodex falliculorum  Has direct anti-inflammatory activity through it’s effect on neutrophil cellular functions.
  122. 122. Before Metronidazole Treatment
  123. 123. After Metronidazole Treatment
  124. 124. Azelaic Acid (Finacea)  Comparable to metronidazole in effectiveness.  The mechanism of action is not clear.  Applied 1-2 times/day as a 15% gel or a 20% cream  Adverse reactions are similar to topical metronidazole but may be more irritating early on in the course of treatment.
  125. 125. Before Azelaic Acid Treatment After Azelaic Acid Treatment
  126. 126. Ivermectin (Soolantra)  Ivermectin is an agent with both anti- inflammatory and antiparasitic properties.  The drug is commercially available for the treatment of inflammatory lesions of rosacea as a 1% cream.  Ivermectin 1% cream is applied once daily.  Adverse reactions are similar to topical metronidazole.
  127. 127. Is Ivermectin effective?  A 16-week randomized trial that compared once-daily use of ivermectin 1% cream with twice-daily use of metronidazole 0.75% in patients with moderate to severe rosacea  Ivermectin was seemed to be more effective for reducing inflammatory lesions when compared to metronidazole.
  128. 128. Sulfacetamide+Sulfur  Several small studies have shown that topical sulfacetamide+sulfur is effective for the treatment of rosacea.  Can be used as alternative the other topical medications.  Not nearly as effective as metronidazole, azelaic acid or ivermectin.  Side effects are similar to metronidazole and azelaic acid.
  129. 129. Topical Antibiotics  Topical clindamycin and erythromycin application has been associated with improvement in papules, pustules and erythema in several studies with a small number of patients  Not considered first line treatment
  130. 130. Most Effective Topical Therapy?  Based upon these observations, topical ivermectin, metronidazole, and azelaic acid are reasonable choices for first-line topical therapy papulopustular rosacea.  Metronidazole or ivermectin is preferred in patients who present with significant facial sensitivity, due to the fairly frequent occurrence of irritation early in the course of therapy with azelaic acid.
  131. 131. Most Effective Topical Therapy?  Reasonable evidence that 15% azelaic acid gel is equal in effect to 0.75% metronidazole gel  Reasonable evidence that ivermectin may be more effective than topical metronidazole.  Reasonable evidence that topical clindamycin and erythromycin are less effective than metronidazole, azelaic acid or ivermectin.  Some scant evidence that sulfacetamide/sulfur lotion maybe effective in certain cases.
  132. 132. Systemic Treatment  Patients who present with numerous inflammatory papules or pustules or those with milder disease that fail to respond to one or more topical therapies may benefit from oral antibiotic therapy.  Of the oral antibiotics, tetracyclines are the best-studied agents.
  133. 133. Severe Papulopustular Rosacea
  134. 134. Severe Papulopustular Rosacea
  135. 135. Systemic Antibiotics  Tetracycline, doxycycline, and minocycline have been used for many years for the management of rosacea.  These agents are most useful for improving inflammatory papules and pustules, and may also reduce erythema in those patient who do not respond to topical treatment.
  136. 136. Antibiotic Mechanism of Action  Since no definitive microbial cause of rosacea has been identified, the efficacy of oral antibiotics in rosacea is often attributed to their anti- inflammatory properties.
  137. 137. Antibiotic Resistance  Due to concern for the development of antibiotic resistance, interest has grown in the use of sub-antimicrobial doses of doxycycline.  Studies have shown that Oracea which is a combination of 30mg of immediate release doxycycline and 10mg of delayed release doxycycline is effective for treatment of papulopustular roscea.
  138. 138. Sub-antimicrobial Dose Study  One randomized trial with 91 patients compared sub-antimicrobial dose doxycycline (40 mg once daily) with doxycycline 100 mg per day.  Both doses were similarly effective for the treatment of inflammatory lesions, but the lower dose was associated with a reduced rate of gastrointestinal side effects.
  139. 139. My Recommendations for Systemic Therapy  Doxycycline 100mg/day administered for 6- 12 weeks or  Minocycline 100mg/day administered for 6- 12 weeks or  Doxycycline (Oracea) 40mg/day administered for 6-12 weeks  Maintenance topical therapy with metronidazole, ivermectin, or azelaic acid after 6-12 weeks of systemic therapy.
  140. 140. Rhinophyma Rosacea  Disorder characterized by a large, red, bumpy, or bulbous nose.  Called “whiskey nose” or “rum blossom”  Occurs more in men than in women.  The exact cause of rhinophyma is unknown.  Pharmacological treatment is for the most part ineffective.  Treatment consists of surgical excision, or carbon dioxide laser therapy.
  141. 141. Rhinophyma Rosacea
  142. 142. Rhinophyma Rosacea
  143. 143. Rhinophyma Rosacea
  144. 144. Rhinophyma Rosacea
  145. 145. Rhinophyma Rosacea
  146. 146. Who is this guy?
  147. 147.  Thanks for your attention.
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