Topical Azelaic Acid Research Articles

Surgical Management of Moderate Rhinophyma with Nasal Nodules: An Electrosurgery Approach

Introduction: Rhinophyma, a severe manifestation of rosacea, is characterized by hypertrophy of sebaceous glands and fibrosis of the nose, often leading to significant aesthetic and functional impairments. Surgical treatment is the preferred approach for advanced cases to restore nasal appearance and function. Case Report: We present the case of a 60-year-old man with moderate rhinophyma and nodules on the nostrils. Surgical management under local anesthesia involved the use of thermal loops for excision of the lesions and bipolar electrosurgery for hemostasis. The patient was also treated for rosacea with topical agents, including metronidazole and azelaic acid, and oral doxycycline for inflammatory lesions. Directed healing followed the surgery, along with LED phototherapy and ablative erbium laser sessions to optimize results. Discussion: The use of thermal loops and electrosurgery allowed for precise excision and control of bleeding. Postoperative care, including daily greasy vaseline dressings, facilitated rapid healing. Mild infection at the excision sites was treated with topical and prophylactic antibiotics. Six sessions of LED therapy combining four types of light (infrared, red, yellow, and blue) improved healing and reduced inflammation. Ablative erbium laser was proposed to further enhance the aesthetic outcome. Conclusion: A combined surgical approach and careful postoperative management yielded satisfactory results in the treatment of rhinophyma.

Assessment of the mental status of patients with rosacea

Rosacea is a common chronic skin disease that significantly impairs patients’ quality of life. Various phenotypic characteristics and the localization on the face can have a negative impact on mental health and socialization, causing anxiety and depression in patients with rosacea. The aim of the study was to determine baseline levels of anxiety and depression in patients with erythematotelangiectatic telangiectatic and papulopustular rosacea and their combination and to compare the effect of combination therapy on patients’ psychoemotional state. We observed 45 patients with a diagnosis of erythematous telangiectatic rosacea and papulo-pustular subtypes of mild and moderate severity and their combination. Patients were divided into three groups according to the choice of combination of treatment methods. In group No. 1: 15 patients received botulinum toxin therapy with topical azelaic acid plus ivermectin. In group No. 2: 15 patients received PDL 595 nm procedure in combination with the topical therapy azelaic acid plus ivermectin. In group No. 3: 15 patients received botulinum toxin therapy with incobotulotoxin in combination with ILC 595 nm and topical azelaic acid therapy in combination with ivermectin. 26.7 % of the patients included in the study showed a deterioration in skin appearance due to emotional strain and stress. All patients showed subclinical manifestations of anxiety and depression according to the Hospital anxiety and depression scale (HADS). In addition, the mental state and anxiety of patients with rosacea can be significantly improved after treatment. Combination therapy with ivermectin, azelaic acid, LC 595 nm and botulinum therapy brings maximum results in normalizing the psychoemotional state. Alleviating the clinical manifestations of rosacea helps to reduce the level of anxiety and depression in patients with rosacea.

Comparative Effectiveness of 20% Azelaic Acid with 1064-nm Nd:YAG Picosecond Laser vs Azelaic Acid Alone for Melasma Treatment in Thai Female Patients: A Split-Face Study

Melasma is one of the most concerning pigmented skin conditions, especially in females. It can be influenced by sunlight, occupation, gender, and drug use, which can aggravate the disease. This split-face clinical trial assesses the effectiveness of picosecond laser in melasma treatment combined with topical azelaic acid compared with azelaic alone. The primary outcome of this study is the Hemi-MASI score, while the secondary outcome is demographic data, physicians' global assessment, patient satisfaction score, and adverse events. The study recruited twenty Thai females aged between 18 and 65 diagnosed with bilateral symmetrical malar-type melasma. The patients were treated with low fluence 1064-nm Nd:YAG picosecond laser three sessions every two weeks combined with topical azelaic acid twice daily on the right side of the face, whereas the left side was treated with topical azelaic acid twice daily alone for 16 weeks. The mean Hemi-MASI decrease is 3.52%, 9.38%, and 19.94% on the combination side, while there are 1.93%, 7.89%, and 16.73% at the 8th, 12th, and 16th, respectively in the topical azelaic alone side. There were no severe side effects from both picosecond laser and azelaic acid, and they can be relieved without treatment. Thus, the overall clinical result demonstrates the improvement as the patient satisfaction score is satisfied. Still, the mean Hemi-MASI score between the two sides is not statistically significantly different (p>0.05). In conclusion, combining the picosecond laser with azelaic acid alone in melasma treatment results in a better overall general outcome than the azelaic alone.

Efficacy of Topical Treatments in the Management of Mild-to-Moderate Acne Vulgaris: A Systematic Review.

Acne vulgaris, commonly called acne, is a skin condition affecting many individuals globally. It is a chronic condition characterized by developing pimples, blackheads (open comedones), whiteheads (closed comedones), and other skin lesions. Acne usually appears on the face, neck, chest, and back. It is commonly associated with puberty and adolescence but can also affect adults of all ages. Acne can be very frustrating and embarrassing, leading to low self-esteem and social isolation. The condition arises from various factors, including clogged pores, excessive sebum production, bacteria, and inflammation. This systematic review assesses the effectiveness of topical antibiotics, retinoids, niacinamide, azelaic acid, and clascoterone in treating mild-to-moderate acne vulgaris. A comprehensive search across PubMed, PubMed Central, and Google Scholar yielded 10 articles focused on topical antibiotics, with findings from 198 subjects indicating the efficacy of doxycycline against inflammatory lesions. Retinoids, such as tretinoin and adapalene, significantly improved both lesion types (open and closed comedones). Niacinamide, examined in a randomized controlled trial involving 41 participants, reduced sebum production. Another study with 60 patients revealed that azelaic acid effectively reduced both inflammatory and non-inflammatory lesions. Clascoterone emerged as a promising antiandrogenic treatment, supported by a randomized controlled trial involving 4,440 patients. It is essential that individualized therapy, incorporating patient preferences and considering adverse effects, is emphasized for optimizing acne management.

Possibilities of using topical retinoids and azelaic acid in acne therapy

Background. Acne is a common, complex and multifactorial inflammatory disease that results from a variety of causes. Acne therapy is an urgent problem of dermatocosmetology. The clinical manifestations of dermatosis can be alleviated, and its long-term consequences can be prevented by early diagnosis and timely initiation of treatment, affecting multifaceted all parts of the pathogenesis.
 Aims. To evaluate the clinical efficacy and safety of the use of monotherapy of 0.1% adapalene cream (Adaclean) with combined external therapy of 0.1% adapalene cream (Adaclean) with 20% azelaic acid cream (Azix-Derm) in the treatment of mild to moderate acne.
 Methods. Under our supervision at the Department of Plastic Reconstructive Surgery, Cosmetology and Regenerative Medicine of the State Budgetary Educational Institution of Higher Professional Education Rost of the State Medical University of the Ministry of Health of Russia, the clinics “Ekaterininskaya” and “MIR-O-MED” there were 50 patients aged 12 to 50 years (18 (36%) men and 32 (64%) women) with mild and moderate acne. Patients with comedonal acne, in the absence of multiple inflammatory elements, which made up group 1 of observation (n = 16), were prescribed Adaclean cream, 1 time per day (evening) against the background of skin care. In the group with mild to moderate papulo-pustular acne and post-inflammatory changes (group 2, n = 34), patients were prescribed a combination of 0.1% adapalene cream and 20% azelaic acid cream (Adaclean (evening) and Azix-Derm (morning)). The follow-up period was 6 months.
 Results. Total clinical remission after 6 months therapy was achieved in 70% of cases, a significant improvement — in 28%, improvement — in 2%. In patients with a comedonal form of acne against the background of monotherapy with Adaclean cream, clinical recovery was obtained in 44% of patients, a significant improvement — in 50%, and an improvement — in 6%. In patients from the group of papulo-pustular acne of mild to moderate severity, after 3 months the use of complex therapy Adaclean and Azix-Derm noted almost complete relief of the inflammatory process; after 6 months therapy clinical recovery was recorded in 58%, significant improvement — in 36%; 6% showed partial improvement, which is associated with irregular use of drugs and skin care products. After 6 months combined treatment was able to achieve regression of dyschromia in 18–46% of patients, atrophic scars — in 5–22%, which significantly improved the results of therapy and made it possible to achieve a good cosmetic effect.
 Conclusion. The combined use of drugs for external use of adapalene (Adaclean) and AK (Azix-Derm) in the treatment of papulo-pustular acne of mild and AK (Azix-Derm) in the treatment of papulo-pustular acne of mild and moderate severity can significantly increase the effectiveness of treatment, achieve a stable clinical effect and remission of the disease, as well as improve the quality of life of patients.

Guidelines of care for the management of acne vulgaris

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9years or older. The objective of this study was to provide evidence-based recommendations for the management of acne. A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations. This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements. Analysis is based on the best available evidence at the time of the systematic review. These guidelines provide evidence-based recommendations for the management of acne vulgaris.

An audit of oral antimicrobial therapy against acne vulgaris NICE guidelines

Abstract Introduction The suggested therapy for moderate to severe acne vulgaris (AV) is a choice of lymecycline or doxycycline, in combination with topical adapalene and topical benzyl peroxide or topical azelaic acid. The guidelines state care should be taken when prescribing tetracyclines and topical retinoids in pregnancy given the potential harm.1 Antimicrobial resistance is rapidly emerging worldwide, endangering the efficacy of antimicrobial therapy which can be attributed to overuse and misuse of antimicrobials. This audit was conducted to identify inappropriate antimicrobial prescribing to allow discussion of therapy options with patients, thus reducing antimicrobial prescribing.2 Aim The audit objectives were to ensure appropriate therapy choice, therapy duration and contraception consideration in women of a childbearing age (WOCBA). To assess the aim of alignment to NICE guidelines, the following audit criteria and standards were used: 100% of patients should be prescribed appropriate therapy for moderate to severe AV; 100% of patients should receive less than 6 months of antimicrobial therapy; 100% of WOCBA should be considered for contraception at the initiation of tetracycline therapy. Methods A search was conducted on the VISION software on 20/01/2023 identifying which of the 25,000 patients registered as applied or permanent in a single GP practice had a repeat prescription issued for lymecycline or doxycycline in the previous 12 months. A pilot of approximately 10% of the sample size was successfully conducted, requiring no alterations to the search. Each included patient record was accessed individually for the required information and recorded under headings using Microsoft Excel. Patients without AV were excluded. The data were subjected to descriptive statistical analysis. As a clinical audit, this study did not require ethics approval. Results The search produced 157 results, leaving 102 patients after the exclusion criteria was applied. Of the included patients, 9.8% (n=10) were on the correct oral and topical therapy aligned with NICE guidance. In 90.2% (n=92) of patients, the duration of oral antimicrobial therapy was longer than 6 months. In 30.4% (n=17) of WOCBA, contraception was not prescribed at the initiation of tetracycline therapy. Discussion/Conclusion All set aims and objectives were met. A lack of adherence to NICE guidelines surrounding choice and duration of therapy was found. This may be attributed to unawareness of updated guidelines. Raising awareness of the guidelines and the implication of antimicrobial resistance may improve the inappropriate prescribing, thereby improving patient outcomes long term. The results suggested inadequate consideration of contraception, which was noted as a priority for being addressed within the practice. Healthcare professionals should be reminded of the potential teratogenicity caused by tetracyclines in pregnancy and the importance of thorough documentation.3 Further audits would be beneficial to address the limitations of the study, which included not knowing whether contraception had been discussed with WOCBAs on initiation, if not documented in the patient’s record, as the audit was conducted retrospectively. It would be useful to observe ordering patterns, issues of acute prescriptions, and the use of topical retinoids to WOCBA to further improve practice.

ANTIHISTAMINE AS AN ADJUNCTIVE TREATMENT IN ACNE VULGARIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Approximately one-tenth of the global population suffer from acne vulgaris, which is a skin disease with considerable psychological impact. Recently, antihistamines have been used in the treatment of acne. However, their overall treatment effects for this indication remain unclear. This systematic review and meta-analysis aim to evaluate the clinical efficacy and safety of the antihistamines in the treatment of acne vulgaris. The following databases were searched: PubMed, Scopus, Embase, Cochrane Central Register of Controlled Clinical Trials, and Google Scholar. We included the randomized controlled trials on acne vulgaris patients which compared any H1- antihistamine drug in combination with other medications to placebo, no treatment, or other medications, with acne lesion (non-inflammatory and inflammatory) counts, acne severity score, patient satisfaction, acne flare, or adverse events as an outcome of interest. Six studies contributing to 388 patients were included, involving two H1 antihistamines (i.e., levocetrizine and desloratadine), isotretinoin, azithromycin, and topical azelaic acid cream. From the network meta–analysis, levocetirizine+isotretinoin was better than the isotretinoin alone in the inflammatory lesion count, but not in the non-inflammatory lesion count. The desloratadine+isotretinoin retained the best balance in terms of non-inflammatory lesion count, inflammatory lesion count, acne flare, and mucocutaneous adverse events. The desloratadine+isotretinoin and levocetirizine+isotretinoin were considered safe.

FRI402 “An Unusual Presentation Of Polycystic Ovary Syndrome” - Isolated DHEA-S Elevation In A Patient With Difficulty Conceiving And Recent Onset of Hirsutism

Abstract Disclosure: C. Musurakis: None. J.L. Gilden: None. Background: Isolated DHEA-S levels and worsening hirsutism often prompt the clinician to investigate more serious causes for the elevation, such as an adrenal mass. Clinical Case: A 29-year-old female G0P0 with Norwegian and English heritage and familial hypertriglyceridemia, was referred for elevated DHEA-S levels, and difficulty conceiving for past three years. She had hirsutism of face, chest, and abdomen, worsening over the last two years. Acne had also progressively worsened to cystic type. Menarche was at age 12, and menses were regular. She had never used contraception. Medications: docosahexanoic acid, eicosapentanoic acid, topical azelaic acid, benzoyl peroxide, clindamycin, pantoprazole, prenatal vitamins, and cholecalciferol. There was a family history of acne, but not for hirsutism or menstrual irregularities. Vitals: BP 137/73, HR 81, Ht 165.10 cm, Wt 86.18 Kg, BMI 31.68. Ferriman-Gallwey score was 10 with normal genitalia. Labs (luteal phase): DHEA-S 756 mcg/dL with repeat of 596 mcg/dl(n=35-430), total testosterone 25 ng/dL(n=2-45), free testosterone 4.3 pg/mL(n=0.1-6.4), prolactin 6.6 ng/mL(n=2.2-30.3), LH 5.1 mIU/mL(n=0.6-16.6), FSH 4.7 mIU/mL(n=1.7-12.9), 17-OH progesterone 74 ng/dL(n=139-431), androstenedione 163 ng/dL(n=73-184), estradiol 59.79 pg/mL(n=55.8-214.2), AMH 1.38 ng/mL(n=0.69-13.39), midnight salivary cortisol <0.03 and 0.05 mcg/dL(n<5), IGF-1 258 ng/mL(n=63-373), ACTH 31 pg/mL(n=0-47), AM cortisol 12.58 ug/dL(n=5.3-22.5), TSH 1.27 uIU/mL(n=0.358-3.74), Free T4 0.88 ng/dL (n=0.76-1.46), peroxidase antibodies 49.8 U/m (n=0-60), thyroglobulin antibodies <15(n=0-60), HbA1c 5.5% (n<=5.6%), 25-OH vitamin D 42.7 ng/mL(n=30-100) and negative pregnancy urine test. US pelvis: small follicles in ovaries and normal size. MRI abdomen w/wo contrast: normal bilateral adrenal glands. Cosyntropin stimulation test: baseline cortisol 15.03 ug/dL,17-OH progesterone 168 ng/dL. 30 mins: Cortisol 30.39ug/dL(n>18),17-OH progesterone 130ng/dL(n<200). 60 mins: cortisol 38.95ug/dL(n>18), 17-OH progesterone 153ng/dL(n<200). Non-Classical Congenital Adrenal Hyperplasia was excluded. Polycystic Ovary Syndrome (PCOS) was diagnosed based on clinical and biochemical hyperandrogenism, lack of adrenal mass, and clinical signs of anovulation. Conclusion: As reported by Carmina et al, few patients with PCOS exhibit isolated increase of serum DHEA-S. It is important to recognize that non-classic forms of PCOS (normal ovaries or normal ovulatory cycles) can present with a higher prevalence of adrenal hyperandrogenism than the common classical forms of PCOS. Reference: Carmina E, Longo RA. Increased Prevalence of Elevated DHEAS in PCOS Women with Non-Classic (B or C) Phenotypes: A Retrospective Analysis in Patients Aged 20 to 29 Years. Cells. 2022 Oct 17;11(20):3255. doi: 10.3390/cells11203255. PMID: 36291122; PMCID: PMC9601254. Presentation: Friday, June 16, 2023

Are antibiotics still relevant in acne? A review of the therapeutic conundrum.

Antibiotics have constituted the mainstay of acne therapy despite acne being classified as an inflammatory disorder. The indiscriminate usage of antibiotics over the years has thus fueled the issue of antimicrobial resistance. Cutibacterium acnes (C. acnes) can acquire resistance due to chromosomal mutation or genetic acquisition. C. acnes can transfer resistance to other resident flora, complicating the management of skin and soft tissue infections. It can also transfer resistant strains to other body sites and to immunocompromised and elderly patients thus putting them at risk of serious infections. Recent studies have highlighted the physiologic role of C. acnes in maintaining the normal homeostasis of the skin microbiome. The role of Malassezia in causation of acne has piqued interest in recent times. The efficacy of antibiotics in acne is attributed to their para-antibiotic, anti-inflammatory action rather than antimicrobial action. Thus, usage of low-dose antibiotics and alternatives to antibiotics has been advocated. Some alternative therapies showing efficacy in acne are probiotics, oral zinc, precision therapy using succinic acid, bacteriophages, and anti-biofilm therapy like myrtacin, topical azelaic acid, and salicylic acid. Using isotretinoin in early stages of acne can reduce the incidence of scarring and alleviate the need for antibiotics. Thus, a gradual shift from antibiotics to alternative therapies in acne is the need of the hour.

Acne exacerbation: the role of exposome factors and current trends in maintenance therapy

At the present stage, acne is considered as a multifactorial dermatosis, in the formation of which a significant role is played by genetically determined hyperandrogenism and impaired secretion of the sebaceous glands, as well as changes in the skin microbiome. It is known that the risk of occurrence and severity of the disease are significantly influenced by various environmental components, which are commonly called exposure factors. This article provides an analysis of studies on the influence of the most common exposure factors on the pathogenesis and clinical course of acne: diet, skin care, stress, novel coronavirus infection (COVID-19), environmental pollution and climatic conditions. It has been shown that these factors affect the main components of the skin barrier, affect the microbiota and immune reactivity, which subsequently leads to the activation of the leading pathological mechanisms of acne formation. Considering the variety of factors that provoke the disease, emphasis is placed on the need for proper skin care and pathogenetically substantiated therapy in a maintenance regimen with the appointment of topical retinoids and azelaic acid. Due to anti-inflammatory and comedonolytic effects, as well as inhibition of the growth of Cutibacterium acne, these active ingredients provide a complex effect on the main pathogenetic links of the disease. The article presents our own clinical observations of patients with acne, who underwent complex therapy and prevention of exacerbations with the use of Adaklin and Azix-Derm. It was noted that these drugs are effective both in the complex treatment and in the prevention of exacerbations in patients with mild to moderate acne, while the therapy is well tolerated by patients - the resulting adverse events are reversible, easily corrected with moisturizing agents and do not require discontinuation of drugs.

Turning Down the Fire: The Role of Botulinum Toxin Microdroplets in Refractory Rosacea Erythema

Introduction: Dermal “micro-injections" of botulinum toxin A (BTX-A) treatment can improve facial flushing and erythema in patients with refractory rosacea. We present a case of a patient with longstanding papulo-pustular rosacea with flushing, refractory to laser, topical and systemic therapies, where intradermal microdroplet BTX-A injections successfully controlled erythema and flushing. Case Description: A 49-year-old White female with a 4-year history of refractory papulo-pustular rosacea presented with bright, central facial erythema and telangiectasias after failing multiple 595 nm pulsed dye laser, topical (azelaic acid 15% gel, 0.025% tretinoin cream, and metrocream 0.75%) and systemic (isotretinoin 20 mg daily, spironolactone 25 mg daily and doxycycline 100 mg twice daily for 14 days) treatments. At treatment 1, 20 U of BTX-A was injected intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) to erythematous lesion. Treatment 2 was performed at her 4 week follow-up were we administer 15 U of BTX-A intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) . The patient was seen 4, 8, and 16 weeks after her second treatment were no BTX-A was administered due to a significant reduction in erythema and lasting results. Discussion: Significant clinical improvement and patient satisfaction was achieved. No adverse events were reported after treatment aside from mild, localized injection site pain during the procedure. BTX-A administered as intradermal microdroplet injects can be a safe and efficacious option in the treatment of refractory rosacea erythema. Microbotox may be an effective adjunct, especially when topical and systemic therapies have failed.

Probiotic supplement combined with topical therapy in the treatment of mild to moderate acne: results from an Italian single centre interventional study.

Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from different cofactors. The alteration of the skin microbiome has recently been revealed to play a role in acne pathogenesis. Concerns with side effects of available systemic treatment for acne resulted in a greater focus on topical therapies, such as topical azelaic acid which showed to be an effective and safe treatment option for acne. The aim of our study was to evaluate the efficacy of a new treatment protocol for acne based on an oral supplement composed of biotin and 3 strains of lactic ferments combined with a topical gel composed of azelaic acid, hydroxypinacolone retinoate, and α-hydroxy acids. An Italian single-center interventional study was performed enrolling patients suffering from mild-to-moderate-acne. Patients were treated with a supplement based on biotin and 3 strains of lactic ferments, combined with a topical gel product (azelaic-acid, hydroxypinacolone retinoate, and α-hydroxy acids). All enrolled patients were scheduled for a total of 2 visits, a baseline visit (V0) and a follow-up visit after 60 days of treatment (V1). A total of 30 patients were enrolled in the study. Between V0 (baseline) and V1 (60 days), there was a reduction of 37.4% in the GAGS Score, 40.7% in the SEBUTAPEtm Score, and 18% in the TEWL Score, and an increment of 44% in the T-Blue Test Score. No cases of serious AEs were reported in our experience. Our results confirmed the promising therapeutic role of a probiotic supplement associated with topical therapy in the treatment of mild to moderate acne.

Acne treatment review and future perspectives.

Acne affects approximately 9% of people worldwide and is the most common skin condition in the USA. There are abundant topical and oral treatment options available for patients with acne. First-line agents include topical retinoids, azelaic acid, benzoyl peroxide, and combinations of these agents. For recalcitrant or more severe acne, oral medications, including oral antibiotics, isotretinoin, or hormonal therapy, may be considered. This review will also discuss the many advances being made in the treatment of acne vulgaris, from the development of microencapsulated medications to targeted treatments.

The Efficacy of Azelaic Acid 20% Cream in the Treatment of Scalp Alopecia Areata

Introduction: Alopecia areata is a common, inflammatory, non-scarring type of hair loss that affects persons of both sexes and all age groups, with prevalence in the general population of approximately 0.1–0.2%. It is characterized by variable clinical presentations, ranging from single or multiple well-circumscribed patches of hair loss to extensive involvement with complete absence of body and scalp hair. Alopecia areata is an autoimmune disease of the hair follicle. Its pathogenesis is associated with loss of follicular immune privilege and T-cell mediated inflammatory response, leading to interruption of the hair growth cycle. The diagnosis of alopecia areata is usually based on clinical manifestations in addition to using severity of alopecia tool score. Currently, there is no treatment for alopecia areata approved by the US Food and Drugs Administration. However, several treatment modalities for alopecia areata have been introduced with variable outcomes. Although topical and systemic immunomodulators are the mainstay options, there is still a lack of high-quality randomized controlled trials supporting these treatment modalities. Topical Corticosteroids are considered the first-line therapy for patch-type alopecia areata. Azelaic acid is a dicarboxylic acid, derived from the fungus Pityrosporum ovale and is regarded as an effective topical therapy for patchy alopecia areata. Aim of study: The present study aims to measure the efficacy of topical azelaic acid cream 20% in the treatment of alopecia areata. Patients and Methods: The all 30 patients were collected from Erbil Dermatology Teaching Center. They were divided into two groups: group A includes fifteen patients on topical clobetasol propionate 0.05% cream; group B includes fifteen patients on topical azelaic acid 20% cream. Both treatment groups were followed up for period of around twelve weeks with monthly check up visits. Both drugs were applied topically once daily at night. Results: the comparison between the baseline and 12 weeks visits for each study group concerning severity of alopecia tool score shows that the mean of the score for both groups at 12 weeks visit is lower than that of baseline visit in a statistically significant way (group A, p=0.007, group B, p=0.036). Conclusions: This study showed that topical azelaic acid cream 20% has an acceptable efficacy in comparison to topical clobetasol ointment 0.05% in the treatment of localized alopecia areata of scalp and can be considered as a therapeutic option for this condition.

A COMPARISON OF EFFICACY OF INTRADERMAL TRANEXAMIC ACID WITH TOPICAL 20% AZELAIC ACID IN THE TREATMENT OF MELASMA

Objective: To compare the efficacy of Intradermal Tranexamic acid and topical 20% Azelaic acid cream in the treatment of melasma.
 Study Design: Comparative prospective study.
 Place and Duration of Study: Dermatology department, Combined Military Hospital Peshawar, from Sep 2018 to Mar 2019.
 Methodology: A total of 116 female patients, at the outpatient department of dermatology at Combined Military Hospital Peshawar, were randomly assigned into two groups; group A (intradermal tranexamic acid) and group B (topical azelaic acid) by lottery method. Patients in group A received intradermal injection, while the participants of group B received topical azelaic acid only, fortnightly for 6 weeks. Melasma area severity index score was calculated for each patient in both groups at the start and at the end of the treatment.
 Results: The mean Melasma area severity index score in group A (intradermal tranexamic acid) before and at 6 weeks of treatment was 7.10 ± 2.94 and 5.27 ± 2.44, respectively. The mean Melasma area severity index score in group B (topical azelaic acid) before and at 6 weeks of treatment was 7.56 ± 2.57 and 5.76 ± 2.89, respectively. Efficacy of intradermal tranexamic acid, as poor response, good response and excellent response was 27.6%, 41.4% and 31% respectively. While, efficacy of topical azelaic acid group as poor response, good response and excellent response was 62.1%, 20.7% and 17.2% respectively. The difference was statistically significant, (p=0.001).
 Conclusion: It can be concluded that intradermal tranexamic acid is more effective as compared to topical 20% azelaic acid in..................

A novel azelaic acid formulation for the topical treatment of inflammatory rosacea: A multicentre, prospective clinical trial

BackgroundTopical azelaic acid (AzA) is a common treatment for mild/moderate inflammatory rosacea.AimsTo assess the efficacy and tolerability of a novel formulation cream containing 15% AzA (anti‐inflammatory/anti‐oxidant/anti‐microbial agent) combined with 1% dihydroavenanthramide D (anti‐inflammatory/anti‐itch) in inflammatory rosacea using clinical/instrumental evaluation.MethodsIn this multicentre, prospective, open‐label trial, 45 patients with mild/moderate inflammatory rosacea enrolled at the Dermatology Clinic of the University of Catania, Naples, and Rome (Italy) were instructed to apply the cream twice daily for 8 weeks. Clinical evaluation was performed at baseline (T0) and at 8 weeks (T1) by (1) Investigator Global Assessment (IGA) score based on a 5‐point scale (from 0 = clear/no erythema/papules/pustules to 4 = severe erythema/several papules/pustules) and (2) inflammatory lesions count. Instrumental evaluation of erythema degree was performed by erythema‐directed digital photography (EDDP) by a 5‐point scale (from 0 = no redness to 4 = severe redness) at all time points. Tolerability was assessed by a self‐administered questionnaire at 8 weeks. Statistical analysis was performed using SAS version 9.ResultsForty‐four patients completed the study. At week 8, a significant decrease in baseline of IGA scores [median from 3 (T0) to 1 (T1)] and inflammatory lesions count [median from 8 (T0) to 1 (T1)] was recorded along with a significant reduction of erythema scores [median from 2 (T0) to 1 (T1)]. No relevant side effects were recorded.ConclusionsOur results suggest that this new non‐irritating product represents a valid therapeutic option for mild/moderate inflammatory rosacea, and EDDP is able to provide a more defined evaluation of erythema changes.

Perioral dermatitis: Diagnosis, proposed etiologies, and management

Perioral dermatitis is a common cutaneous condition characterized by acneiform facial eruptions often with an eczematous appearance. A granulomatous subtype exists in addition to the classic variant. While topical corticosteroids have been largely implicated in this condition, its etiology is not completely understood. Using the keywords "corticosteroids," "dermatology," "fusobacteria," "perioral dermatitis," and "periorificial dermatitis," we searched the databases PubMed, MEDLINE, and EMBASE to find the relevant literature. Only articles in English were chosen. The level of evidence was evaluated and selected according to the highest level working our way downwards using the Oxford Centre of Evidence-Based Medicine 2011 guidance. This systematic review found the strongest evidence to support topical corticosteroid misuse as the principal causative factor in the pathogenesis of perioral dermatitis. In terms of treatment, further research is required to robustly investigate promising treatment options including tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel, and oral isotretinoin.

Rosacea.

Rosacea is a common cutaneous condition affecting predominantly the face. It is historically characterised into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular rosacea. This article describes the pathophysiology, clinical features and current treatment options for rosacea, and discusses updated diagnostic criteria. General guidance is required on the need to avoid possible triggers including dietary and environmental triggers. The strongest evidence supports the use of 0.75% metronidazole, topical azelaic acid or topical ivermectin for inflammatory rosacea. Erythema should be treated with brimonidine tartrate gel, oral medication such as beta blockers or vascular laser and light-based therapy. Oral doxycycline 40 mg modified release can be used as monotherapy or in combination with other treatments for recalcitrant disease. Further understanding of the pathogenesis of rosacea could allow identification and targeted avoidance of triggers and the development of new treatment modalities.

Evidence-based topical treatments (azelaic acid, salicylic acid, nicotinamide, sulfur, zinc, and fruit acid) for acne: an abridged version of a Cochrane systematic review.

The effects of topical azelaic acid, salicylic acid, nicotinamide, sulfur, zinc, and fruit acid (alpha-hydroxy acid) for acne are unclear. We aimed to assess the effects of these topical treatments by collecting randomized controlled trials. We searched The Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS up to May 2019. We also searched five trials registers. Two review authors independently extracted data and assessed risk of bias. Meta analyses were performed by using Review Manager 5 software. We included a total of 49 trials involving 3880 participants. In terms of treatment response (measured using participants' global self-assessment of acne improvement, PGA), azelaic acid was probably less effective than benzoyl peroxide (RR=0.82, 95% CI 0.72-0.95). However, there was probably little or no difference in PGA when comparing azelaic acid to tretinoin (RR=0.94, 95% CI 0.78-1.14). There may be little or no difference when comparing salicylic acid to tretinoin (RR=1.00, 95% CI 0.92-1.09). There were no studies measured PGA when evaluating nicotinamide. With respect to alpha-hydroxy acid, there may be no difference in PGA when comparing glycolic acid to salicylic-mandelic acid (RR=1.06, 95% CI 0.88-1.26). We were uncertain about the effects of sulfur and zinc. Adverse events associated with these topical treatments were always mild and transient. Moderate-quality evidence was available for azelaic acid and low- to very-low-quality evidence for other topical treatments. Risk of bias and imprecision limit our confidence in the evidence.