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Advanced Dermatologic Therapy II. Philadelphia: WB Saunders; Rosacea and perioral dermatitis. Treatment of Skin Disease. London: Mosby; Principles of Dermatology. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. A clinical and histopathologic study of granulomatous rosacea. Del Rosso JQ. Medical treatment of rosacea with emphasis on topical therapies. Exp Opin Pharmacother. Norwood R, Norwood D. Treating rosacea. Dressler-Carre M. Acne vulgaris and rosacea.
In: Arcangelo VP, editor. Interventions for rosacea. Cochrane Database Syst Rev. Rosacea II: Therapy. Topical therapies for rosacea. J Drugs Dermatol. Arch Dermatol. Allergic contact dermatitis to topical metronidazole: Three cases. Contact Dermatitis. Br J Dermatol. Chu CY.
An open-label pilot study to evaluate the safety and efficacy of topically applied pimecrolimus cream for the treatment of steroid-induced rosacea-like eruption. J Eur Acad Dermatol Venereol. Successful treatment of the erythema and flushing of rosacea using a topically applied selective alpha 1 -adrenergic receptor agonist, oxymetazoline. Topical application of 1-methylnicotinamide in the treatment of rosacea: A pilot study.
Clin Exp Dermatol. Callender VD. Acne in ethnic skin: Special considerations for therapy. Anti-inflammatory dose doxycycline 40 mg controlled-release confers maximum anti-inflammatory efficacy in rosacea. Low-dose doxycycline Oracea for rosacea. Med Lett Drugs Ther. Update on rosacea and anti-inflammatory-dose doxycycline. Drugs Today Barc ; 43 — The role of Chlamydia pneumoniae in the etiology of acne rosacea: Response to the use of oral azithromycin.
The effect of azithromycin on reactive oxygen species in rosacea. Rebora A. The management of rosacea. Am J Clin Dermatol. Fowler JF. Recalcitrant rosacea successfully treated with multiplexed pulsed dye laser. Objective evaluation of the effect of intense pulsed light on rosacea and solar lentigines by spectrophotometric analysis of skin color. Dermatol Surg. Rosacea: A common, yet commonly overlooked, condition. Am Fam Physician. Beneficial use of Cetaphil moisturizing cream as part of a daily skin care regimen for individuals with rosacea.
J Dermatol Treat. Topical kinetin 0. Treatment of rosacea with herbal ingredients. Effect of treatment of rosacea in females by Chibixiao recipe in combination with minocycline and spironolactone. Chin J Integr Med. Millikan L. Recognizing rosacea: Could you be misdiagnosing this common skin disorder? Postgrad Med. Smith K, Leyden JJ. Safety of doxycycline and minocycline: A systematic review.
Clin Ther. Baxi S. OTC products for the treatment of acne. Teenagers and acne: The role of the pharmacist. Rochester CD. Drug interactions in dermatology: Are they just skin deep? Stone DU, Chodosh J. Ocular rosacea: An update on pathogenesis and therapy. Curr Opin Ophthalmol.
Corneal manifestations of ocular Demodex infestation. In children, especially preteens, perinasal involvement is often the only affected location, at least initially, and is frequently misdiagnosed as SD and erroneously treated with a TC.
Figure 9 depicts an year-old boy with idiopathic perioral dermatitis presenting only with perinasal involvement. In some children, idiopathic nongranulomatous perioral dermatitis often presents as noninflamed micropapular lesions, which, in some areas, may simulate lesions of molluscum contagiosum. Perioral dermatitis idiopathic : Perioral involvement in a nine-year old half-African American and half-Mexican girl not associated with topical corticosteroid use.
Perinasal dermatitis in an year-old boy. Such cases are commonly misdiagnosed as seborrheic dermatitis and are often erroneously treated with a topical corticosteroid. Same patient as Figure 8a : Periocular involvement. Patients with untreated perioral dermatitis have been shown to exhibit higher levels of centrofacial TEWL than patients with ETR and PPR, and an atopic history has been suggested as a potential predisposing factor.
Although there are important distinctions between CIRD, including the perioral subset, and idiopathic perioral dermatitis, certain common characteristics suggest that a unified management plan is likely to be efficacious.
However, the time course of response may be more prolonged in CIRD. However, there is no support for this approach other than anecdotal suggestion. Medical therapy options. Several therapies, including oral antibiotics e. Topical therapy considerations. Essentially, it is strongly recommended to limit as much as possible what is applied to the skin, including both skin care products and topical medications, especially over the first few weeks of treatment.
Oral therapy considerations. Despite the absence of well-controlled clinical trials, among the available therapeutic agents used to treat perioral dermatitis, the tetracyclines appear to be consistently efficacious. This dosing regimen has been shown to exhibit anti-inflammatory activity without producing antibiotic selection pressure or emergence of antibiotic-resistant bacterial strains, including with chronic administration over nine months or greater. Although a comprehensive understanding of the pathophysiology of these disorders is not currently known, certain features may be taken into account when considering treatment options.
In both CIRD and idiopathic perioral dermatitis, addressing repair of the altered permeability barrier of the stratum corneum and reduction of increased TEWL is significant in order to reduce associated skin sensitivity, erythema, and propensity for secondary inflammation. Conceptual and rational approach to management. Although a controlled study has not yet been initiated, the author has regularly used this approach for the past two years with consistent success in the vast majority of cases, with experience in more than 50 adult and pediatric patients to date with perioral dermatitis, CIRD, and PPR over the past 18 months.
Priming the skin. The patient is instructed to disband other cleansers and moisturizers, astringents, facial scrubs, and any procedures, such as exfoliation procedures e. Photoprotection with use of a dermatologist-selected sunblock and avoidance of ultraviolet light exposure as much as possible is recommended.
How is priming of the skin carried out by the patient? Priming the skin is done by incorporating a gentle nonmedicated cleanser and moisturizer without initial use of topical medication for the first 3 to 5 days.
In idiopathic perioral dermatitis, the addition of topical medication is often not needed, as oral therapy alone is almost always sufficient. In CIRD, after initially priming the skin with gentle skin care, use of a topical agent can then be initiated with less potential for cutaneous irritation. Priming the skin allows for this by first improving the functional integrity of the epidermal permeability barrier by incorporating proper skin care from the outset of management and by removing any patient-directed improper skin care approaches that augment damage to the stratum corneum and potentiate skin sensitivity.
However, marked rebound may still occur and facial sensitivity to even gentle skin care products may be present in some cases, especially with intensely inflamed CIRD. Selection of topical therapy. There is no single topical medication definitively shown to be most effective in either idiopathic perioral dermatitis or CIRD. In most cases of CIRD, the author initiates priming of the skin and oral therapy from the outset.
After five days of this regimen, proper skin care is continued along with oral therapy, and in many cases a topical agent is added. However, there are no well-controlled studies to differentiate the therapeutic impact or relative benefits among these topical therapies in CIRD or perioral dermatitis. Available data are primarily anecdotal and based on small studies and case report series.
Selection of oral therapy. Oral tetracycline agents, including tetracycline, doxycycline, and minocycline, exhibit anti-inflammatory properties that appear to contribute to their efficacy in disorders such as PPR and perioral dermatitis. The following cases illustrate clinical presentations of CIRD and idiopathic perioral dermatitis with focus on a simplified management approach selected to address underlying pathophysiological abnormalities occurring in these disorders.
Case 1. A year-old healthy, white, female college student presented with a three-month history of erythematous papules with occasional pruritus on the chin and inner cheek region bilaterally. She related no history of TC use and has no history of any skin disorders other than mild acne in her early teen years. She did admit to picking at her facial lesions and recently had used a facial scrub along with an OTC benzoyl peroxide BP product.
Examination revealed erythematous papules on the inner cheeks and chin with some light red diffuse erythema and diffuse scaling. Excoriated papules were also noted Figure 10a. A diagnosis of idiopathic perioral dermatitis was made. Irritant dermatitis secondary to inappropriate skin care and OTC treatment was also noted.
The patient was treated with a ceramide-based gentle cleanser, a ceramide-based physiological lipid moisturizer cream, and doxycycline-MR 40mg capsule once daily. One month later, there was definite improvement with marked reduction in inflammatory lesions, absence of pruritus, and absence of scaling and background erythema Figure 10b. The patient was very pleased with the results, and treatment was continued for four more weeks. No adverse reactions were reported or observed. Perioral dermatitis before treatment in a year-old white woman with obvious visible signs of cutaneous irritation diffuse erythema, scaling caused by overly aggressive skin care, and multiple secondarily excoriated inflammatory papules.
Perioral dermatitis one month after use of a ceramide-based gentle cleanser, a ceramide-based physiologic lipid moisturizer cream, and doxycycline-MR 40mg capsule once daily. Note the clearance of diffuse redness and scaling attributed to the change to proper skin care, and the reduction in inflammatory lesions related to the treatment regimen. A few persistent papules are noted; however, most of the raised papular lesions present at baseline are now resolved, with presence of only flat macular residual erythema at those sites.
Excoriations are no longer present. Case 2. A year-old Caucasian male insurance agent presented with a two-month history of pink erythematous pinpoint papules and papulopustules noted within a background of confluent pink erythema involving the lateral third of the left upper and lower eyelid and the left lateral canthus Figure 11a.
The right periocular region was minimally affected. A mild stinging sensation was noted intermittently. No other areas of involvement were present. The patient had not used any TCs or other prescription or OTC topical medications on the face, and there was no history of use of any prescription or OTC ophthalmic products. The patient did not wear goggles of any type or contact lenses, and there was no history of this type of periocular or facial eruption occurring in the past.
Designed to be part of your daily routine: EPSOLAY cream is designed to be delicate on skin, so you can apply it every day as prescribed, either in the morning or evening.
If you are a prescribing dermatologist, you can find additional information at www. Irritation and contact dermatitis may occur. Avoid application to cuts, abrasions, eczematous, or sunburned skin. Use sunscreen or protective clothing when sun exposure cannot be avoided.
The effectiveness and safety of the acne drug azelaic acid Azelex has been supported by two double-blind, randomized controlled trials RCTs , leading the FDA to approve its use for the treatment of rosacea.
Adverse events were insignificant. Azelaic acid may be used as a first- or second-line therapy for rosacea. Other Effective Topical Treatments. One study compared the cream with placebo, 5 and two compared it with metronidazole.
Adapalene Differin , a retinoic acid receptor agonist used for treating acne vulgaris, has been shown to effectively reduce papules and pustules, but not erythema or telangiectasias.
Studies have shown that silymarin combined with methylsulfonylmethane improves papules, erythema, hydration, and itching, but not pustule number, making it an option for patients with erythematotelangiectatic rosacea. Evidence for using oral antibiotics to treat rosacea is limited and is often based on clinical experience or older, low-quality studies instead of on well-designed RCTs.
Initial therapy for moderate to severe rosacea should include oral treatment or a combination of topical and oral treatments. Because rosacea is a chronic disease, the long-term use of antibiotics can lead to adverse effects. Additionally, concerns about long-term use of antibiotics leading to resistant bacterial strains need to be addressed.
One potential management strategy is to taper the dosage of oral antibiotics after six to 12 weeks of successful treatment, transitioning to topical agents only. Licorice is the only herbal therapy studied in clinical trials that reduced erythema in patients with mild to moderate rosacea.
Subantimicrobial dose antibiotics may act as anti-inflammatory agents without creating bacterial resistance. Doxycycline is the only drug approved by the FDA to specifically treat papulopustular rosacea.
Two RCTs with a total of patients have shown that subantimicrobial dose doxycycline, alone or added to topical metronidazole therapy, reduces inflammatory lesions in patients with moderate to severe rosacea. Three to four weeks of therapy with a tetracycline is required before substantial improvement occurs; typical duration of therapy ranges from six to 12 weeks.
Three small, older studies evaluating the use of tetracycline in patients with rosacea concluded that tetracycline is significantly more effective than placebo, but specific outcomes were not included. Second-Generation Macrolides. Second-generation clarithromycin and azithromycin have been studied in patients with rosacea, but study quality is poor. Azithromycin mg three times per week appeared to be as effective as doxycycline mg daily in decreasing facial lesions in two unblinded trials of total patients.
In two studies with a total of 69 patients, oral metronidazole Flagyl was as effective as oral tetracycline in reducing papules and pustules; however, study quality was poor. Isotretinoin Accutane has been reported to be effective for treating rosacea, including rhinophyma, and appears to positively affect more than one subtype of the disease.
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