Volume 11 | Issue 6
C. William Hanke MD MPH FACP|No abstract details for the moment.
James Q. Del Rosso DO FAOCD|No abstract details for the moment.
Why Is Rosacea Considered to Be an Inflammatory Disorder?
The Primary Role, Clinical Relevance, and Therapeutic Correlations of Abnormal Innate Immune Response in Rosacea-Prone Skin
The pathophysiology of rosacea has undergone renewed interest over the past decade, with a large body of evidence supporting the role of an abnormal innate immune response in rosacea. Many mechanisms interact with the cutaneous innate immune system that may be operative. A variety of potential triggers stimulate this immune detection system which is upregulated and hyper-responsive in facial skin of patients with rosacea as compared to normal skin. Based on the most current data, two conclusions have been reached. First, the major presentations of rosacea appear to be inflammatory dermatoses. Second, the presence of a microbial organism is not a primary or mandatory component of the pathogenesis of rosacea. Available therapies for rosacea exhibit reported modes of action that appear to correlate with the inhibition of inflammatory processes involved in the pathophysiology of at least some presentations of rosacea.
J Drugs Dermatol.2012;11(6):694-700.
Effectiveness and Safety of Modified-Release Doxycycline Capsules Once Daily for Papulopustular Rosacea Monotherapy Results from a Large Community-Based Trial in Subgroups Based on GenderThis article is a prospective planned analysis of data evaluating the effectiveness and safety of modified-release doxycycline capsules (30 mg immediate-release and 10 mg delayed-release beads) used once daily for up to 12 weeks in subgroups of males and females with papulopustular (subtype 2) rosacea from a large, open-label, multicenter, community-based study. A total of 1421 patients participated in the study. The per-protocol population comprised 826 patients on monotherapy, with 28.5% male participants (n=235) and 71.5% female participants (n=591). Rosacea was assessed on a 5-point investigator's global assessment (IGA) scale (0=clear, 1=near clear, 2=mild, 3=moderate, 4=severe). Erythema was also assessed on a 5-point clinician's erythema assessment (CEA) scale (0=none, 1=mild, 2=moderate, 3=significant, 4=severe). At baseline, males had a higher percentage of IGA scores of 3 (116 per 235; 49.4% versus 273 per 591; 46.2% in females) and 4 (32 per 235; 13.6% versus 35 per 591; 5.9% in females). Significant improvements in severity rating and erythema were observed in males and females as demonstrated by shifts in the distribution of IGA and CEA scores between baseline and week 12 (P<.001). Treatment success (IGA score of 0 or 1) at week 12 was achieved in 172 per 235 (73.2%) of males and in 444 per 591 (75.2%) of females. Adverse events (primarily mild or moderate gastrointestinal events) were reported in 9.9% of males and 12.8% of females. Anti-inflammatory dose doxycycline, which is administered as a 40 mg modified-release capsule once daily was effective and safe as monotherapy for papulopustular rosacea in both the female (n=591) and male (n=235) study groups. This specific 40 mg capsule delivers 30 mg immediate-release and 10 mg as delayed release using specially designed beads, and is subantimicrobial with both single and repeated dosing.
J Drugs Dermatol. 2012;11(6):703-707
Current evidence suggests that post-adolescent acne in women is on the rise. Acne in this subgroup of patients commonly follows a specific pattern that can often be treatment resistant and/or prone to relapse, including after oral isotretinoin therapy. With a plethora of medications to choose from for acne treatment, many of which have been used in the past by patients without success, dermatology practitioners often find oral contraceptives and spironolactone to be of benefit in otherwise healthy adult females. Also, some of these patients may have concurrent hormonal anomalies such as polycystic ovarian syndrome or other underlying endocrine disorders, which should also be appropriately worked up by the clinician and managed accordingly. This article reviews some of the underlying pathophysiological factors, available treatment options, and screening guidelines to assist clinicians in the management of acne in adult females.
J Drugs Dermatol. 2012;11(6):708-713.
Effects Of Benzoyl Peroxide 5% Clindamycin Combination Gel Versus Adapalene 0.1% on Quality of Life In Patients With Mild to Moderate Acne Vulgaris: A Randomized Single-blind Study
Background: Patients with acne vulgaris often have impaired quality of life (QOL). The fixed-dose combination of benzoyl peroxide 5%/clindamycin 1% gel (BPO/C) topical gel provides an earlier onset of action and is more effective against inflammatory and total facial lesions than adapalene (AP) 0.1% gel.
Objective: To compare BPO/C and AP with regard to the early effect on QOL, efficacy, and tolerability in patients with mild to moderate acne vulgaris.
Methods: Patients were randomized to BPO/C or AP once nightly for 12 weeks in a multicentre, single-blind trial. The primary efficacy endpoint was QOL at week 2, assessed using the Skindex-29 questionnaire. Secondary endpoints included grading and counting of acne lesions; investigator assessments of peeling, erythema, and dryness, and patient-reported burning or itching. Adverse events were monitored during the study and during the 14-day minimum follow-up period.
Results: A total of 168 patients were enrolled, and 114 patients completed the study. In the intent-to-treat population, after 2 weeks of treatment, BPO/C was associated with a small but noticeably better improvement in global QOL compared with AP (-4.9 versus -1.1; P<0.001). A greater reduction in both total and inflammatory lesions was noted from week 1 onward (P<0.05) with BPO/C versus AP. At all time points, BPO/C was better tolerated than AP for all investigator-rated (dryness, peeling, erythema) and patient-rated (burning, itching) events (P<0.036).
Conclusions: BPO/C is associated with early improvements in QOL compared with AP. These QOL improvements are likely to be the result of better efficacy and tolerability outcomes observed with BPO/C.
J Drugs Dermatol. 2012;11(6):714-722
Rosacea is a common disorder that is both under recognized and undertreated. Prevalence figures indicate that it may be present in 1 of every 10 adults in a primary care waiting room. Untreated, patients with rosacea can suffer significant emotional, workplace, and social impairments. While rosacea has been recognized since ancient times, only recently have investigators begun to identify the pathophysiologic elements responsible for the characteristic erythema, flushing, dysesthesias, and papulopustular manifestations of the disease. Although the etiology of rosacea is unclear, inflammation appears to be a central element. Experimental evidence suggests that abnormalities of the skin's innate and adaptive immune responses may play pivotal roles. Once recognized, effective topical and systemic therapies can be prescribed to lessen the impact of the disease on the patient's life. Although initially administered in an empiric fashion, it now seems clear that the role of antibiotics in patients with rosacea depends upon their anti-inflammatory rather than their antimicrobial properties. Consequently, practitioners have the opportunity to practice good antibiotic stewardship when treating the disease, particularly with systemic therapies. Therapy with subantimicrobial dosing and with topical treatments can modulate the inflammation of rosacea without exerting antibiotic pressure responsible for the emergence of antibiotic resistance.
J Drugs Dermatol.2012;11(6):725-730.
Botulinum neurotoxin-A (BoNT-A) has become widely used in aesthetic applications over the past 20 years with several formulations now available. Although widely assumed to be equipotent, recent claims that the original commercial formulation, onabotulinumtoxinA (Botox®/Vistabel®, Allergan UK, Marlow, UK) is more potent than incobotulinumtoxinA (Bocouture®/Xeomin®, Merz Pharma, UK) have raised concerns that clinicians may be persuaded to increase doses to the potential detriment of their patients. To investigate this further, a review of the clinical evidence for the commercially available cosmetic formulations of BoNT-A was undertaken alongside a meta-analysis, carried out using mixed treatment analysis (MTA) methodology, of the available clinical data in the aesthetic setting. This demonstrated that at a dose of 24 units, there was a 94% likelihood that incobotulinumtoxinA was more effective than onabotulinumtoxinA in achieving a response as defined in the included studies; however, the scale of this advantage was not clinically meaningful. Of 11 clinical and preclinical studies identified comparing incobotulinumtoxinA and onabotulinumtoxinA directly, the weight of evidence suggested that there was no difference in the relative potency of the two products. As such, clinicians should continue to consider the formulations to be equipotent until such time that compelling clinical evidence to the contrary becomes available.
J Drugs Dermatol. 2012;11(6):731-736.
Safety and Efficacy of Two Anti-Acne/Anti-Aging Treatments in Subjects With Photodamaged Skin and Mild to Moderate Acne Vulgaris
Background: Although reliable prevalence data are not available, adult acne is thought to be somewhat common, and it is not unusual for patients to have acne as well as early signs of skin aging. A novel anti-acne/anti-aging formulation (Treatment A) has been developed for daily use by patients to address both signs of skin aging and facial acne vulgaris. The novel, non-prescription formulation includes several ingredients shown to target factors underlying the pathogenesis of acne vulgaris while also addressing multiple components in the pathophysiology of skin aging.
Methods: A blinded, randomized, split-face study was conducted to evaluate and compare the tolerability and efficacy of the novel anti-acne/ anti-aging product in subjects with photodamaged skin and acne vulgaris relative to tretinoin cream 0.025% (Treatment B). All subjects also were given supportive skincare, consisting of a cleanser, moisturizer, and sunscreen. Each treatment was assessed for its effects on subjects' appearance, lesion count reductions, and tolerability.
Results: Treatment A produced statistically significantly greater improvements in skin tone evenness, skin tone clarity, and blemishes and blotchiness. There were also statistically greater reductions in total lesion count for acne patients on the side of the face treated with Treatment A compared to Treatment B; Treatment A was also associated with early (day 2) improvement in skin tone evenness and clarity, tactile skin smoothness, and blemishes and blotchiness. Both treatments demonstrated favorable tolerability.
Conclusion: The novel topical anti-aging/anti-acne therapy (Treatment A) within a comprehensive skin care regimen of cleanser, moisturizer, and sunscreen may maximize efficacy and tolerability and contribute to our armamentarium for treating both photodamage and acne at the same time.
J Drugs Dermatol. 2012;11(6):737-740
Acne Vulgaris: The Role of Oxidative Stress and the Potential Therapeutic Value of Local and Systemic AntioxidantsAcne vulgaris is a common dermatological condition characterized by hormonally-mediated sebum overproduction, follicular hyperkeratinization, and chronic inflammation of the pilosebaceous unit. Microbes, genetic susceptibilities, and various environmental factors have been linked to the pathogenesis of the condition. Over the last several years it has become apparent that patients with acne are under increased cutaneous and systemic oxidative stress. Moreover, the burden of oxidative stress may not be a mere consequence of acne; rather, the oxidative stress, lipid peroxidation in particular, may be an early event that helps to drive the acne process. Here, we explore the role of oxidative stress and review the preliminary research involving the administration of local and systemic antioxidants.
J Drugs Dermatol. 2012;11(6):742-746
Efficacy and Safety of a Ceramide Containing Moisturizer Followed by Fixed-dose Clindamycin Phosphate 1.2%/Benzoyl Peroxide 2.5% Gel in the Morning in Combination With a Ceramide Containing Moisturizer Followed by Tretinoin 0.05% Gel in the Evening for the Treatment of Facial Acne Vulgaris
Joshua A. Zeichner MD, Rita V. Patel MD, Madelaine Haddican MD, and Vicky Wong BS|Combination therapy addressing multiple pathogenic factors should be used to achieve optimal outcomes in treating acne. The following study demonstrated both safety and efficacy of fixed-dose clindamycin phosphate 1.2%/benzoyl peroxide 2.5% in the morning with micronized tretinoin 0.05% gel in the evening. Both products were applied to the skin following the use of a ceramide containing moisturizing lotion.
J Drugs Dermatol. 2012;11(6):748-752
Background: Trichoscopy is widely used in differential diagnosis of non-cicatricial alopecia.
Objective: The aim of this prospective study was to identify possible characteristic trichoscopy patterns of diseases leading to primary cicatricial alopecia.
Methods: Trichoscopy was performed in a total of 1,884 consecutive patients presenting with hair loss. In this group, 84 patients were diagnosed with cicatricial alopecia and 1,800 patients with non-cicatricial alopecia. Sixty healthy persons served as healthy controls. Trichoscopy was performed with the use of Fotofinder II videodermoscopy system. Following unique or characteristic features were identified: scattered dark-brown discoloration of the skin, large yellow dots and thick arborizing vessels in cutaneous (discoid) lupus erythematosus (n=20), tubular perifollicular scaling and elongated blood vessels in lichen planopilaris (n=28), minor perifollicular scaling in frontal fibrosing alopecia (n=19), tufted hairs with starburst pattern perifollicular hyperplasia in folliculitis decalvans (n=9) and large, "3D" yellow dots imposed over dystrophic hairs in dissecting cellulitis (n=8).
Results: All patients with cicatricial alopecia trichoscopy showed white and milky-red areas lacking follicular openings. These features were not found in patients with non-cicatricial alopecia or healthy controls.
Conclusion: These results indicate that trichoscopy may be applied as a quick and non-invasive auxiliary method in differential diagnosis of diverse diseases leading to cicatricial alopecia, such as cutaneous lupus erythematosus, classic lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans, and dissecting cellulitis.
J Drugs Dermatol. 2012;11(6):753-758
Complex forehead defects may result from excision of tumors or trauma. The reconstructive challenge is determined by the extent of tissue loss, the quality of the remaining tissue, possibly comprised vascular supply to the affected region, and special considerations (eg, exposed bone or injury to underlying structures). This paper describes a novel reconstructive approach to correct a complex forehead defect with exposed bone and discusses the armamentarium of reconstructive options for such cases.
J Drugs Dermatol. 2012;11(6):759-761.
This is a case report of a 69-year-old female with Parkinson's disease who developed an asymptomatic eruption on her legs bilaterally. Clinical and histologic examination was consistent with livedo reticularis, which was temporally associated with initiation of rasagiline. The pathogenesis of livedo reticularis is discussed along with the possible mechanisms for both rasagiline and amantidine causing drug-induced livedo reticularis in patients.
J Drugs Dermatol.2012;11(6):764-765.
Capecitabine is emerging as an important drug in the treatment of metastatic breast and colorectal cancers. Marketed as Xeloda ®, this prodrug is taken orally and readily absorbed. It is novel in its increased convenience for patients, similar efficacy to the intravenous form of its active metabolite and its increased tolerability.1 We present a woman with metastatic breast cancer who presented with cutaneous abnormalities two months after starting treatment with capecitabine. Various dermatologic side effects have been attributed to capecitabine, often requiring cessation of the offending drug. We describe an unreported dermatological side effect of capecitabine therapy, systemic lupus erythematosus concurrent with palmoplantar erythrodysesthesia. As the use of this chemotherapeutic agent becomes more prevalent, it is important to recognize the range of its cutaneous side effects.
J Drugs Dermatol. 2012;11(6):769-771.
Resident Rounds is a section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds includes three sections: (1) a program spotlight, highlighting pertinent information about the department and residency training program; (2) a section presenting study materials used by residents at the program; and (3) a section designed to highlight recent interesting cases seen at the institution. This issue of Resident Rounds features the University of Iowa Hospitals and Clinics (UIHC). The editor of Resident Rounds is Omar A. Ibrahimi MD PhD. He is currently the Director of Cutaneous Laser and Cosmetic Surgery and a Mohs surgeon at the University of Connecticut. Dr. Ibrahimi is also a Visiting Scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital/Harvard Medical School. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at OIbrahimi@jddonline.com.
No abstract details for the moment.
No abstract details for the moment.
Jason Chouake and Adam Friedman|No abstract details for the moment.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug Administration (FDA) approval.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs and devices undergoing clinical testing. It is our goal to inform the reader of the status of select drug and device studies relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.
Steven R. Feldman MD PhD, Linda H. Stein Gold MD, Joshua A. Zeichner MD|This supplement covers practical, real world strategies for customizing acne regimens to the patients' specific needs. Dr. Linda Stein Gold presents information on topical retinoids and antibiotics and discusses the role of benzoyl peroxide. Dr. Joshua Zeichner describes the issues of acne treatment in specific populations, mainly pre-pubertal patients. Dr. Feldman describes the typical ways patients use their treatments and then concrete approaches dermatologists can undertake to enhance patients' adherence behavior.
This is a CME supplement; visit the JDD Medical Education Library to participate in this activity and earn 2 AMA PRA Category 1 Credits.