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RESEARCH REVIEW Stopping the Flush Antimicrobial peptides (AMP) may offer a new approach to acne treatment. In "What is the role of antimicrobial peptides in acne vulgaris?" (Experimental Dermatology, May 2013), researchers Jürgen Harder, et al, of the University of Kiel, department of dermatology in Kiel, Germany, examine two potential roles for AMPs—one involves using AMPs to treat acne, the second involves using topicals that interfere with AMP expression to treat acne. They note that peptides RNase7, psoriasin and hBD2, for example, offer antimicrobial effects that reduce P .Acnes, while cathelicidin LL-37 appears to offer both antimicrobial and anti-inflammatory effects. Conversely, there is evidence that while hBD-2 offers antimicrobial benefits, it may also increase the skin's inflammatory response, along with AMP HNP-1-3 and granulysin. The authors posit that therapeutic options for the use of AMP in acne patients may one day include the use of synthetic AMP that inhibit both P .Acnes and the release of pro-inflammatory cytokines. Vitamin D, which has been successful in treating other inflammatory skin diseases, may show promise in acne due to its role in inducing cathelicidin LL-37. The application of a multifunctional peptide hormone adrenomedullin may also reduce the severity of acne breakouts when applied topically, as "its expression is not markedly upregulated in acne lesions," said Jürgen, et al. The diffuse redness and flushing of rosacea is one of the most difficult symptoms to control. Typically, camouflage makeup, intense pulsed light and pulsed dye lasers have offered the most consistent results. But there are some new treatment options on the horizon. Brimonidine (Galderma, galdermausa.com) is poised to become the first FDA-approved topical vasoconstrictor. "In terms of new ingredients, I think the next big, big thing that's coming around the bend are the topical vasoconstrictors," says Diane Berson, MD, associate clinical professor of dermatology at Cornell Medical College and attending dermatologist at New York Presbyterian Hospital. Facial plastic surgeon Steven Dayan, MD, of SDMD in Chicago, released an anecdotal report on the use of botulinum toxin for the treatment of rosacea in December 2012 ("A New Treatment Regimen for Rosacea: OnabotulinumtoxinA" Journal of Drugs in Dermatology). He treated 12 patients with intradermal injections of botulinum toxin diluted with 7cc of water and saw improvement in the flushing and inflammation, but did not see a reduction in pustules. "The results last 2½ to 3 months," says Dr. Dayan. "I think there is a subset of patients it's not working for. Some respond well, some don't and I can't say which ones will respond, but it is a curious response and very interesting." Dr. Dayan is currently performing a larger, placebocontrolled study with results expected in early 2014 and believes the treatment could be promising, particularly if topical neurotoxins come to market. Isotretinoin and Antibiotic Therapy Disrupt Microbial Floras The use of isotretinoin and antibiotics in the treatment of acne can disrupt microbial floras in patients' bodies, with isotretinoin causing the most significant disruption, according to "The effects of systemic isotretinoin and antibiotic therapy on the microbial floras in patients with acne vulgaris" (JEADV, March 2013). PY Basak, et al, of Suleyman Demirel University in Isparta, Turkey, treated 35 acne patients, who were randomized into two groups. One group was treated with isotretinoin (0.5-1mg/kg/day until they reached a cumulative dose of 120mg/kg). The second group was treated with either azithromycin (500mg/day) or doxycycline (100mg/day). Microbial flora in the oropharynx, nose and feces were cultured at baseline and once a month during the four to six month treatment period. In the isotretinoin group, three patients had staphylococcus aureus (s. aureus) colonies in the nose and oropharynx at baseline. During treatment, s. aureus colonies were identified in the oropharynx of eight patients, the nose of 14 patients and the feces of four patients in the isotretinoin group. Among the patients treated with antibiotics, s. aureus colonies were seen in fecal cultures in three patients at baseline and five patients during treatment. MRSA was found in the nasal floras of two patients in the isotretinoin group. 2 July/August 2013 | ACNE & ROSACEA Left: Kwangshin Kim / Science Source; Right: © istockphoto.com Antimicrobial Peptides and Acne