Dr Matthew Strack Dermatologist Christchurch Dunedin Invercargill 11:00 - 11:55 WS #90: Rosacea Can Be Tricky - Treatment Options 12:05 - 13:00 WS ...
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Dr Matthew Strack
Dermatologist
Christchurch
Dunedin
Invercargill
11:00 - 11:55 WS #90: Rosacea Can Be Tricky - Treatment Options
12:05 - 13:00 WS #101: Rosacea Can Be Tricky - Treatment Options
(Repeated)
Roscaea Can be Tricky
Dr Matthew Strack
Dermatologist
360 Papanui rd Marinoto Clinic, Mercy Hospital
Christchurch Dunedin
Rosacea: Origin
Latin
Rosaceous = rose coloured
Rosacea
A. Erythematotelangiectatic rosacea
(EMT)
B. Papulopustular rosacea (PPR)
C. Phymatous rosacea
(D. Ocular rosacea)
Mimics Lupus Fungal Infection Seborrhoeic Dermatitis Acne
Discussion case #1 a
79y F
Repeat presentations of rosacea
3 presentations over last 15y
Medication:
bendrofluazide, lisinopril - both for last
3y
Usually settles well with:
minocycline
Dilution of Methylprednisolone aceponate
Treatment options?
Discussion case #1 b
Given:
minocycline
Dilution of Methylprednisolone aceponate
Also checked: is protecting from UV
Rapid recurrence on tapering treatment:
Treatment options?
Discussion case #1 c
Treatment options?
Cetyl Alcohol cleanser
Dairy free diet
Discussion case #1 d
1 Year Follow up
Almost clear
Fine to continue Dairy free
Added topical metronidazole
2 Year Follow up
Clear
But…Discussion case #2 a
Rosacea – ref by GP
settles on doxycycline
Returns soon after stopping
48y M
Outdoors with work
Reacts to sunblock
Exam ppr also features of seb derm
Suggestions?Discussion case #2 b Doxycycline Dilution of Methylprednisolone aceponate Low allergen/sensitive skin sunblock Cetyl Alcohol cleanser 2 Month follow up – much better 4 Month follow up – clear Suggestions?
Discussion case #2 c
Isotretinoin
2 months 5mg
Contact Allergy Patch Test
Done 4y later!Discussion case #2 d Post Patch test Allergen identified and new skincare products given Still using small amount top steroid Rosacea not needing rx other than cleanser placed on 1y review
Triggers
Heat
UV Light
Cold
Spicy Food
Excitement
Physical Exertion
AlcoholTrigger Foods Cinnamaldehyde foods cinnamon tomatoes citrus fruits chocolate
Other Diet Approaches
Possible Causes Demodex Helicobacter Pylori Small intestinal Bacterial Overgrowth (SIBO) Specific Skin Bacteria – staph epidermidis Topical Steroid Systemic Steroid
Proposed Pathways
TLR2 = Toll Like receptor 2
TRPV = transient receptor potential vanilloid receptor
Journal of the American Academy of Dermatology 2015 72, 749-
758DOI: (10.1016/j.jaad.2014.08.028)Role of Demodex mite infestation in rosacea Yin-Shuo Chang, MD, Yu-Chen Huang, MD Journal of the American Academy of Dermatology Volume 77, Issue 3, Pages 441-447.e6 (September 2017) DOI: 10.1016/j.jaad.2017.03.040
Demodex
D folliculorum
chitin
Saphylococcus epidermidis
Bacillus oleronius
Permethrin
Ivermectin SIBO, Parodi Et al
50
45
40
35
30
25 Rosacea
20 Control
15
10
5
0
SIBOFigure 3 Clinical Gastroenterology and Hepatology 2008 6, 759-764DOI: (10.1016/j.cgh.2008.02.054) Copyright © 2008 AGA Institute Terms and Conditions
Figure 1 Clinical Gastroenterology and Hepatology 2008 6, 759-764DOI: (10.1016/j.cgh.2008.02.054) Copyright © 2008 AGA Institute Terms and Conditions
Figure 2 Clinical Gastroenterology and Hepatology 2008 6, 759-764DOI: (10.1016/j.cgh.2008.02.054) Copyright © 2008 AGA Institute Terms and Conditions
Helicobacter, SIBO
60
50
40
30 Rosacea
20 Control
10
0
Helicobacter SIBO
Helicobacter pylori infection but not small intestinal bacterial overgrowth may
play a pathogenic role in rosacea AG Gravina et al,
United European Gastroenterology Journal 2015, Vol. 3(1) 17–24
DOI: 10.1177/2050640614559262Disease associations:
n=130
Odds Ratio P
GERD 4.6 .005
Hyperlipidaemia 6.8 .003
Hypertension 4.0 .01
Diabetes 4.4 .007
All Cardiovascular 4.3 .006
Rosacea is associated with chronic systemic diseases in a skin severity dependent manner: Results of a case-
control study
Barbara M. Rainer et al ; Journal of the American Academy of Dermatology, Vol. 73, Issue 4, p604–608Thoughts on Aetiology
Parodi
H pylori Erythematotelangiectatic rosacea (EMT)
SIBO Papulopustular rosacea (PPR)
Demodex - Bystander?
Metabolic Syndrome - Part of the club?
Mechanism - Vagal instability?Treatment UV Protection Face Wash Laser Topical Oral
Superiority of ivermectin 1% cream over metronidazole 0·75% cream in treating
inflammatory lesions of rosacea: a randomized, investigator‐blinded trial
reduction from baseline in
inflammatory lesions; n=962
84
82
80
78
76
P=Superiority of ivermectin 1% cream over metronidazole 0·75% cream in treating
inflammatory lesions of rosacea: a randomized, investigator‐blinded trial
reduction from baseline in
inflammatory lesions; n=962
100
80
60
40 P=Randomised controlled trial of topical kanuka honey
for the treatment of rosacea
Reduction in severity, week 8
compared to baseline n=138, p=.02
40
35
30
25 Reduction in
20 severity, week 8
15 compared to
10 baseline p=.02
5
0
Control Kanuka Honey
I Braithwaite et al,
http://dx.doi.org/10.1136/bmjopen-2015-
007651Treatment
UV protection
Cleanser
Topical
Metronidazole
Ivermectin, azelaic acid, tretinoin, honey
Systemic
Doxycycline
Minocycline
Isotretinoin
Other
Rifaximin
H pylori triple rx protocol
Diet
Avoid trigger Foods
Low starch, gluten free – take your pick!Aggressive Rosacea 78y F mtx 10mg, floic acid, questran lite, vit d, multi ift arthralgia on mino Isotretinoin only partly helpful
Discussion case #3 b Aggressive Rosacea pneumonia - hospital admission Methotrexate stopped Rosacea settled!
Discussion case #4 a
56y m
Seen in practice 7y
Asthma
Fluticasone propionate 125 2 puffs bd
Beclometasone dipropionate nasal spray
Rosacea
settles with Isotretinoin 5mg
Still not settled after 1yDiscussion case #4 b
Flared with dexamethasone – ENT
Surgery
Dabigatran – further flare
Borderline synacthen testDiscussion case #4 c
Dabigatran stopped
Fluticasone propionate 125 – dose halved
Hydrocortisone 5mg bd then 2.5 bd
DischargedMinocycline
Broad spectrum tetracycline
Compared to Doxycycline
More lipid soluble
Longer half life
Some anti Staphylococcus epidermidis activity
More side effects
Side effects
Intracranial hypertension
Drug induced Lupus
RA like syndrome
Renal damage – esp expired
Oesophageal/Gastric Irritation
Photosensitivity
Pigmentation
Contraindicated in pregnancy
Tooth staining – any ageMinocycline – Pigmentation
Take home
Rosacea is common and treatable
May coexist with Seborrhoeic dermatitis
Cause is usually not clear but may be in specific patients
Most cases respond well to treatment
UV Protection
Cetyl Alcohol cleanser
Topical Metronidazole
Minocycline
Isotretinoin
Diet Changes can be helpful
Keep drug interactions in mindYou can also read
