Sun exposure is the most preventable risk factor for all skin cancers, including melanoma as well as skin aging.

The following are Skin Cancer Foundation sun safety guidelines:

• Seek the shade, especially between 10 AM and 4 PM
• Do not burn
• Avoid tanning and UV tanning booths
• Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses
• Use a broad-spectrum sunscreen with an SPF of 30 or higher every day
• Apply 1 ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outside. Reapply every two hours or after swimming or excessive sweating.
• Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months.
• Wear sun-protective clothing
• Use extra caution near water, snow and sand as they reflect damaging rays
• Get vitamin D safely through a healthy diet, including vitamin supplements
• Examine your skin head to toe every month
• See your doctor every year for a professional skin exam

For Every Day Sun Protection

Sunscreen should be worn every day, regardless of the weather or season. Sun exposure occurs all day long, through clouds, through glass windows of our homes and cars.

Limiting sun exposure, by wearing hats/gloves/sun protective clothing and avoiding exposure between 10am-3pm, is essential. You should wear sunscreen every day on exposed areas (i.e., face, neck, V-neck, chest, hands/forearms, and legs) for both skin cancer protection and defense against photo-aging.

SPF (Sun Protection Factor) is defined as a ratio of time in the sun required to sunburn with sunscreen on to the length of time in the sun required to burn without sunscreen.

• SPF30: blocks 96.7% of ultraviolet radiation
• SPF50: blocks 98% of ultraviolet radiation

Choose a daily sunscreen that is at least SPF30 (if you have dark skin) or SPF 40-50 (if you have light skin) and has both UVA and UVB (i.e. broad spectrum) coverage. If you have a personal or family history of skin cancer, or if you are often outdoors, consider using a sunscreen with higher than SPF 50.

There are two basic types of sunscreen:

• Mineral sunscreen (physical blocker): physically blocks ultraviolet radiation. Active ingredients include zinc oxide or titanium dioxide.
• Chemical sunscreens: contain special chemicals that absorb ultraviolet radiation such as oxybenzone, avobenzone, ecamsule, padimate O,PABA, octyl methoxycinnamate, octyl salicylate, phenylbenzimidazole sulfonic acid, homosalate, octisalate, octocrylene, octinoxate.

For face: UVA/UVB (broad spectrum) coverage higher than SPF30 is recommended

• There are now many facial moisturizers that contain sunscreen, and this is adequate for regular daily use if the majority of your day is spent indoors and/or out of direct sunlight. Re-apply the sunscreen every few hours throughout the day.
• Choose a non-comedogenic (non-pore clogging) sunscreen with zinc oxide and/or titanium dioxide if you have acne-prone skin or if you experience skin irritation with other chemical-containing sunscreens. Consult your doctor if sunscreens cause persistent significant skin irritation, or if you believe that you have a sunscreen allergy.
• There are several powder-based products containing mineral sunscreens that can be applied over moisturizer or make-up.
  For lips: lip-balm containing SPF30 is recommended
  For body: UVA/UVB (broad spectrum) coverage greater than SPF50 is recommended
• Lotion, cream, gel is recommended over spray.
• Consider wearing SPF30-50 UV-blocking articles of clothing as an alternative to sunscreen.

What about sun protection for sports and outdoor activities?

For water sports, a wetsuit or UV-proof (SPF50) water jersey is recommended. Other sun-exposed areas require special sunscreens that will stay on in the water or after sweating. They need to be reapplied often, especially after sweating, toweling off or after extended periods of time when skin is immersed in water.

• Very water resistant sunscreens: SPF is maintained after 80 minutes water immersion
• Water resistant sunscreens: SPF is maintained after 40 minutes water immersion

Rosacea is a common, chronic skin disorder that frequently affects light-skinned Caucasian population.  Overall prevalence of rosacea ranges from less than 1% to 10%. The nose, cheeks, chin, forehead, and glabella are the most frequently affected sites. The disease has a variety of clinical manifestations ranging from flushing, persistent erythema, telangiectasias, papules, pustules and sebaceous gland hyperplasia.

Lasers and light sources revolutionized the treatment of rosacea.

GLOBAL SKIN REJUVENATION with Aerolase

• Concern: uneven skin tone, redness, skin inflammation, papules, pustules
• Solution: Aerolase® (1064 Nd:Yag 650 microsecond) targets redness and melanin within the skin. In addition to improvement of rosacea redness and skin sensitivity, patients you can see an overall improvement in skin tone, texture, and elasticity.
• Expectations: Patients can expect mild warming sensation with little to no post-procedural downtime (~few hours-days of redness). 3-4 treatments are recommended for optimal results

IPL (INTENSE PULSED LIGHT) 

• Concern: irregular or unwanted rosacea redness
• Solution: IPL is light-based therapy targets redness, broken capillaries for a clear, radiant, even-toned complexion.
• Expectations: Patients should expect a mild warming sensation during treatment with minimal to no downtime. Around 6 treatment sessions are recommended for rosacea redness.

MICRONEEDLING RADIOFREQUENCY (RF) VIVACE, GENIUS 

• Concern: surface irregularities, redness, skin sensitivity
• Solution: Vivace and Genius combine radiofrequency and gold-plated microneedling technology, delivering heat into the deeper layers of the skin promote new collagen rich tissue, which helps to even skin tone, while also helping to lift and tighten the skin. Vivace and Genius can help globally enhance the appearance of skin and reduce surface irregularities present in rosacea.
• Expectations: Following local anesthesia in the treatment areas, most find the treatment very tolerable with little to no downtime. 2-4 treatments are recommended for optimal collagen induction.

PERFECTA V-BEAM VASCULAR LASER

• Concern: dilated or broken capillaries, overall redness
• Solution: This laser produces a burst of light to specifically target vascular lesions, unwanted blood vessels, and redness that are common in rosacea.
• Expectations: Patients should expect a mild warming sensation with no local anesthesia required. 3-4 treatments are best for optimal reduction of rosacea redness.

Currently, only the following medications are FDA-approved for use in rosacea:

1. Topical medications: metronidazole (0.75 and 1%) (gel, cream, lotion), azelaic acid (15 and 20%) cream, sulfacetamide 10%-sulfur 5% (gel, cream, topical suspension, wash)
2. Systemic: Oracea 30 mg immediate release & 10 mg delayed release doxycycline

Other non-FDA approved treatments used off-label have also been beneficial and will be discussed below.

Extended information on rosacea

Rosacea is a common, chronic skin disorder that frequently affects light-skinned Caucasian population.  Overall prevalence of rosacea ranges from less than 1% to 10%.  The nose, cheeks, chin, forehead, and glabella are the most frequently affected sites.  The disease has a variety of clinical manifestations ranging from flushing, persistent erythema, telangiectasias, papules, pustules and sebaceous gland hyperplasia.  Significant psychological stress and diminished perceive quality of life often accompanies this condition.  The pathogenesis is likely multifactorial and includes genetic and vascular elements, climatic exposures, pilosebaceous unit abnormalities, and possibly microbial organisms.

Diagnosis of rosacea is based primarily on clinically recognizable morphologic characteristics. An expert committee assembled by the National Rosacea Society on the Classification and Staging of Rosacea defined and classified rosacea in April 2002 into 4 clinical subtypes based primarily on morphologic characteristics.  The subtypes include erythemato-telangiectatic rosacea (ETR), papulo-pustular rosacea (PR), phymatous rosacea, and ocular rosacea.

In order to design appropriate treatment regimen it is essential to correctly identify the subtype of rosacea.   In addition, rosacea has to be distinguished from its clinical mimickers.  ETR must be differentiated from chronic sun damage and photodermatitis.PR must be distinguished from acne vulgaris, seborrheic dermatitis, lupus miliaris disseminates faciei, collagen vascular diseases, perioral dermatitis, and Demodex folliculitis.  Differential diagnosis of ocular rosacea includes allergic conjunctivitis and blepharitis.

Therapy of rosacea is centered on symptomatic improvement i.e. reduction of facial erythema and number of inflammatory lesions, decrease in the number, duration and intensity of flares, and reduction of concomitant symptoms of itching, burning, and facial tenderness.

In addition to medical therapy sun protection and appropriate skin care regiment need to chosen as rosacea patients often exhibit marked skin sensitivity and suffer from intolerance to skin products and cosmetics. Triggers for cutaneous flushing should be identified and eliminated.   Commonly identifiable triggers include topical cosmetics and corticosteroids, alcohol, tobacco, exercise, hormonal changes, sun exposure, hot weather, exercise, ingestion of hot or spicy foods/ drink, caffeine, emotional stress and medications such as topical and systemic steroids, niacin and nitroglycerin. A flare of rosacea may be anticipated when steroids are discontinued and may be dramatic requiring therapy with systemic antibiotics and topical tacrolimus.

Currently, only the following medications are FDA-approved for use in rosacea:

• Topical medications: metronidazole (0.75 and 1%) (gel, cream, lotion), azelaic acid (15 and 20%) cream, sulfacetamide 10%-sulfur 5% (gel, cream, topical suspension, wash)
• Systemic: Oracea 30 mg immediate release & 10 mg delayed release doxycycline

Other non-FDA approved treatments used off-label have also been beneficial and will be discussed below.

Erythemato-telangiectatic rosacea (ETR)

ETR subtype is clinically characterized by diffuse erythema and telangiectasias on the cheeks, forehead, dorsal nose, or sometimes entire face.  Patients frequently complain of intolerance or sensitivity to topical products and cosmetics.

This type of rosacea is best treated with avoidance of triggers leading to flushing, strict photoprotection, electrosurgery and phototherapy.  In recent years phototherapy and laser therapies are gaining popularity as treatments of rosacea associated erythema and telangiectasias.  Laser therapies include pulse-dye laser (PDL), potassium-titanyl-phosphate (KTP) laser, Nd-YAG laser, or intense-pulsed light (IPL).  In a study of 34 patients with ETR, IPL treatment resulted in overall patient and physician reported over 50% improvement in 73% and 83% of patients, respectively. The results were sustained at 6 months.  In a different study 83% of patients had less facial redness, 75% noted less flushing and better skin texture, and 64% noted fewer acneiform breakouts.

Topical selective alpha-agonist, oxymetazoline, represents a novel approach to management of ETR associated erythema and flushing.   A small study showed significant benefit with the use of the alpha-agonist oxymetazoline in reducing the flares and the inflammatory symptoms in patients with traditional medication resistant ETR.

Facial edema may be a prominent clinical feature of rosacea.  Recurrent vasodilation results in a feeling of fullness of the cheeks and visible subtle induration of the cheeks, so called solid facial edema.   Solid facial edema of ETR responds to isotretinoin.

Papulo-pustular rosacea (PR)

PR subtype is characterized by papules and pustules often on erythematous base primarily affecting the nose, cheeks, and forehead. Predilection of the lesions on the central, convex aspect of the face, sometimes with corresponding central facial edema is frequently noted.

Topical Therapy

The major topical antibiotics used to treat PR are metronidazole, clindamycin and erythromycin. Other topical therapies include azelaic acid, pimecrolimus, antiparasitics, alpha-adrenergic agonists and topical sulfacetamide 10% with sulfur 5%.

Metronidazole

Clinical efficacy of the topical metronidazole in the treatment of rosacea has shown in a number of clinical trials.  The mechanism of action of metronidazole is not yet well established, but appears to be anti-inflammatory.  Topical metronidazole is commercially available in a 0.75% gel, lotion and cream for twice daily use, and a 1% cream or gel for once daily use.   Twice-daily 0.75% metronidazole was shown to be well-tolerated and effective in the treatment of 582 patients with mild to moderate severity PR.  Mean erythema severity score was reduced by 50% by week 12 of treatment. In a 12-week, randomized control study, Jorizzo et al. showed that once daily dosing of 1% metronidazole cream is as effective as twice daily dosing.  Metronidazole is generally well tolerated and has a low incidence of adverse side effects.  Most commonly reported include mild pruritus, skin irritation and dryness.

In a recent Cochrane review, topical metronidazole was shown to be significantly more effective than a vehicle in 174 patients with marked reduction of number of inflammatory lesions and erythema scores with an odds ratio of 5.96.  Metronidazole plays a role in maintenance therapy, either with or without prior concomitant systemic antibiotic therapy. Effect of metronidazole on rosacea associated telangiectasias is generally minimal.

Sodium sulphacetamide with sulphur

Despite the lack of randomized controlled studies, sodium sulphacetamide 10% with sulfur 5% has been used as a safe, well-tolerated and effective treatment option for rosacea for over 50 years.  Eight week therapy with sodium sulphacetamide 10% with sulfur 5% resulted in a significant reduction in inflammatory lesions and facial erythema (78% vs. 36% and 83% vs. 31%, respectively) compared to a vehicle.  Adverse effects of topical application were generally mild and included pruritus, contact dermatitis, irritation, erythema, scale and xerosis.

Newer, emollient foam formulation of 10% sodium sulphacetamide and 5% sulfur offer similar benefits with less lingering odor and reduced irritation potential. Preliminary anecdotal evidence suggests synergistic benefit of concurrent sodium sulphacetamide10% with sulfur 5% and metronidazole application.

Azelaic acid

Azelaic acid, commercially available as 15% gel or 20% cream, is a naturally occurring, saturated 9-carbon dicarboxylic acid derived from Pityrosporum ovale.  Azelaic acid is FDA-approved for the treatment of mild to moderate rosacea.  Its biologic effects encompass anti-inflammatory, anti-keratinizing and anti-bacterial properties.  Recently, PPAR gamma activation was shown as a main modulator of the inflammatory response modulated by azelaic acid in normal human keratinocytes.

Clinical safety and efficacy of azelaic acid 15% gel applied twice daily for 12 weeks has been demonstrates in two phase III, vehicle-controlled, randomized trials of 664 patients with PR. On average improvement of erythema ranged from 44-46% in patients treated with azelaic acid, compared with 28-29% in the vehicle group.   A mean reduction in inflammatory papules and pustules ranged from 51-58% in the azelaic acid group, compared with 39-40% in the vehicle group.

Data from three clinical trials analyzed by Cochrane review showed rates of improvement in azelaic acid group of 70-80% compared with 50-55% in the placebo group.  In a randomized trial comparing topical metronidazole with azelaic acid the efficacy of 20% azelaic acid was greater than metronidazole in improving erythema and inflammation in physician rating of global improvement.  Application of azelaic acid was associated with a greater irritation.  Wolf et al. found the efficacy of once-daily application of metronidazole 1% gel and twice daily azelaic acid 15% gel to be similar.  Both medications were well tolerated, with the number of adverse effects slightly higher in azelaic acid group.  All reported adverse effects were mild to moderate.

Anecdotal evidence suggests beneficial effects of topical clindamycin, erythromycin, and combination benzoyl peroxide-clindamycin in the treatment of rosacea, but efficacy of these modalities have not yet been evaluated in well-designed clinical trials.  In a double-blind, randomized controlled trial of once daily clindamycin 1% benzoyl peroxide 5% gel a significant reduction in inflammatory lesion count and erythema was noted. The treatment was generally well tolerated.

Tacrolimus and pimecrolimus

Topical tacrolimus (0.03% or 0.1%ointment) and pimecrolimus (1% cream) are macrolide non-steroidal immunomodulators.  Their mechanism of action is by inhibition of T-cell activation and inhibition of subsequent cytokine release.  In a pilot study, topical pimecrolimus showed clinical benefit with decreased erythema and number of inflammatory lesions in after 12-18 weeks of therapy.  Another randomized trial, nonetheless, demonstrated that pimecrolimus was no more effective than the vehicle when used for 4 to 6 weeks.

A recent single-centre, randomized, open-label study of 48 patients comparing pimecrolimus with metrondazole both treatments were very effective in the treatment of PR. There were no significant differences between the treatments in inflammatory lesion counts, overall erythema severity scores and physician global assessment scores evaluated from baseline to week 12.  Neither treatment produced any clinically relevant improvement in telangiectasia.

Rarely pimecrolimus may produce a syndrome similar to steroid-induced acne.

Anecdotal evidence suggests that topical tacrolimus may be an effective treatment of steroid induced rosacea especially when combined with systemic minocycline.

Retinoids

The role of topical retinoids in the management of rosacea remains controversial.  The mechanism of action of the retinoids is by regulation of the retinoic acid receptor, an important regulator of keratinocyte proliferation, differentiation, and cutaneous inflammation.  Use of retinoids carries a theoretical benefit of decreased angiogenesis and decrease in cutaneous vascularity and possible prevention of new telangiectasias.  In a few small series, topical retinoid, tretinoin, have demonstrates benefit for rosacea with a lessening degree of erythema and a partial to complete disappearance of telangiectasias as well as decreased in the number of inflammatory lesions although the clinical response was delayed and not evident until 2 or more months of therapy.

A small study demonstrated the efficacy of topical free radical scavenger vitamin C for rosacea suggesting the possibility that free radical production may play a significant role in the pathological inflammatory response seen in rosacea.

Some antiparasitic drugs have been observed to be helpful as both oral and topical agents in the treatment of the inflammatory rosacea. Oral ivermectin and lindane have shown some efficacy in the eradication of Demodex folliculorum, one possible factor that may lead to the inflammation underlying rosacea.  Permethrin and crotamiton topically have not shown great usefulness in eradicating Demodex folliculorum, but may still lead to the resolution of some of the underlying inflammation. In a small randomized double-blind placebo-controlled study permethrin 5% cream was found superior to the vehicle and similar in efficacy to 0.75% metronidazole gel.

 

Oral Therapy

Antibiotics

Tetracyclines are broad-spectrum antibiotics that remain the mainstay of oral pharmacotherapy for rosacea.  Tetracycline (250 to 500 mg twice daily) and more recently second generation tetracyclines, doxycycline (100 to 200 mg per day and extended release 20-40 mg per day) and minocycline (100-200 mg per day),are commonly used oral therapies.  Second generation tetracyclines have an improved bioavailability, longer elimination half-life, once daily dosing and can be taken with food which minimizes gastrointestinal side effects.  Azithromycin has also been shown to be beneficial for treating rosacea, is better tolerated than first generation tetracyclines and can be dosed 3 times a week.

The precise mechanism of action of tetracyclines remains unknown.  Most likely anti-inflammatory and not anti-microbial actions of tetracyclines such as their actions on inhibition of angiogenesis, neutrophil chemotaxis, release of pro-inflammatory cytokines, cellular apoptosis, cell proliferation and inhibition of matrix metalloproteinases contribute to clinical benefit in management of rosacea.   A significant benefit of second generation tetracyclines is their clinical effectiveness at sub anti-microbial, anti-inflammatory doses limiting undesired side effects (candidal vulvovaginitis, gastrointestinal distress) and possibly bacterial resistance. Systemic tetracycline antibiotics should not be used in children under the age of 8 because of potential permanent discoloration of teeth.

Anti-inflammatory dose of doxycycline, a 40 mg doxycycline monohydrate containing 30 mg immediate-release and 10 mg delayed release doxycycline, commercially available as Oracea, is the only tetracycline approved in the US for the long-term (12 months) use.  Oracea has been shown effective in treatment of PR with favorable risk/benefit ratio.  Used at sub anti-microbial doses, long-term use of anti-inflammatory doxycycline might not exert selective pressure on bacteria, and thus limit development of bacterial resistance.

Two phase III, controlled studies have demonstrated the safety and efficacy of a 16-week treatment with anti-inflammatory 40 mg doxycycline administered daily in the management of PR. Both studies included patients with inflammatory PR with 10-40 papules, moderate to severe erythema and telangiectasias.  At the end of 16 weeks, the mean change in lesion count in doxycycline groups was -11.8 and -9.5 in compared with -5.9 and -4.3 in the placebo group?  Doxycycline was well tolerated with low incidence of side effects.  Most commonly reported side effects included nasopharyngitis, diarrhea and headaches.  Efficacy beyond 16 weeks and safety beyond 9 months has not yet been established in randomized controlled studies.

Current research on small number of patients suggests that combination therapy of oral anti-inflammatory dose of doxycycline and topical metronidazole leads to quicker and more effective alleviation of inflammatory lesions.

Oral erythromycin at 250-1000 mg per day is considered an effective drug for the treatment of PR.  The use of erythromycin is reserved for those patients that are intolerant, allergic or refractory to tetracyclines or in cases when tetracycline therapy is contraindicated (e.g. pregnancy).

Second generation macrolides, clarithromycin and azithromycin have both been found to be effective and tolerable drugs in short term therapy of rosacea.  At the end of a 12-weektreamtent with azithromycin, a 75% decrease in total scores and an 89% decrease in inflammatory lesion scored was noted compared with baseline values.

A significant amount of circumstantial evidence links the eradication of Helicobacter pylori with the “triple therapy,” consisting of omeprazole and 2 of the following antibiotics: clarithromycin, amoxicillin, or metronidazole and the successful treatment of rosacea.

Metronidazole

In a randomized study of oral metronidazole (200 mg twice daily) vs. oxytetracycline (250 mg twice daily) both drugs produced an improvement after 6 and 12 weeks of therapy with no significant differences between the two.   In rare instances, treatment with oral metronidazole might be associated with epileptiform seizures, encephalopathy, and sensory neuropathy.  Oral metronidazole also requires abstinence from alcohol.

Isotretinoin

In a small number of clinical trials, isotretinoin was found to be effective for both ETR and PR.  Isotretinoin, although not working directly as an antibiotic, has strong antibacterial effects.  Irvine et al. noted a reduced facial cutaneous blood flow in the isotretinoin group compared with oxytetracycline group.

A small study of 22 patients showed the effectiveness of a 4 month low-dose (10 mg) isotretinoin therapy in patients with therapy-resistant rosacea.  The treatment led to a reduction of number of inflammatory lesions, erythema and telangiectasia.   The overall effect of isotretinoin therapy was delayed in comparison to therapy with oral antibiotics.

Gollnick et al. compared efficacy of isotretinoin (0.1. mg/kg, 0.3 mg/kg or 0.5 mg/kg) with doxycycline (100 mg daily for 14 days, followed by 50 mg daily) in the treatment of grade II and III rosacea in a double-blinded randomized 12 week study.  Isotretinoin 0.3 mg/kg proved to be the most effective dose compared with placebo. Isotretinoin 0.3 mg/kg treatment resulted in 90 % reduction of number of lesions compared with 83 % reduction with doxycycline.  Isotretinoin 0.3 mg/kg was generally well-tolerated.

Other oral therapies

Other oral therapies that have shown benefit are medications that reduce flushing beta-blockers, clonidine, naloxone, ondansetron, and selective serotonin reuptake inhibitors.

Oral contraceptive therapy has been helpful in patients who provide historical information of worsening rosacea with their hormonal cycle.

Dapsone has been used in severe, refractory rosacea, and dapsone has been particularly beneficial for patients who cannot take isotretinoin.

 

Phymatous rosacea

Phymatous rosacea is characterized by marked by thickening of the skin, irregular skin texture, edema, hypertrophy and hyperplasia of sebaceous glands, connective tissue, and vascular bed.  Phymatous rosacea commonly involves the nose (rhinophyma) but changes can also be seen on the chin (gnathophyma), ears (otophyma), forehead (metophyma), and eyelids (blepharophyma).  This severe form of rosacea requires aggressive medical therapy with systemic antibiotics, and sometimes warrants use of isotretinoin. Once the medical regimen has been maximized, the patient is a candidate for surgical/ laser resurfacing of the affected area.  Electrosurgical sculpturing of the phymatous skin gives excellent results, is fast, and is almost bloodless.   A CO₂ laser or erbium-YAG laser may also be used for the treatment of rhinophyma, although it is more costly and time-consuming than electrosurgical treatment. Electrosurgical treatment is more likely to scar compared to laser therapy.

Cold-steel surgery and dermabrasion are also effective, but they are more difficult owing to the vascularity of the nose.

 

Ocular rosacea

Ocular rosacea can be seen in the presence or absence of skin manifestations of rosacea. Clinically, ocular rosacea is characterized by conjunctival erythema and injection, sometimes accompanied by eyelid edema), foreign body sensation, inflammation of the lids , blepharitis and meibomian glands, interpalpebral conjunctival hyperemia, conjunctival telangiectasias and/or glandular inflammation (chalazion) along the eyelid margin.⁴³  Patients report subjective symptoms: foreign body sensations, dry eyes, stinging, itching and burning, photosensitivity. The vision is rarely affected. Ocular rosacea requires systemic antibiotics, and oral tetracyclines including low dose doxycycline are an excellent first-line therapy for this form of rosacea.  Topical corticosteroid eyedrops may also be beneficial.

 

Other rosacea subtypes

Granulomatous rosacea is a variant of rosacea clinically presenting with erythemaotus to brownish papules with peripheral erythema on the malar and perioral region.  Treatment of granulomatous variant is difficult.  In a case report, granulomatous rosacea refractory to traditional treatments was treated with IPL with satisfactory improvement.⁴⁴  Authors postulated that IPL system with non-fixed wavelengths, ranging from visible to infrared might provide added benefit of treating telangiectasias at different depths leading to subsequent improvement.

Rosacea fulminans (sudden onset of coalescent papules, pustules, nodules) may occur during pregnancy, thyroid diseases, depression, emotional stress, induced by medications.  This exacerbation may require use of systemic corticosteroids (prednisone 0.5 to 1 mg/kg/day) and/or isotretinoin.

Conclusion

The mainstay of rosacea therapy remains topical metronidazole or azelaic acid and oral tetracyclines. As this disease process causes increased skin sensitivity, many of the topical therapies may not be well tolerated, necessitating other therapies. It is therefore important to have as many treatment options as possible.

Melasma is a skin pigmentary disorder affecting millions of patients worldwide. Melasma is characterized by patterns of patchy hyperpigmentation, usually on the cheeks, under the eye, upper lip, and forehead. Skin discoloration associated with melasma is due to an over accumulation of skin pigment melanin, is produced by pigment cells called melanocytes. Although etiology of melasma is largely unknown, it is understood that genetics plays the largest role. Melasma can be further exacerbated by UV exposure, heat and visible light.  Occurrence of melasma is often linked to hormonal triggers like oral contraceptive pills, IUDs, hormone therapy and pregnancy.

Melasma can be categorized as “epidermal” or “dermal”, or mixed.

In epidermal melasma melanin is present in the more superficial epidermal layers

In dermal melasma melanin is in the deeper layers of the skin and is typically visualized best under Wood’s lamp examination. This distinction is crucial because epidermal melasma responds more quickly to treatment.  Dermal melasma is much more difficult to treat.

Mixed melasma is a combination of epidermal and dermal melasma.  Melasma is often associated with increased vascularization ie. increased number of blood vessels, vessel size, and vessel density.

When treating pigmentary disorders it is important to be evaluated by a board-certified dermatologist to first accurately diagnose melasma as an underlying cause of hyperpigmentation and second to determine melasma subtype prior to pursuing any treatments or products as some treatments might significantly worsen melasma.

 

Treatment for Melasma

The management of melasma is often challenging, with partial responses and frequent relapses. A combination of therapies targeting multiple pathogenic elements, such as photodamage, inflammation, aberrant vascularity, and abnormal pigmentation, generally provides the best clinical outcomes. The best therapeutic armamentarium includes a variety of agents that

• inhibit the biosynthesis of melanin
• increase skin epidermal turnover and therefore removal of excess of melasma pigmentation
• chemical peels and lasers that directly remove of excess melanin

Sun Protection

Sunscreens are essential to prevent progression of melasma due to UV exposure, visible light, and blue light from electronic devices. The best sunscreen for melasma is physical sunblock with SPF 30 or higher that contains zinc oxide or titanium dioxide as the active ingredient.

Lasers

NeoClear by Aerolase

The NeoClear by Aerolase® has proven to be effective against both dermal and epidermal melasma. This laser targets pigment/melanin itself, without causing any additional tissue damage and without any risk of post-inflammatory hyperpigmentation or pigmentation worsening. This makes 1064 lasers an ideal choice in melasma treatment, as many other treatments (including both topicals and other lasers) result in tissue inflammation. Also unlike other lasers, due to its 650 – microsecond technology the laser can effectively penetrate to the deeper layers of the skin ie. dermal layers treating dermal melasma and melasma associated increased vascularity  without risk of tissue damage.

Clear + Brilliant, Permea

Clear + Brilliant is a non-invasive laser that creates thousands of “micro injuries” to the epidermis. These micro-injuries trigger the body’s healing process, replacing damaged cells with new, healthy tissue.  Clear and Brilliant resurfacing also allows for optimal penetration of products that help to reduce pigmentary change.  Clear + Brilliant is the most gentle fractional resurfacing laser (treating up to 20% of the skin), which is optimal for those who are looking to minimize downtime or those who have milder cases of melasma. Multiple sessions are required to achieve clinical reduction of melasma.

Fraxel DUAL 1550/1927 Fractional Resurfacing

Fraxel is a non-ablative fractional resurfacing laser that creates microthermal injury zones in the skin to stimulate the body’s own healing and rejuvenating process.  The procedure targets a portion of tissue at a time, leaving the surrounding tissue enact. As this laser does not cause complete tissue damage, the laser itself can remove tissue containing melanin pigment. Fraxel is from the same family as Clear + Brilliant, however Fraxel targets a larger percentage of skin tissue (treating up to 40% of the skin). This is an optimal treatment option for patients who are comfortable with having more downtime as well as patients with a most severe melasma.

Coolpeel CO2 Resurfacing, Lumenis UltraPulse CO2 Ablative Resurfacing

Considered one of the most intensive resurfacing lasers, the CO2 laser is an ablative fractional laser. By comparison to the other lasers in this category, the CO2 laser removes via vaporization the outermost (epidermal) layers of skin cells, relying on the dermal tissue beneath to initiate a healing response. This again creates new, healthier tissue that is free of pigmentary changes or evidence of UV damage. These lasers not only target the melanin pigment in the epidermal skin layers, but can also target the pigment producing melanocytes. This laser is extremely efficacious, but requires the most significant amount of downtime. This laser is ideal for patients who are comfortable with extended periods of downtime as well as patients with stubborn, resistant melasma that has not responded with more conventional laser therapies.

Oral medications

Tranexamic acid- which has been shown to be effective in the treatment of melasma. The largest study on the use of oral tranexamic acid for treatment of melasma was a retrospective review of 561 melasma patients treated with tranexamic acid.  More than 90% of patients received prior treatment for their melasma, including bleaching creams and laser treatments. Among patients who received oral tranexamic acid over a 4-month period, 90% of patients demonstrated improvement in their melasma severity. Tranexamic acid has been shown to be safe but is not recommended for a long term use. It is also contraindicated in patients with personal or family history of clotting disorders, personal history of deep vein thrombosis (DVT), or patients who are currently pregnant or are preparing to conceive.

 

 

CHEMICAL PEELS

Chemical peeling involves the topical application of a chemical agent, wherein the desired outcome is a controlled regeneration of the skin and removal of excess pigmentation.

Cosmelan depigmenting solution by mesoestetic offers a professional depigmenting protocol designed to eliminate or reduce dark spots while unifying the skin tone and enhancing overall skin luminosity.

Topical skin care

There are many active ingredients used to improve existing hyperpigmentation of melasma. The most common and effective ones are hydroquinone (HQ), kojic acid, azelaic acid, ascorbic acid/Vitamin C, glycolic acid (AHA or alpha hydroxy acids), tranexamic acid, licorice root extract, and Vitamin A derivatives (ie retinol, all-trans retinoic acid). Most of these ingredients work mostly by either inhibiting melanin synthesis or exfoliating excess of superficial pigmentation.

• HQ- Of the components mentioned above HQ has shown to be one of the most effective topical treatments and is widely considered the gold standard in clinically reducing the appearance of melasma. However, due to its strong effects on skin cells, HQ should not be used for long periods of time, and the recommended duration should not exceed more than 3-6 months of continuous use.
• Vitamin A (Retinoids, Retinols) – Acts by tyrosinase inhibition, preventing melanosome transfer, and increases epidermal turnover, by essentially “ungluing” the bonds that hold damaged, melanin-containing skin cells and effectively exfoliate these dead skin cells. Cellular turnover by using vitamin A is typically seen over a period of 28 days, however increased use of vitamin A has shown to increase the rate of cell turnover to 21 days or even 18 days. Vitamin A on its own and the combination of vitamin A + HQ can be very irritating and drying on the skin, so these medications are often compounded further with a corticosteroid (commonly called triple combination or TC therapy) to help reduce inflammation resulting from these active ingredients. They also make your skin increasingly photosensitive, which further stresses the importance of daily sunscreen with SPF of 30 or higher.
• Vitamin B3 (Niacinamide) – Studies have shown that Vitamin B3 may decrease skin pigmentation by preventing melanosome transfer within skin cells. It also plays a role as both an antioxidant and an anti-inflammatory. Similarly to Vitamin C, Vitamin B3 neutralizes reactive oxygen species (ROS). As an anti-inflammatory, Vitamin B3 can effectively reduce the inflammatory response from intensive active ingredients such as HQ and Vitamin A.
• Vitamin C (Ascorbic Acid) – Another tyrosinase inhibitor, widely used in skincare as a potent antioxidant and for its skin “brightening” abilities. Vitamin C also donates electrons to neutralize reactive oxygen species (ROS) that are generated due to UV exposure. Harmful ROS occur when there are alterations of cellular DNA, the cell membrane, and cellular proteins (including collagen).
• Alpha Hydroxy Acids (Lactic Acid, Glycolic Acid, Mandelic Acid) – Water loving acids derived from a natural substance (sugar cane, milk, almonds, grapes), most effective for surface level pigmentary changes. The large molecular size allows penetration to be limited to the epidermis. AHA’s assist in superficial skin turnover and allow the skin to shed spent cells to reduce the appearance of pigmentation.
• Beta Hydroxy Acid (Salicylic Acid) – Oil loving acids that penetrate deeper into the skin through bypassing the oil that clogs pores and dissolve the mix of sebum and dead skin as well as stabilizing the lining of the pore. Unglue the bonds holding dead skin to the surface and allow the skin to shed spent cells to reduce the appearance of pigmentation.
• Azelaic Acid – Recent studies have shown that Azelaic Acid is an effective tyrosinase inhibitor and continuous use has been shown to reduce clinical appearance of melasma and pigmentary changes. Azelaic acid, however, must be used in a high enough concentration for maximal effectiveness (between 5-20%).
• Ferulic Acid – Ferulic acid may work minutely to prevent melanin formation, but where it really stands out as an active ingredient is it’s effects on other skin ingredients. When combined with other actives (such as Vitamins A, C, and E), it enhances the effectiveness of these ingredients. Especially in the case of Vitamin C (which is an excellent skin ingredient, however it’s effectiveness is often deterred by it’s instability) where ferulic acid helps to stabilize the molecule from degrading and also increase its photoreceptiveness (i.e. the ability to minimize sun damage).
• Kojic Acid – A tyrosinase inhibitor produced by several fungi species.
• Cysteamine – At high concentrations, cysteamine has been shown to inhibit melanogenesis. Cysteamine may also have anti[cancer and anti-melanoma effects for added benefit by comparison to some other active ingredients. Cysteamine by comparison has similar side effects to HQ (including skin irritation, dryness, etc.) but otherwise proves to be safe for use.
• Epidermal Growth Factor (EGF) – A tyrosinase inhibitor which has been shown to gently and safely improve pigmentary changes.
• Tranexamic Acid – Tranexamic acid (TXA) is a fibrinolytic agent that blocks the plasmin pathway and can be delivered in various forms (oral, topical, intradermal). Knowing that an increased vascular component is observed histologically in those with melasma, TXA has shown to significantly reduce the appearance of melasma. TXA modulates the blood vessels and vascularization to the melanocyte itself, which can thereby reduce melanin output. All three have been studied in relation to their effects on melasma,, with oral formulations demonstrating the greatest improvement in patients. All three forms have shown in recent studies to improve melasma and quiet possibly have equal effects to HQ. Side effects of TXA are often related to large doses (to treat blood disorders such as hemophilia), which are vastly larger than the doses given to treat melasma. Dosing of TXA should always be consulted with a physician prior to use.
• 4-n-butylresorcinol – A tyrosinase inhibitor that has been shown to reduce hyperpigmentation and melasma related skin changes when applied at low concentrations with minimal to no skin irritation in recent studies.

Microneedling

Microneedling has been proven to have many anti-aging and skin rejuvenating benefits. Microneedling helps to create micro injuries within the skin to stimulate the healing response, promoting new, healthier tissue with more uniform pigmentation. The creation of these microscopic “tunnels” from the microneedling act as effective passageways to maximize the penetration of topical ingredients beneficial in management of melasma

As melasma is a chronic condition, it is widely accepted that a combination of all the aforementioned treatments (sun protections, topical remedies, laser treatments) offers most benefits. Melasma is often a lifelong condition, but it can be effectively controlled with continuous use of topical treatments ad regular maintenance with laser therapy.

Excessive sweating (hyperhidrosis) of the palms, feet face, and underarms can be treated with a simple 15-30 minute outpatient session of BOTOX/DYSPORT/Xeomin/Jeuveau.

Anesthesia of the area to be treated is sometimes obtained with a topical anesthetic (applied at home a few hours before treatment) and/or local application of ice.

The effect of BOTOX/DYSPORT/Xeomin/Jeuveau injection begins to be apparent 2-3 days after the injection session, and lasts 6-12 months. Side effects are minimal to non-existent, and include injection related discomfort and minor bruising.