Stephanie Diamantis, Heidi A.Waldorf MD
Acne rosacea is one of the most common diagnoses seen in the clinical dermatologic practice. The classic presentation
of rosacea, acneiform papules, and pustules on a background of telangiectasia, is often easily identified by primary care
physicians, patients, or their similarly afflicted friends or family members. However, rosacea actually represents a spectrum of
disease from chronic skin hypersensitivity and flushing to rhinophyma. Although the pathogenesis of rosacea remains
unknown, it is important to understand its various presentations and possible etiologies prior to developing individualized
This article will examine oral therapies utilized in the treatment of rosacea. Important topics include recognizing which types
of rosacea can benefit from oral therapy and concerns regarding the emergence of bacterial resistance.
Jennie B. Nally MD, Diane S. Berson MD
Therapeutic options for rosacea include topical agents, oral therapies, laser and light treatments, and surgical procedures.
Topical therapies play a critical role in the treatment of patients with papulopustular rosacea and erythematotelangiectatic
rosacea, and have the ability to effectively minimize certain manifestations of the disease, including papules, pustules, and
erythema. The 3 primary agents for the topical treatment of rosacea are metronidazole, azelaic acid, and sodium sulfacetamide-
sulfur. Each of these therapies is approved for the treatment of rosacea and has been validated by multiple studies.
Additional topical therapies including benzoyl peroxide, clindamycin, retinoids, topical steroids, calcineurin inhibitors, and
permethrin are not approved for the treatment of rosacea and play variable roles in the management of this condition.
Since rosacea is a chronic disease and many patients find prescription therapies unsatisfactory, they frequently turn to herbal
ingredients for relief of their persistent facial redness. The most useful and frequently used herbal compounds include licorice,
feverfew, green tea, oatmeal, lavender, chamomile, tea tree oil, and camphor oil. The utility of most of these herbs is based
on their purported anti-inflammatory properties. Some of these herbs have proven effects, many have potential benefits, and
some may aggravate rosacea. Due to the fact that many patients fail to inform their physicians about their use of herbal ingredients,
dermatologists should be aware of what patients may be using and be able to advise them about the efficacy of these
ingredients or the potential for adverse effects.
Kimberly J. Butterwick MD, Lorren S. Butterwick, Amy Han MD
Acne rosacea is a multifactorial, somewhat mercurial disorder that can be a challenge to control with standard
pharmacologic agents. Laser and light sources have been increasingly utilized, particularly for control of the generalized
erythema, flushing, and telangiectasia of rosacea. This paper will review the clinical studies presented in the literature
specifically treating patients with rosacea. Long-pulsed dye lasers and intense pulsed light devices can offer patients effective
treatment without the purpura of short-pulsed dye lasers. Long-term efficacy has not been studied but maintenance therapy
may be necessary to control the vascular manifestations of this disease.
Sivan Shemesh BS, James M. Spencer MD, Robert G. Phelps MD
Background: Basal cell and squamous cell carcinomas both arise in the epidermis of fair-skinned people in response to
ultraviolet light, with the overall frequency of basal cell carcinoma being 4 times that of squamous cell carcinoma. Despite
the similarities in the population at risk, and the presumed etiology of these tumors, it is unclear if any one individual has
a proclivity to develop only one type of tumor.
Objective: The study explores whether or not there is a pattern of expression of basal versus squamous cell carcinoma
among people with these cancers.
Methods: This case-control study involved patients with a total of more than 3 and fewer than 10 basal or squamous cell
carcinomas. Patient age and gender, as well as number and location of diagnosed basal and squamous cell carcinomas were
gathered and patterns within these values were sought.
Results: Patients found to have at least one basal cell carcinoma tended to produce more basal cell carcinomas and patients
found to have at least one squamous cell carcinoma tended to produce more squamous cell carcinomas.
Conclusion: The study supports the possibility that people who develop basal cell carcinoma are more likely to develop
more basal cell carcinomas. Similarly, people who develop squamous cell carcinoma are more likely to develop more squamous cell carcinomas.
Alexiades-Armenakas MD PhD
Background: Acne patients who fail to respond to conventional treatments have been treated with isotretinoin, an effective
treatment coming under strict regulation due to the risk of significant side effects. Photodynamic therapy (PDT) may be a
viable alternative treatment for recalcitrant acne of various types and levels of severity.
Objective: To determine the safety and efficacy of combination PDT with topical 5-aminolevulinic acid (ALA) and activation
by long-pulsed, pulsed dye laser (LP PDL, 595 nm) energy with topical therapy in patients with mild to severe acne.
Methods: A prospective, controlled pilot, proof-of-principle study of 19 consecutive patients (aged 16-47 years, Fitzpatrick
skin types I-VI) with mild to severe cystic, inflammatory, or comedonal acne of the face was conducted. All patients had
failed conventional therapy, including oral antibiotics, topical treatments, hormonal therapy, laser procedures (without
ALA), and/or oral isotretinoin. Fifteen patients were treated with ALA PDT and 4 patients served as controls; all were
continued on topical medications. Patients undergoing PDT were initially randomized to receive either blue light or laser
energy. Because recrudescence occurred in 1 patient while undergoing multiple treatments with ALA and blue light, all
subsequent patients were treated with ALA and laser energy. The total number of patients treated with LP PDL-mediated
ALA PDT was 14. ALA was applied for a short 45-minute incubation followed by 1 minimally overlapping pass with the LP
PDL (595 nm, 7.0-7.5 J/cm2 fluence, 10-ms pulse duration, 10-mm spot size, and dynamic cooling spray of 30 ms with a 30-
ms delay). Patients treated with conventional therapy (oral antibiotics, oral contraceptives, and topical medications) or laser
energy without ALA PDT served as control groups. Patients were followed monthly for up to 13 months.
Results: Complete clearance was achieved in 100% (14 out of 14) patients in the LP PDL PDT-treated group. A mean of
2.9 treatments (range 1-6; 2.0-3.7, 95% CI; n=14) was required to achieve complete clearance for a mean follow-up time of
6.4 months (range 1-13; 3.8-8.9 95% CI; n=14). The patient mean percent lesional clearance rate per treatment was 77%
(64%-90%, 95% CI; n=14). Improvement in acne lesions became apparent within 1 to 2 weeks after the first treatment.
Clearance in the LP PDL PDT group was superior to control groups. In the LP PDL-only control group (n=2), the patient
mean percent lesional clearance rate per treatment was 32% without complete clearance after 3 to 4 treatments. In the oral
antibiotics, oral contraceptives, and topicals control group (n=2), the clearance rate per treatment was 20%, the mean clearance
rate per month was 4%, and complete clearance was not achieved after 6 to 10 months. In the LP PDL-mediated PDT
group, treatments were well-tolerated with minimal erythema lasting 1 to 2 days. No cases of crusting, blistering, purpura,
scarring, or dyspigmentation occurred. A reduction in the erythema in erythematous acne scars was observed.
Conclusion: For teenage to adult patients with recalcitrant comedonal, inflammatory, or cystic acne of various degrees
of severity, ALA PDT with activation by LP PDL appears to be a safe and effective treatment with minimal side effects.
LP PDL-mediated PDT may serve as an important alternative to isotretinoin. Cosmetically well-accepted, LP PDL PDT
combined with topical therapy is the first PDT modality to achieve complete clearance with long-term follow-up as
compared to controls.
Stephen W. Dusza MPH, Ruby Delgado MD, Klaus J. Busam MD, Ashfaq A. Marghoob MD, Allan C. Halpern MD
Objective: To assess the clinical and histologic effects of topical imiquimod therapy on dysplastic nevi, and to determine the
feasibility of using in vivo confocal microscopy (CSLM) to non-invasively monitor histological response of
dysplastic nevi to imiquimod therapy.
Design: Single-blinded pilot study with patients not blinded as to treatment status.
Setting: Dermatology Outpatient Clinic, Memorial Sloan-Kettering Cancer Center, New York, NY.
Patients: The study population comprised of 10 patients with clinically dysplastic (atypical) nevi and at least 8 large nevi,
(?5 mm) on their trunk.
Intervention: Sixteen weeks of imiquimod 5% cream applied to treatment lesions 3 times per week.
Main Outcome Measure: Clinical response as gauged by comparison of baseline and week 20 1:1 standardized photographs
for all study nevi and histological assessment of each patient’s 4 largest study nevi at completion of therapy.
Results: There were no obvious clinical changes in the size and morphology of the study nevi. Subtle changes in nevus color
could not be assessed due to imperfect spectral registration of images over the course of the study. Histologically, 4 of 14 treated
nevi and 0 of 14 untreated nevi p=0.03 showed a significant relative reduction of junctional and intraepidermal nevocytes
accompanied by papillary dermal fibroses and variable inflammation suggestive of partial regression. Non-invasive CSLM
imaging of study nevi demonstrated previously reported in vivo features of dysplastic nevi. but the imaging equipment and
protocol utilized proved inconsistent across lesions and time.
Conclusions: The histological changes seen in a subset of treated nevi suggest a possible role for the use of topical immune
response modifiers for the treatment of dysplastic nevi with the intent of melanoma chemoprevention. The dose regimen of
topical imiquimod utilized in this study failed to induce sufficient clinical or histological responses to warrant further study.
Targeting of dysplastic nevi and intermediate endpoints for melanoma chemoprevention with more intense and/or prolonged
treatment regimens with imiquimod or the use of other immune response modifiers seems promising. Technical improvements
are required for the use of non-invasive CSLM imaging in lieu of invasive histology for the study of topical nevus
No abstract details for the moment.