Integration of alternative acne, rosacea interventions

Aruba - Clear and unambiguous data demonstrate that therapeutic outcomes for patients with acne and rosacea can be enhanced by augmenting traditional care with more novel interventions, said Richard G. Fried, M.D., Ph.D., at the Caribbean Dermatology Symposium here.

Stress reduction key There are a number of novel approaches to consider for use in acne and rosacea management, including psychological and psychocutaneous interventions, he says. The potential value of psychological interventions is underlined by a number of published studies in preclinical and clinical models demonstrating the negative role of stress on the human immune system, skin barrier function and skin disease status along with the benefits of interventions for reducing stress.

"We clearly know that stress management intervention can exert a positive effect on a range of neuropeptides that are elevated in inflammatory skin diseases," says Dr. Fried, clinical director, Yardley Dermatology and Yardley Skin Enhancement and Wellness Center, Yardley, Pa. "Against the background of that biochemical evidence, it makes sense for some patients to augment traditional care by offering stress management techniques."

Educating patients that rosacea and acne are associated with immunologic dysregulation and helping them to understand the concept of skin hyperreactivity in the pathogenesis of their disease is also fundamental for enhancing short-term and long-term management, Dr. Fried tells Dermatology Times.

Halting psychocutaneous cascade Selected use of psychocutaneous medications can also play a role in the management of rosacea and acne. For example, considering the psychocutaneous cascade of events involved in the perpetuation of blushing and flushing in rosacea, a drug that can abrogate the pathway may be a useful adjunct.

Dr. Fried explains that regardless of the trigger for blushing and flushing, for some patients, the emotional response to those disease features incites sympathetic nervous system stimulation and adrenergic responses that worsen anxiety and perpetuate the blush and flush. Treatment with a beta-blocker, such as propranolol (Inderal, Wyeth), can be very effective in decreasing the adrenergic response to an initial blush/flush episode, thereby lessening the physiological reactions that help to fuel the cascade.

In fact, patients who have been taking propranolol for some time may develop a conditioned response wherein they sense the characteristic taste of propranolol in the mouth at the onset of blushing and flushing even though they have not ingested the drug. That response alone can be enough to bring patients a feeling of control so that they respond in a favorable way to the blush/flush rather than in a negative way that perpetuates it, observes Dr. Fried.

"That model can be used throughout the spectrum of skin problems we treat," he says. "Understanding the global concept of stress as a trigger for skin disease and an erosive factor for wellness and longevity should be a motivating factor for teaching patients how to handle it. Recognizing what stress does to the skin and other organ systems should also make physicians realize we have an obligation to ourselves, our families and our patients to personally embrace some of these same techniques and philosophies."

Alternative treatments Complementary medicine should not be ruled out. Data from well-designed clinical trials show that some herbal or natural treatments have measurable effects on the skin, including benefits for improving acne.

As patients are also bringing with them concerns about the risks of antibiotic therapy, there is also a place for dermatologists to think outside the box in selecting antimicrobial regimens. In that regard, data show that subantimicrobial dose doxycycline (Periostat, CollaGenex) 20 mg twice a day, is effective for rosacea . Integrating low-dose treatment into patient care can be accomplished either as a steppingstone to more aggressive intervention for patients failing to respond to topical modalities alone, or as a "back end" approach to withdrawing ongoing treatment with a conventional antimicrobial dose.

"As clinicians, we know that community-acquired methicillin-resistant Staphylococus aureus is a real and important problem, and patients are also worried about antibiotics. Prescribing subantimicrobial doses in appropriate situations can allow us to minimize regimens that can contribute to resistance emergence and also presents an approach patients may find more natural and more palatable," Dr. Fried says.