Multi-Faceted approaches to rosacea Management

The market for cosmeceuticals is large and growing. In fact, the market is estimated to increase by 5.8 percent annually through 2015. Antioxidants remain the largest ingredient category, but the botanical field is growing at the fastest rate.¹ Among the dermatologic disease states for which patients are using these popular ingredients is rosacea.

WHY COSMECEUTICALS FOR ROSACEA?

According to the National Rosacea Society, an estimated 16 million Americans have rosacea and many don’t know it. The society cites a Gallup poll that revealed that 78 percent of Americans do not know about rosacea. As such, a number of patients may be reaching for cosmeceuticals for symptomatic relief without recognizing that they have an underlying medical cause. Patients may attribute symptoms to “sensitive skin,” simple aging, or to chronic photo-damge—which is linked to rosacea’s pathogenesis.

Additionally, given the chronic nature of rosacea, some patients undergoing physician-directed treatment prefer to take a holiday from pharmacologic therapy, at which time cosmeceuticals may be used for maintenance.

The use of cosmeceuticals in rosacea can make sense— assuming patients use the right products. “Many cosmeceuticals have calming effects on the skin,” notes Joshua Zeichner, MD, Director of Cosmetic and Clinical Research at Mt. Sinai Medical Center in Manhattan. “Skin hydration,reduction of inflammation, and improvement of skin barrier function are all necessary in patients with rosacea,” he states.

HOW TO USE COSMECEUTICALS

“For some patients with mild rosacea, topical treatment with over-the-counter moisturizers or cosmeceuticals may suffice,” observes Dr. Zeichner. “For more moderate to severe rosacea, topical or oral prescription medications are usually necessary.”

Topical metronidazole (Metro, Galderma) and azaleic acid (Finacea, Bayer Dermatology) remain the most commonly prescribed topical agents for rosacea. According to one recent review article, randomized, controlled, comparative studies have failed to show a statistically significant differ- ence between the two treatments, though in two studies investigators said that they believed that azelaic acid (AzA) was more effective.²

Interestingly, given that rosacea is considered to be mediated in part by cumulative photodamage, researchers recently showed that AzA can counteract stress-induced premature cell senescence (SIPS).³ AzA was associated with reduced MMP-1 release and SA-β-galactosidase-positive cells, a reduction in ROS generation, an up-modulation of antioxidant enzymes, a decrease in cell membrane lipid damage, repression of p53 and p21, increase in type I pro-collagen, and enhanced expression of growth factors, such as HGF and SCF.

Cosmeceuticals can be added to either topical or oral rosacea prescription therapies, but patients must be directed to those products that will calm and soothe, rather than irritate. “I stick to products with hydating ingredients, calming botanicals, like licorice root extract, and moisturizing cleansers,” says Dr. Zeichner. “I typically have patients stay away from irritating ingredients, such as alpha and beta hydroxyacids or drying, foaming cleansers.”

Green tea, niacinamide, and feverfew have all been recommended for the management of rosacea and acne.⁴ One of the most promising cosmeceutical ingredients for rosacea may be niacinamide. According to a recent review, “Niacinamide is the ingredient investigated that most closely upholds the ‘Kligman standards’ of cosmeceutical- ingredient analysis. With the available scientific evidence on topical niacinamide, clinicians are able to adequately answer questions about permeability, mechanism, and clinical effect.”⁵

Popular Botanical Ingredients in Cosmeceuticals

• Rosamarinus officinalis
• Vitis vinifera (grape seed extract)
• Citronellol, Limonene
• Oenothera biennis (evening primrose)
• Glycyrrhiza glabra (licorice extract)
• Aframomum angustifolium seed extract
• Diosgenin (wild yam)
• N6 furfuryladenine (kinetin)
• Ergothioneine

Researchers’ Note: “Through researching each of these botanical ingredients, we have concluded that randomized controlled trials are still needed in this area, but there is promise in some of these ingredients and science to validate them.”

— J Cosmet Dermatol. 2010 Sep;9(3):218-25

WHERE'S THE EVIDENCE?

A recent Cochrane review update on rosacea therapy included 58 trials (27 from the original review), comprising 6,633 participants. Interventions considered were:

• topical metronidazole,
• oral antibiotics,
• topical azelaic cream or gel,
• topical benzoyl peroxide and/or combined with topical antibiotics
• sulphacetamide/sulphur, and
• others.

The majority of included studies were assessed as being at high or unclear risk of bias; however, the authors concluded that evidence supports the effectiveness of topical metroni- dazole, azelaic acid, and doxycycline (40mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% oph- thalmic emulsion for ocular rosacea.

— Cochrane Database Syst Rev.

2011 Mar 16;(3):CD003262.

ANOTHER ANGLE

Increasingly, patients are seeking energy-based solutions for the redness of rosacea. Light-based devices—the pulsed dye laser and intense pulsed light devices—are effective for targeting erythema and telangiectasias.⁶ Patients should be treated with prescription and/or over-the-counter agents to help reduce the likelihood of recurrence. Sunscreen use is critical for every rosacea patient.

As the cosmeceutical market grows and the evidence accumulates, patients with rosacea are being treated in both the short- and long-term with combinations of over-the-counter and prescription agents and/or devices. Dermatologists who look at treatment from multiple angles may help guide their patients to the optimal combination of interventions.

1. Cosmeceuticals to 2015: http://www.freedoniagroup.com/DocumentDetails.aspx?ReferrerId=FG-01&studyid=2758
2. Fallen RS, Gooderham M. Rosacea: update on management and emerging therapies. Skin Therapy Lett. 2012; 17(10):1-4.
3. Briganti S, Flori E, Mastrofrancesco A, et al. Azelaic acid reduced senescence-like phenotype in photo-irradiated human dermal fibroblasts: possible implication of PPAR. Exp Dermatol. 2013; 22(1):41-7.
4. Fowler JF Jr, Woolery-Lloyd H, Waldorf H, Saini R. Innovations in natural ingredients and their use in skin care. J Drugs Dermatol. 2010; 9(6 Suppl):S72-81.
5. Levin J, Momin SB. How much do we really know about our favorite cosmeceutical ingredients? J Clin Aesthet Dermatol. 2010; 3(2):22-41.
6. Kennedy Carney C, Cantrell W, Elewski BE. Rosacea: a review of current topical, systemic and light-based therapies. G Ital Dermatol Venereol. 2009; 144(6):673-88.

Check out DermTube Journal club to watch Patti Farris, MD discuss the latest in cosmeceutical science and ingredients: http:// dermtube.com/series/dermjournalclub/cosmeceutical-science/

Or go to DermTube.com and search: “Cosmeceuticals.”