Letter - Clinical
Neurogenic rosacea successfully treated with neuromodulators and intense pulsed light
Diana Isabel Conde Hurtado
, Andrea Paola Céspedes Pérez, Ricardo Flaminio Rojas López
Corresponding author
DermaHair Center, Floridablanca, Colombia
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She also had a history of anxiety and depression.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We rule out other possible causes of <span class="elsevierStyleItalic">red face syndrome</span> such as systemic lupus erythematosus, carcinoid syndrome, and pheochromocytoma through laboratory and imaging studies. Given the history of poor response to standard treatments and the concomitance of neurological symptoms, we diagnosed Neurogenic Rosacea (NR). She was treated with pregabalin 150<span class="elsevierStyleHsp" style=""></span>mg/day and duloxetine 90<span class="elsevierStyleHsp" style=""></span>mg/day for six months. This significantly reduced pain and burning symptoms. However, the erythema persisted therefore Intense Pulsed Light (IPL) therapy was added (Harmony-Alma Laser®, wavelength of 550‒650<span class="elsevierStyleHsp" style=""></span>nm, fluence of 10 Joules/cm<span class="elsevierStyleSup">2</span>, pulse width of 12<span class="elsevierStyleHsp" style=""></span>ms). A small test exposure was made to make sure was adequately tolerated (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). She received a monthly session for three months while continuing with pharmacological treatment. After this combined therapy all her signs and symptoms disappeared (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) improving her quality of life.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">NR develops intense facial redness associated with stinging, burning, and dysesthesias out of proportion to the concomitant flushing or swelling,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and was described by Scharschmidt in 2011.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The degree of erythema is more severe in NR than in other variants, and the pain has been described as stabbing, electric shock-like, or shooting. Triggering factors in NR are similar to other rosacea variants. NR patients have an association with complex regional pain syndrome, essential tremor, anxiety, depression, and obsessive-compulsive disorder.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathophysiology is still unknown but is thought to be a dysfunctional regulation in the neurovascular system called <span class="elsevierStyleItalic">neurogenic inflammation</span>,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> which is mediated by neuromodulators. The most important are Calcitonin Gene-Related Protein (CGRP) and Substance P (SP). They act on the endothelial cells and smooth muscle cells leading to vascular changes. SP induces edema and neovascularization. CGRP is a potent microvascular vasodilator that worsens local inflammation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The response of NR is poor to conventional therapies.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Drugs that attenuate neurotransmitter release could be effective (pregabalin, gabapentin, antidepressants, memantine, and duloxetine).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pregabalin modulates the release of SP and CGRP. Duloxetine has an anti-inflammatory and immune-modulatory effect.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Both drugs helped with her anxiety and depression symptoms as well as the somatic symptoms.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Light therapies, like IPL, are successful for rosacea. IPL uses photothermolysis to destroy blood vessels reducing facial erythema. The fluence, pulse width, and inter-pulse interval considerations will depend on the patient's phototype, the severity of the condition, and tolerance to treatment, and is adjustable according to the physician’s criteria. Light-based interventions should be used with caution because of skin sensitivity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Other treatments are surgical intervention (sympathectomy), botulinum toxin, and local cold stimuli.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Few NR cases are described, and there still exist gaps in its management. Our patient had a successful response to neuromodulators and IPL without side effects. This combination has not been previously reported.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Andrea Paola Cespedes Pérez: Adequate the study concept and design; writing of the manuscript; research guidance; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Diana Isabel Conde Hurtado: Adequate the study concept and design; writing of the manuscript; research guidance; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ricardo Flaminio Rojas López: Adequate the study concept and design; acquisition of data, analysis of data; intellectual participation in propaedeutic and/or therapeutic conduct of the studied case; writing of the manuscript; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">Dr. Ricardo Flaminio Rojas is an advisory board member and speaker at Galderma.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-06-05" "fechaAceptado" => "2022-09-05" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the DermaHair Center, Floridablanca, Colombia.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 904 "Ancho" => 2508 "Tamanyo" => 135777 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient at the time of first consultation with evidence of profuse erythema predominantly on cheeks.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 922 "Ancho" => 1508 "Tamanyo" => 92231 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0085" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Trial of IPL therapy on a small area of the left cheek, after six months of pharmacotherapy with pregabalin and duloxetine, but persistence of erythema.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1081 "Ancho" => 1508 "Tamanyo" => 87186 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Three months after concomitant use of pharmacotherapy and IPL.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurogenic rosacea: an uncommon and poorly recognized entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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Tanum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2340/00015555-2702" "Revista" => array:6 [ "tituloSerie" => "Acta Derm Venereol" "fecha" => "2017" "volumen" => "97" "paginaInicial" => "897" "paginaFinal" => "905" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28512664" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009900000002/v2_202407221312/S0365059623002544/v2_202407221312/en/main.assets" "Apartado" => array:4 [ "identificador" => "95691" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter – Clinical" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009900000002/v2_202407221312/S0365059623002544/v2_202407221312/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623002544?idApp=UINPBA00008Z" ]
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| 2024 May | 394 | 106 | 500 |
| 2024 April | 499 | 118 | 617 |
| 2024 March | 672 | 101 | 773 |
| 2024 February | 266 | 116 | 382 |
| 2024 January | 161 | 81 | 242 |
| 2023 December | 116 | 50 | 166 |
