Timolol for the Treatment of Acne and Rosacea

Rosacea affects roughly 16 million Americans who desire better treatments than those currently available. Acne vulgaris, another chronic inflammatory skin disorder, mainly affects teenagers but also affects 20-40% of adults. Investigating potential new treatments will not only satisfy a clinical need, but also offers the opportunity to learn about the pathogenesis of the disease and skin biology. The purpose of this study is to investigate the possible role of timolol as a therapy for the erythema and papules associated with acne and rosacea. It has been shown that timolol is beneficial and safe to treat infantile hemangiomas. The investigators hypothesize that it may also be safe and effective in the treatment of acne and rosacea.

In a single experiment where the test case was the PI (a practicing physician), the investigators treated his rosacea with timolol for this off-label indication and have noticed an improvement in flushing and an unexpected improvement in acneiform eruptions associated with the rosacea. After 30 days, less flushing and acneiform lesions were noted on the treated right side compared to the left side . Similarly, at 60 days after treatment, as visualized by infrared imaging, significantly less inflammation and flushing was noted on the treated right side even outside of episodes of flushing. The improvement was durable, such that after a 60 day washout, improvements were still noted. In summary, during testing of the PI as a case subject, timolol appeared effective, safe, and with some disease-remissive effects.

Our aim is to conduct a 16 week split-face pilot study with up to 30 patients who have a diagnosis of either inflammatory acne or rosacea to assess whether timolol maleate effectively reduces erythema, flushing, telangiectasias, and/or papules. The investigators also propose to biopsy a subset of our study patients to examine the biological activity in the skin before and after treatment. The investigators are particularly interested in studying epigenetic DNA methylation abnormalities in these conditions at baseline to compare to normal subjects and as a result of therapy.

Inclusion criteria

• In the opinion of the investigator, must be medically able to undergo the administration of study material
• Be able to comprehend the informed consent document and provide consent for participation
• Females of childbearing potential must:

• Not be pregnant by subjective report
• agree to not become pregnant or breastfeed for the period of the study through 1 month after completion of the study
• be willing to use a reliable form of contraception during the study
• Be willing and able to comply with the scheduled visits and other study procedures for the duration of the study.
• Be willing not to take any other medicine for acne or rosacea during the study
• Acne specific inclusion criteria:

o 10-100 noninflammatory, 20-50 inflammatory lesions (nose excluded)

• Rosacea specific inclusion criteria:

• History of frequent flushing
• Skin erythema - Positive (not negative) chromometer minimum reading difference when subtracting nonaffected reading from affected reading.

Goal would be greater than 1 unit difference between red areas. For example, the red area (average 17.7 Chroma Meter a) and nonaffected areas (average 14.1 Chroma Meter a), yields in an optimum scenario greater than 3 point difference in this example (in subjects with average Chromometer L value averaging 56.6-59.6). Example from (Helfrich et al., 2015).

o Presence of inflammatory papules

Exclusion criteria

• Having received any investigational drug within 30 days prior to study entry
• An allergy history to any study materials including any beta-blockers.
• Pregnant, lactating, or trying to become pregnant
• Severe depression
• Hypotension or history
• Bradycardia or history
• History of Cardiac Heart Failure
• History of Myocardial infarction
• History of heart arrhythmia
• Asthma or Bronchospasm or history
• Rosacea specific exclusion criteria:

Recent topicals within 3 weeks Oral rosacea medications such as antibiotics within 3 weeks • Acne specific exclusion criteria: nodular acne man with beard which interferes with clinical evaluation history of Accutane Oral contraceptive pills changes last 3 months Topical retinoid within 4 weeks Cosmetic procedures (like facial or peels) for 4 weeks Photodynamic therapy , laser therapy or microdermabrasion for 4 weeks Other topicals or oral acne medications such as antibiotics within 3 weeks

o Biopsy volunteer specific exclusion criteria: History of keloids History of hypertrophic scars Allergy to lidocaine or epinephrine