What causes rosacea?

Although we diagnose it frequently and have treatments available to control it, it is striking that we still do not know its exact cause. This is frustrating for both patients and us dermatologists.

Rosacea is considered to be a chronic inflammatory skin disease that evolves in flare-ups. It seems that there may be a certain genetic predisposition; that is, if someone in your family has rosacea, you may be more likely to suffer from it. Simply put, there are two main characteristics: redness and red pimples.

It is known that there are two main factors involved in rosacea. On the one hand, there is increased skin inflammation (related to receptors called TLR-2 (toll-like receptors) and molecules called cathelicidins. On the other hand, it is thought that certain microbes may also play an important role: the mite Demodex folliculorum and the bacterium Bacillus olenorium (which in turn lives in Demodex).

What is demodex folliculorum?

Demodex folliculorum is a mite that lives on our skin. It has eight legs and a tail-like appendage called an opisthosoma. It thrives in areas with high sebum production and is therefore found mainly in the follicular openings (pores) on the face.

We are born without demodex on our skin, and as we grow, they colonize us through contact with other people.

Demodex and rosacea

It has been proven that people with rosacea have a higher number of Demodex mites in their pores than people without rosacea. What is unclear is which came first, the chicken or the egg.

It is unclear whether skin prone to rosacea facilitates the growth of more demodex mites (as it is redder, has more blood flow, which makes it warmer and more comfortable for the mite) or whether these mites cause the inflammation characteristic of rosacea. It is also unknown how much of the blame lies with the mite itself and how much with the bacterium Bacillus olenorium (which colonizes Demodex), as rosacea often improves with antibiotics (antibiotics would destroy the bacteria, but not Demodex).

Pityriasis folliculorum and rosacea

In any case, despite the controversy surrounding the cause, we know that in many cases using a treatment that eliminates demodex can significantly improve rosacea.

This approach has usually been associated with papulopustular rosacea, i.e., rosacea that predominantly appears as red pimples on the cheeks.

However, pityriasis folliculorum is particularly interesting, as it causes a rough skin surface with white “plugs” in each pore in people with the typical redness we attribute to rosacea. These plugs correspond to the opisthosomes of the mite that protrude from the follicular opening.

In these cases, treatment to eradicate Demodex (e.g., ivermectin) indirectly achieves not only the elimination of these “blackheads,” improving texture, but also greatly reduces redness and sensitivity.

Here you can read more about pityriasis folliculorum and demodex.

In conclusion…

The evolution and response of skin redness after treatment for pityriasis folliculorum (which consists of eliminating demodex overgrowth) suggests that this mite is more a cause than a consequence of rosacea.

Demodex would influence not only cases of rosacea with inflammatory pimples, but also less severe cases in which only some redness is visible on the skin.

Do you have redness and roughness on your skin? Did you know about the influence of demodex?

The post Demodex and rosacea: cause or consequence?? first appeared on Dra. LOREA BAGAZGOITIA.

Although we doctors prescribe them with peace of mind (because they are accepted in all atopic dermatitis treatment guidelines), the reality is that the package insert of these two creams contains “controversial” parts that can undoubtedly frighten those who use them for the first time:

“Cases of malignant disease, including cutaneous malignant disease (e.g. cutaneous T-cell lymphomas) and other types of lymphoma, and skin cancers have been described in patients using tacrolimus ointment.”

But should we be so afraid of them? I anticipate that we should not be, but I will now explain one by one the different aspects of this treatment for atopic dermatitis…

How do tacrolimus and pimecrolimus work?

Both tacrolimus and pimecrolimus slow down the action of a molecule called calcineurin, which is found inside skin cells. When this molecule does not perform its function, other cells, the T lymphocytes involved in dermatitis, are prevented from being activated, thus preventing or reducing the occurrence of flare-ups.

When should they be used?

Pimecrolimus and Tacrolimus are excellent creams for mild to moderate atopic dermatitis. We usually use them specifically for the face, neck, creases (armpits, groin) or genital area. Corticosteroid creams and calcineurin inhibitors have very similar effects. Therefore, we should not forget that corticosteroid creams are still the mainstay of treatment, as discussed in this recent article in the JAAD (Journal of the American Academy of Dermatology).

Calcineurin inhibitors “save corticosteroids”.

The most common side effects of pimecrolimus and tacrolimus are redness and burning after application. These effects do not occur with corticosteroids, which on the other hand are much cheaper. Thus, calcineurin inhibitors are now considered second-line agents, but they are very useful because they allow us to reduce the frequency with which a person with dermatitis will need corticosteroid creams.

What is the risk?

These creams were launched in the US in 2000 and in Spain in 2002. Clinical trials conducted prior to approval showed them to be safe. However, in the years following their launch, isolated cases of lymphoma and skin cancer were reported in children and adults treated with these medicines. It was therefore decided in 2006 to add this information to the package insert.

The causal relationship between topical calcineurin inhibitors and cancer has not yet been demonstrated.

The causal relationship between the creams and the appearance of these cancers has not been proven. The fact that people who used these creams developed cancer is not necessarily due to the creams; in fact, the incidence of lymphoma in people who use these creams is the same as in the normal population (article on this subject).

The frequency of lymphomas is the same among people treated with calcineurin inhibitors as in the normal population.

To date, several studies have been performed in search of this causal relationship and to date, after more than 10 years of experience, no study has concluded that these lymphomas and skin tumors occurred because of Tacrolimus or Pimecrolimus (as stated in this article published a few months ago).

In fact, opinion articles have recently been published in medical sources and scientific journals calling for a modification of the paragraph in question in the package inserts to avoid the fear it causes in patients and their parents. It is believed that because of this warning, people who could benefit from the positive effects of these drugs do not use them because of unfounded fear.

¿Se pueden utilizar en bebés?

The package inserts for both creams state that they are approved for use from 2 years of age. However, their usefulness in infants is well known to dermatologists. This is supported by the Petite study published in 2015 in Pediatrics, the premier pediatric journal, which demonstrated the safety of these medications (as well as topical corticosteroids) in more than 2000 children over 5 years.

It is safe to use calcineurin inhibitors in children under 2 years of age.

Can they be used for other skin diseases?

Strictly speaking these creams are approved exclusively for atopic dermatitis, but they can be safely used on other skin conditions, such as seborrheic dermatitis or rosacea on occasion. If you have any doubts about this, it is best to consult a dermatologist who can indicate the best option in your case.

In conclusion…

Tacrolimus (Protopic®) and pimecrolimus (Elidel®) are creams included in all atopic dermatitis treatment guidelines and we have more than 10 years of experience in their use. Although the package insert is alarming, numerous scientific studies confirm that the risk is not such and that they are an excellent choice for dermatitis of delicate areas, as well as for reducing the need for corticosteroid creams, both in children and adults.

The post Protopic®(tacrolimus) and Elidel® (pimecrolimus) for atopic dermatitis, are they safe? first appeared on Dra. LOREA BAGAZGOITIA.

What is ivermectin

Ivermectin is a chemical compound derived from avermectin, which is produced by the bacterium Streptomyces avermitilis. Precisely the 2015 Nobel Prize in Medicine has been awarded to William C. Campbell and Satoshi Ōmura for their discovery.

Ivermectin is an antiparasitic that has won the 2015 Nobel Prize.

SIvermectin is an antiparasitic compound that has been shown to cure diseases such as river blindness (onchocerciasis) and elephantiasis (filariasis), which have a significant impact in tropical developing countries. Ivermectin also has anti-inflammatory properties.

Why is ivermectin effective for rosacea?

A small mite that normally lives in the follicles of our skin (called Demodex folliculorum) is thought to be involved in the development of rosacea, as it has been found to be present in greater numbers in people who suffer from rosacea than in those who do not. Although the exact role of Demodex in the development of the disease is not known, since ivermectin is an antiparasitic compound, it is possible that by using it we are destroying the Demodex on the skin and this leads to an improvement in the pimples.

Ivermectin is believed to work by destroying Demodex living in skin follicles.

However, in addition to its antiparasitic properties, ivermectin also has anti-inflammatory properties, and it is not entirely clear which of these two functions is more important in the treatment of rosacea.

How is ivermectin for rosacea applied?

Before starting treatment, it is important to have a proper medical diagnosis. I recommend that you be evaluated by a dermatologist for this purpose. In my experience, people are sometimes diagnosed with rosacea when they do not have rosacea, and in such cases, it would not be wise to use ivermectin.

Ivermectin 1% cream is applied to the pimples once a day. Improvement may be seen after the second week of use. Skin irritation may occur in 1% of cases.

Not recommended if you are pregnant or breastfeeding. There is currently no data on the effects on children.

What is the bottom line?

This is undoubtedly a promising treatment for papulopustular rosacea, i.e. people whose rosacea is associated with the appearance of pimples (it is not indicated for skin redness). Given the significant impact that rosacea can have on a person’s daily life, and often on their self-esteem, it is great to see new treatments being developed for rosacea.

Ivermectin cream is a promising treatment for rosacea pimples, although it is more expensive.

Scientific work has been done comparing ivermectin with topical azelaic acid and metronidazole, both drugs commonly used for rosacea. They have found ivermectin to be more effective. Perhaps the two biggest drawbacks at the moment are that its cost is higher than other treatments and that in Spain it is not covered by Social Security System. We will see what the experience tells us…

Have you tried ivermectin for rosacea?

The post Ivermectin cream for rosacea first appeared on Dra. LOREA BAGAZGOITIA.