Future Rosacea Treatments and Realistic Time Frames

[drnase]

Group,

There were some good questions about rosacea treatments, time frames and rosacea gene therapy on ESFB board.

All good questions and valid points. I personally see the treatment of rosacea coming in three waves:

1. 0 to 2 years

-- Much better lasers
-- Topical chemicals for better targetting of blood vessels or sebaceous glands
-- Topical angiogenesis inhibitors (prescription) with or without laser
-- Topical constrictors SansRosa (2 to 2.5 yrs)
-- Topical dapsone for rosacea and acne
-- Chemically modified antibiotics for nitric oxide, CAM and VEGF


2. 2.5 to 5 years

-- Topical VEGF inhibitors
-- Tremendous improvement in laser effectiveness
-- Pathogenesis elucidated for subtype 1 and II
-- Rambazole topical and oral substitutes for accutane -- tremendous potential for drug
-- Able to eliminate most symptoms and some triggers
-- Neural blockers (NANC) and sympthatic dilator substance blockade within varicosity (targetted for blushers and rosacea)
-- Better hypathalmic temperature control regulation
-- Blockade and treatment of facial burning sensations (2 to 2.5 years)


3. 6 - 9 years

--Topical gene therapy targetted at inflammation and rosacea genes. Symptom and Trigger Treatment.
-- Left over laser for broken blood vessels


Very rough estimate with time frames and some key drugs and treatments we know are on the way. There are many other experimental drugs that will be added along the way and used off label with great success. Two psoriasis drugs are in Phase IIb that should actually be first line rosacea drugs. These are not only in the pipeline, but coming through the pipe.

There are a lot of unknowns right now with gene therapy and it is a scary term to some. But there is also a heck of a lot known about gene therapy right now. These companies can make any type of gene therpy if you just tell them what gene you want blocked or what gene you want increased. They can make this right now. They can apply all these genes topically and get them into the cells to do their thing. These are two great steps. They have been doing tons of animal studies and benchwork studies in inflammatory skin disorders and are ready to start clinical trials on almost all fronts.

[hope]

this is a lot of great news. i am personally far more interested in the gene therapy than anything else (but its all great!). thank you for these estimates dr. nase. they give me hope

[drnase]

this is a lot of great news. i am personally far more interested in the gene therapy than anything else (but its all great!). thank you for these estimates dr. nase. they give me hope



There are actually many other potential treatments, but I wanted to stay conservative in the time frame and the treatment recommendations. We will continue to see a lot of off label use for rosacea from medications developed for other inflammatory skin disorders -- just like Elidel (which was predicted when it was ascomycin).

[Jonesy]

I think all these potentially great developments leave some of us with a dilemma- whether to spend a lot of money on stuff like IPL now or ride it out, take our chances and hopefully deal with it for a tiny fraction of the price of IPL a couple of years down the line with some of the new products which will hopefully be hitting the shelves. :?

[drnase]

I think all these potentially great developments leave some of us with a dilemma- whether to spend a lot of money on stuff like IPL now or ride it out, take our chances and hopefully deal with it for a tiny fraction of the price of IPL a couple of years down the line with some of the new products which will hopefully be hitting the shelves. :?


Hi Jonesy,

You are absolutely right. This is a freakin expensive disorder to treat in certain subtypes. The dilemma -- if it is significantly impacting your quality of life and making you miserable, I would consider starting treatment soon. Just my 2 cents.

[chickie]

Dr.Nase,
I noticed Botox wasn't anywhere on your list, can you tell me why. This seemed like such a promising solution at one point, especially if it could be delivered by ionotophoresis. Do you know if anything happened with the research into that. I may be in a different boat than some of the rosaceans here, I have been flushing and blushing badly for years (is that pre-rosacea) but have no permanent redness so far (only a matter of time perhaps). I would try Botox tomorrow if I could find someone to perform it on me for this. Any ideas on why this alternative isn't getting more attention? Thanks, Chickie

[drnase]

Dr.Nase,
I noticed Botox wasn't anywhere on your list, can you tell me why. This seemed like such a promising solution at one point, especially if it could be delivered by ionotophoresis. Do you know if anything happened with the research into that. I may be in a different boat than some of the rosaceans here, I have been flushing and blushing badly for years (is that pre-rosacea) but have no permanent redness so far (only a matter of time perhaps). I would try Botox tomorrow if I could find someone to perform it on me for this. Any ideas on why this alternative isn't getting more attention? Thanks, Chickie


Hi Chickie,

The results are extremely mixed right now and physicians are not sure whether it is due to the way its applied (injection) or if it is only good for very specific cases. For example, one case published from IU School of Medicine showed a dramatic decrease in facial redness and flushing.

I believe that it is more likely to help reduce certain triggers that release the dilator acetylcholine. Hot spicy foods, blushing (to a certain extent), overheating ( to a certain extent) and a few others.

I am just guessing right now, but I believe the big holdup on the iontophoresis unit application is the price of the machine. But, you would have much better control of drug delivery, more uniformity, and could stay away from the muscles of the face by just dialing in the correct number to the iontophoretic unit to deliver the drug to a superficial depth where the nerves are.



Dermatol Surg. 2004 Jan;30(1):102-4. Related Articles, Links

Botulinum toxin for the treatment of facial flushing.

Yuraitis M, Jacob CI.

Indiana University Medical School, Indianapolis,

BACKGROUND: Facial flushing is a common problem that is encountered by fair-skinned patients of Celtic and Northern European descent. Although usually transient in nature, some patients display a persistent reddened skin tone, with periods of increased erythema. Treatment of this condition is limited. OBJECTIVE: To describe a novel method for the treatment of persistent facial flushing. METHOD: We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A. RESULTS: The posttreatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome. CONCLUSION: Botulinum toxin A can be used in small quantities to decrease persistent facial flushing temporarily.

[SuzyG]

This is exciting stuff. I'm hoping to get some handle on my situation before menopause hits about 10 years down the road. Meanwhile, supplements, good diet, & IPL help . . .but I do so miss red wine!

[chickie]

Dr. Nase,
Do you know how I would go about finding a doctor who would try Botox on me? I think even injections would be helpful, they may not be the best way to deliver the drug, but it would give me some idea if my flushing would respond to Botox. Thanks, Chickie

[drnase]

Dr. Nase,
Do you know how I would go about finding a doctor who would try Botox on me? I think even injections would be helpful, they may not be the best way to deliver the drug, but it would give me some idea if my flushing would respond to Botox. Thanks, Chickie


Chickie,

Actually, almost any dermatologist or plastic surgeon that has extensive experience with BOTOX injections in the facial region will extend their area of treatment after some discussion. Just find the most experience BOTOX doctor in your area and talk to him about acetylcholine mediated flushing and sweating. Make sure you go over the benefit/risk ratio and discuss face freeze.

[todmiller]

Dr. Nase, two questions if I may:

1) Could we first try to apply acetylcholine on our faces to see if that induces a flush, in which case BOTOX could potentially help our situation? What else might we try?

2) How much can the initial phase I protocol change in a clinical study? It might be that SansRosa is too strong, producing a rebound effect. Can they change the compound until they get the best results, and then continue with the study? Is this what the numbering system is for, eg. SR-101 vs, say SR 171?

Thank you.

[drnase]

Dr. Nase, two questions if I may:

1) Could we first try to apply acetylcholine on our faces to see if that induces a flush, in which case BOTOX could potentially help our situation? What else might we try?

2) How much can the initial phase I protocol change in a clinical study? It might be that SansRosa is too strong, producing a rebound effect. Can they change the compound until they get the best results, and then continue with the study? Is this what the numbering system is for, eg. SR-101 vs, say SR 171?

Thank you.


Hi Todd,

Acetylcholine will produce a flush in almost anyones skin. Very potent dilator when put on exogenously (topically).

That is exactly right. Phase I and II are (up to IIc) there are often many changes based on the groups response.

[hope]

dr. nase,

i assume that gene therapy research is extremely expensive. money seems to be in short supply in R&D for rosacea. given these 2 factors, wouldn't it seem reasonable to infer that rosaceans probably will not see the benefits that could be gleened from gene therapy for a long time? (please tell me that i'm wrong)

but even if we did find the genes responsible for rosacea, couldn't it take "generations" to come up gene therapy treatments that target these defective genes?

the following article on the genes related to acne seems to have a "to bad for your generation, better luck for future ones" kind of conclusion. i hope that this conclusion does not also apply to rosaceans when it comes to gene therapy. here it is: http://news.bbc.co.uk/1/hi/health/3936263.stm

mind you, the dude who comments at the end of the article that treatment targetting genes will take generations is not a scientist, but merely an acne website organizer. so his pessimism should not be seen as authoritative (especially because he does not give any reasons for it).

[jjmaxx]

Dr Nase,
I recall you mentioning about 8-10 months ago on the other board that a new prescription only topical was coming out that had a high amount of Epidermal Growth Factor. I don't recall the manufacturer or any other details other than you though it might be out in 2005 and that it looked promising for all sorts of rosacea/seb derm symptoms.

Do you recall what the product was or have any news on it?

Thanks

[JimJimson]

We should really keep this topic stickied