Aesthetic Dermatology

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

hsplete@frontlinemedcom.com

On Twitter @hsplete

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

hsplete@frontlinemedcom.com

On Twitter @hsplete

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

hsplete@frontlinemedcom.com

On Twitter @hsplete

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:

Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:

Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top scar treatments. Consideration must be given to:

Cutis invites readers to send us their recommendations. Over-the-counter antifungals, antiperspirants, and sunless tanners will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to sanews@frontlinemedcom.com.

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to sanews@frontlinemedcom.com.

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to sanews@frontlinemedcom.com.