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    • Image of Demodex Folliculorum courtesy of National Geographic - by Darlyne A. Murawski There are substantial anecdotal reports that treatment for demodectic rosacea gets worse before it gets better. The logic behind this is that killing the demodex mites causes a die-off of the mites that takes weeks to accomplish since new eggs are being hatched each day and the "life cycle of demodex mites consists of five phases of development and lasts from 14 to 18 days". [1] Furthermore because the movement of the mites has been shown to be "at a speed of 8-16 mm/h" [2] they may leave the area being treated and return later while planting eggs along the route. During the initial treatment which may take weeks some of the mites are reported to be killed which may cause inflammation and worsen the skin. One explanation of this is the "Jarisch–Herxheimer reaction" (JHR) which has been "traditionally associated with antimicrobial treatment of syphilis." [3] The principle of JHR may indicate a reason why it gets worse before it gets better. One source comments on this by stating, "And while the JHR only technically relates to spirochetal infections (spiral-shaped bacteria) and antibiotics, the concept of symptom-onset or worsening after starting treatment with antimicrobials has been seen to apply more broadly in clinical practice. This is why you’ll often hear practitioners talk about a Herx-reaction, even if it isn’t scientifically accurate. But, what we call ‘die-off symptoms’ is certainly something we see commonly when clients begin addressing bacteria, parasites and yeast pathogens using natural antimicrobials." Furthermore, there are at least six types of bacteria that have been associated with demodex mites. [5] At least one virus has been associated with rosacea [6] and viruses have not been ruled out in demodectic rosacea. There are very little clinical studies done on virus and rosacea. Viruses are in bacteria and comprise more weight in the human body than bacteria by a factor of ten times. [7] More study should be done on why treatment for demodectic rosacea seems in many cases to get worse before it gets better. Nevertheless, reducing demodex density counts in rosacea improves the patient with rosacea. [8] End Notes [1] Demodex Update Subheading, The potential role of Demodex folliculorum mites and bacteria in the induction of rosacea, third paragraph  [2] Russian Study on Demodex Mites and Rosacea Illuminating, (2) The report confirms the size and movement of demodex, second paragraph [3] Jarisch–Herxheimer reaction, Wikipedia [4] Pathogen & Parasite Die-Off Symptoms: How to manage detox side-effects, Bella Lindemann, June 24, 2019 [5] Bacteria Associated with Rosacea and Demodex Mites [6] Candida Albicans [7] Human Microbiome, Brady Barrows  [8] Decreasing Demodex Density Count Improves Rosacea  
    • Related Articles Intense pulsed light for improving dry eye disease in rosacea. J Am Acad Dermatol. 2019 Dec 03;: Authors: Vazirnia A, Wat H, Danesh MJ, Anderson RR PMID: 31809814 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Rosacea-like acute reaction after hyaluronic acid dermal filler. G Ital Dermatol Venereol. 2019 Dec 04;: Authors: Valenti M, Guanziroli E, Mancini LL, Costanzo A PMID: 31804049 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Rosacea associated with increased risk of generalized anxiety disorder: a case-control study of prevalence and risk of anxiety in patients with rosacea. An Bras Dermatol. 2019 Oct 26;: Authors: Incel Uysal P, Akdogan N, Hayran Y, Oktem A, Yalcin B Abstract BACKGROUND: Rosacea may result in emotional distress and anxiety. However, data on the presence of generalized anxiety disorder in rosacea patients are scarce. OBJECTIVE: The aim of the study was to detect the frequency and level of anxiety and depression in patients with rosacea. METHODS: A total of 194 consecutive rosacea patients and 194 age- and sex-matched controls were enrolled. Severity of rosacea was assessed in patients according to the criteria of the National Rosacea Society Ethics Committee. Both patients and controls were evaluated by the Generalized Anxiety Disorder 7-item scale, and severity was measured by the Generalized Anxiety Disorder-Adult. RESULTS: Individuals who were diagnosed with an anxiety and/or depressive disorder were more common in patient group (24.7% vs. 7.2%, p<0,01). Female patients were particularly at risk for having generalized anxiety disorder (OR=2.8; 95% CI 1.15-7.37; p=0.02). STUDY LIMITATIONS: Single center study and limited sample size. CONCLUSIONS: Rosacea patients show greater risk of having anxiety disorders, including generalized anxiety disorder. Female patients, those with lower educational levels, those with phymatous subtype, untreated patients, and patients with prior psychiatric morbidity may be at particular risk for anxiety. It is essential to consider the psychological characteristics of patients to improve their well-being. PMID: 31789266 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles ACTH-dependent Hypercortisolemia in a Patient with a Pituitary Microadenoma and an Atypical Carcinoid Tumour of the Thymus. Medicina (Kaunas). 2019 Nov 27;55(12): Authors: Baranowska-Jurkun A, Szychlińska M, Matuszewski W, Modzelewski R, Bandurska-Stankiewicz E Abstract Cushing's syndrome (CS) is a set of clinical symptoms which occur as a result of hypercortisolemia. Endogenous ACTH-dependent CS related to an ectopic ACTH-secreting tumour constitutes 12%-17% of CS cases and is one of the most common causes of paraneoplastic syndromes. This study presents a case of a 31 year-old man with diabetes, hypertension, rosacea, purple stretch marks and hypokalemia. Findings of diagnostic procedures include high concentrations of cortisol and ACTH, pituitary microadenoma and a tumour in the anterior mediastinum. Dynamic hormone tests determined the source of excess hormone secretion and ectopic ACTH-dependent CS was diagnosed. Due to increasing symptoms of superior vena cava syndrome, an emergency resection of almost the whole tumour was performed, with only a small part of the upper pole left because of the proximity of large vessels and a risk of damaging them. On the basis of histopathological tests, an atypical carcinoid tumour of the thymus was identified. Immediately after the surgical procedure, there was a significant reduction of clinical and laboratory traits of hypercortisolemia, yet, during the 46 weeks of postoperative observation, despite chemotherapy, the progression of residual masses of the tumour occurred with metastases and increased hormone indices. The presented case shows and discusses the differentiation of ACTH-dependent hypercortisolemia and its causes, difficulties in surgical therapy and chemotherapy, as well as prognosis for atypical carcinoid of the thymus, which is a rare disease. PMID: 31783507 [PubMed - in process] {url} = URL to article
    • Ocular surface changes in the treatment of rosacea: comparison between low-dose oral isotretinoin and doxycycline. Arq Bras Oftalmol. 2019 Nov 25;: Authors: Andrade FMX, Picosse FR, Cunha LPD, Valente CM, Bezerra FM, Miot H, Bagatin E, Freitas D Abstract PURPOSE: To compare the impact of ocular changes between systemic treatment with doxycycline and low-dose oral isotretinoin in patients with moderate-to-severe papulopustular rosacea. METHODS: Patients were randomized to receive either isotretinoin 0.3-0.4 mg/kg (group A) or doxycycline 100 mg/day (group B) for 16 weeks. Ocular symptoms were searched and evaluated, including best-corrected visual acuity (BCVA), Schirmer test, breakup time, rose bengal staining score, and meibomian gland dysfunction grading. The patients were retested at the end of treatment. RESULTS: The present study included 39 patients (30 females and 9 males). Best-corrected visual acuity was > 20/30 in >90% of patients in both groups and did not change after treatment. After treatment, improvement in ocular symptoms and meibomian gland dysfunction was more pronounced in group B (p<0.05); the other parameters did not reach statistical significance. CONCLUSION: Doxycycline improved meibomian gland dysfunction, ocular symptoms, and ocular surface in patients with rosacea. Even though some patients experienced worsening meibomian gland dysfunction and symptoms, no subject experienced any serious complications after administration of low-dose isotretinoin. PMID: 31778446 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Rhinophyma is associated with alcohol intake. J Am Acad Dermatol. 2019 07;81(1):249-250 Authors: Second J, Severac F, Paix A, Cribier B PMID: 30630023 [PubMed - indexed for MEDLINE] {url} = URL to article
    • Related Articles Rosacea treatment: a patient-centric approach. Br J Dermatol. 2019 Nov 26;: Authors: Elewski B PMID: 31773725 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Unilateral Periocular Intralymphatic Histiocytosis, Associated With Rosacea (Morbihan Disease). Am J Dermatopathol. 2019 Nov 19;: Authors: Belousova IE, Kastnerova L, Khairutdinov VR, Kazakov DV Abstract Intralymphatic histiocytosis is a rare reactive skin condition characterized by a nonspecific clinical presentation and, microscopically, by the collections of mononuclear histiocytes within the lumina of dilated lymphatic vessels. We report a rare case of intralymphatic histiocytosis associated with rosacea and prominent periocular edema (Morbihan disease). The patient is a 56-year-old woman with a 12-year history of rosacea who suddenly developed edema of the right upper eyelid that persisted 6 months before she sought medical advice. Because of an unclear clinical diagnosis, surgical excision of the edematous upper eyelid was performed. The histologic slides showed interstitial edema of the dermis with dilated vascular channels and small epithelioid cell granulomas around hair follicles. In addition, there were aggregates of cells inside numerous lymphatic vessels that were immunohistochemically positive for CD45, CD4, CD68, CD163, CD64, CD14, CD11c, and lysozyme and negative for CD3, CD20, CD30, CD56, S100, CD1a, and langerin. PMID: 31764086 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Microvascular Effects of Pulsed Dye Laser in Combination With Oxymetazoline. Lasers Surg Med. 2019 Nov 22;: Authors: Kelly A, Pai A, Lertsakdadet B, Choi B, Kelly KM Abstract BACKGROUND AND OBJECTIVE: Oxymetazoline, an α-1A agonist, is approved by the United States Food and Drug Administration (FDA) for treatment of persistent facial erythema associated with rosacea and induces vasoconstriction by interacting with α receptors. The objective of our study was to study the microvascular effects of oxymetazoline and pulsed dye laser (PDL). MATERIALS AND METHODS: A dorsal window chamber was surgically installed on 20 mice. Each animal was assigned to one of four experimental groups: saline alone, oxymetazoline alone (10 μl applied once daily × 7 days), saline + PDL (saline applied 5 minutes before PDL irradiation [10 mm spot, 1.5 ms pulse duration, 7 J/cm2 delivered to epidermis]), or oxymetazoline + PDL (10 μl oxymetazoline applied 5 minutes before PDL and then once daily × 7 days). Brightfield and laser speckle imaging were performed for 7 days to monitor vascular architectural and functional changes. RESULTS: We observed persistent blood flow in all of the saline-only and oxymetazoline-only experiments. A higher rate of vascular shutdown was observed with oxymetazoline + PDL (66.7%) compared with saline + PDL alone (16.7%). Oxymetazoline application increased venule diameter at 5 minutes post-application and decreased both arteriole and venule diameters at 60 minutes post-application. CONCLUSION: The combination protocol of oxymetazoline + PDL induces persistent vascular shutdown observed 7 days after irradiation. This result may be associated with the acute vascular effects of oxymetazoline. Oxymetazoline + PDL should be evaluated as a treatment for cutaneous vascular disease, including rosacea and port wine birthmarks. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc. PMID: 31758568 [PubMed - as supplied by publisher] {url} = URL to article
    • Related Articles Global Perspectives of the Patient of Color J Drugs Dermatol. 2019 Jul 01;18(7):615 Authors: Burgess CM Abstract Many cultures associate beauty with an even complexion. It has been shown in many reported references, the major cosmetic concern in patients of color is discoloration. This issue addresses discoloration of individuals of color and the use of a multitude of preparations that can blend the complexion. Authors in Asia, Sweden, France, and Brazil discuss the use of injectable deoxycholic acid in nonsubmental regions and hyaluronic acid for skin boosting, an off-label usage or procedures in the United States. Skin boosting improves hydration and the smoothness of the skin. Additionally, international methods of treating cosmetic patients with multiple modalities are discussed. PMID: 31329381 [PubMed - indexed for MEDLINE] {url} = URL to article
    • Related Articles Effects of Zinc Supplementation on Inflammatory Skin Diseases: A Systematic Review of the Clinical Evidence. Am J Clin Dermatol. 2019 Nov 19;: Authors: Dhaliwal S, Nguyen M, Vaughn AR, Notay M, Chambers CJ, Sivamani RK Abstract BACKGROUND: Zinc has been used in patients with acne vulgaris for its anti-inflammatory effects; however, it is unclear if zinc supplementation is also beneficial in other inflammatory skin conditions. OBJECTIVE: The objective of this article was to determine the effect of zinc supplementation on inflammatory dermatologic conditions. DATA SOURCES: We searched the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Ovid with no time limit up to 29 May, 2019. Trials examining supplementation with zinc in the treatment of inflammatory dermatological conditions (acne vulgaris, atopic dermatitis, diaper dermatitis, hidradenitis suppurativa, psoriasis, and rosacea) in children and adults were selected. RESULTS: Of 229 articles, 22 met inclusion criteria. Supplementation with zinc was found to be beneficial in ten of 14 studies evaluating its effects on acne vulgaris, one of two studies on atopic dermatitis, one of one study on diaper dermatitis, and three of three studies evaluating its effects on hidradenitis suppurativa. However, the one article found on psoriasis and the one article found on rosacea showed no significant benefit of zinc treatment on disease outcome. CONCLUSIONS AND IMPLICATIONS: Some preliminary evidence supports the use of zinc in the treatment of acne vulgaris and hidradenitis suppurativa; however, more research is needed with similar methodologies and larger sample sizes in these diseases. Further, zinc may be of some benefit in the treatment plan for atopic dermatitis and diaper dermatitis; however, additional studies should be conducted to further evaluate these potentially positive associations. To date, no evidence is available to suggest that zinc may be of benefit in rosacea and psoriasis; however, limited data are available evaluating the use of zinc in these conditions. PMID: 31745908 [PubMed - as supplied by publisher] {url} = URL to article
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