RoseCLiu1,ManiMakhija2,XinLWong3,DeshanFSebaratnam1,3

1UniveristyofSydney,2KossardDermatopathologists,3UniversityofNewSouthWales

Casereport

Figure2. Biopsydemonstratedectatic dermalbloodvessels,andpandermalinflammationwithperifollicular granulomascomposedofepithelioid histiocytes,multinucleargiantcells,lymphocytesandneutrophils.(a)Haematoxylinandeosin,originalmagnificationX10,(b)Haematoxylinandeosin,originalmagnificationX40.

Figure1.(a)Baselinephotographsofapatientwithapapular eruptionaffectingtheglabellar andmalarregions.(b)FollowingtwelvetreatmentswithCGAP,significant

improvementisobserved.

Discussion

Granulomatousrosaceaisnotoriouslydifficulttotreat,andthereisnocurrentconsensusregardingthebestapproachtomanagement.Small-volumecasereportsandserieshaveadvocatedtherapeuticoptionsincludingdapsone,tetracyclines andisotretinoin.1 Howeversystemictreatmentisnotalwaysacceptedortolerated,asinthecaseofourpatient.CGAPisanewtherapeuticmodalitythathasbeenshowntobeeffectiveinpapulopustular rosacea,2 aswellotherconditionssuchasacne3,4anderlotinib inducedacneiform eruptions.5CGAPinvolvesirradiationofachromophore gel(Kleresca®)withlightatthewavelengths415nmand447nmtogenerateafluorescentspectrumfromapproximately510-630nm.CGAPisnon-invasive, in-officeinterventionwithnoknownsystemicsideeffects.Whilethepathophysiologyofrosaceaisunclear,thereappearstobeanovergrowthofcommensalorganismspairedwithalterationsininnateimmuneresponse.1FurtherstudieswithgreatermethodologicalrigorshouldbeemployedtodeterminetheroleofCGAPinthissetting.Howeveritisbiologicallyplausible thatCGAPmayhavebeeffectiveinthemanagementofrosaceaduetoitsproposedanti-inflammatoryandantibacterialeffects.6Additionally, lightbasedmodalitiessuchasphototherapyandphotodynamictherapyhavebeenshowntobehelpfulinothergranulomatousdiseases,suchsarcoidosis,bydecreasinginterleukin1andtumournecrosisfactoralphalocallywhich arenecessaryforgranulomaformationandmaintenance.7Thiscasesuggests thatthereispromiseinCGAPasmanagementofgranulomatousrosacea.However,asinglecasereportcannotdiscounttheimpactofaplaceboeffect,orthepossibilityofspontaneousremission. Nonetheless,thenoteworthyresponseofourpatienttotreatmentsuggests thatCGAPmaybeoftherapeuticvalue,andwarrantsfurtherresearchwithmorerigorousstudies.

TreatmentofGranulomatousRosaceawithChromophore Gel-AssistedPhototherapy

Granulomatousrosaceaisavariantofrosaceacharacterizedbydiscreteerythematouspapulesmostcommonlyaffectingthecentral face.Itisarareconditionreportedprimarilyinmiddle-agedwomen,andtendstohaveachroniccourseoftenrecalcitranttotherapy.Wereportacaseofgranulomatousrosaceatreatedwithchromophore gel-assistedphototherapy(CGAP).A50-year-oldwomanofLebanesebackgroundpresentedwithathree-month historyofapapulopustular eruption.Shedescribedparoxysmsofpapulesaffectingtheglabellar,malarandmentalregions.Shedeniedanyflushingorophthalmologicalsymptoms.Examinationdemonstratedtumidpapulesandpustulesaffectingtheglabellawithmalarerythemacomposedoffinetelangiectasia.Therewasnoappreciablephymatous change(Fig.1a).Biopsydemonstratedectatic dermalbloodvessels,andpandermal inflammationwithperifollicular granulomascomposedoflymphocytesandneutrophils (Fig.2a&b).Microbialstudiesincludingspecialstains,aswellasbacteria,Mycobacteria anddeepfungalculture&PCRwerenegative.Theclinicalandpathologicalfindingswereconsistentwithgranulomatousrosacea.Modestimprovementwasobservedwithtopicalmetronidazole,ivermectin,andbrimonidine andsystemicminocycline50mgBDledtothedevelopmentofheadache.Thepatientwasreticent topursuealternatesystemictreatmentsandaccordinglyatrialofCGAP waspursued.Thepatientreceivedtwelvetreatmentsessionsoversixweeksinvolvingapplicationofa2mmlayerofthephotoconverter chromophore gel(Kleresca®)followedbyirradiationwithamulti-LEDlamp(415nmand447nm)(Kleresca®,Balerup,Denmark).Significantimprovementwasobservedinboththepapulopustular anderythematotelangiectatic componentsofherrosacea(Fig.1b). Todate,therehasbeennorelapseinherrosaceaoffallactivetreatment,atatime-pointsixmonthsaftercessationofCGAP.

References1. LeeGL,Zirwas MJ.Granulomatousrosaceaandperiorficial dermatitis:controversiesandreviewofmanagementandtreatment.Dermatol Clin 2015;33(3):447-552.BraunSA,GerberPA.Aphotoconvertergel-assistedbluelighttherapyforthetreatmentofrosacea.Int JDermatol 2017;56(12):1489-90.3.Nikolis A,Fauverghe S,Scapagnini G,etal.Anextensionofamulticenter,randomized,split-faceclinicaltrialevaluatingtheefficacyandsafetyofchromophoregel-assistedbluelightphototherapyforthetreatmentofacne.Int JDermatol 2018;57(1):94-1034.AntoniouC,Dessinioti C,Sotiriadis D,etal.Amulticenter,randomized,split-faceclinicaltrialevaluatingtheefficacyandsafetyofchromophore gel-assistedbluelightphototherapyforthetreatmentofacne.Int JDermatol 2016;55(12):1321-5.Mahendran A,WongXL,KaoS,etal.Treatmentoferlotinib inducedacneiform eruptionwithchromophore-gelactivatedphototherapy.PhotodermatolPhotoimmunol Photomed.2018.doi:10.1111/phpp.12446.6.Ghate VS,NgKS,ZhouW etal.Antibacterialeffectoflightemittingdiodesofvisiblewavelengthsonselectedfoodbornepathogensatdifferentilluminationtemperatures.Int JFoodMicrobiol 2013;16(166):399–406.7.PenroseC,MercerSE,Shim-ChangH.Photodynamictherapyforthetreatmentofcutaneoussarcoidosis.JAAD2011;65(1)e12-e14