A Vehicle-Controlled, Double-Blind, Randomized Phase II Study of B244 Delivered as a Topical Spray to Determine Safety and Efficacy in Subjects With Mild to Moderate Rosacea
Phase: PHASE2
Conditions: Rosacea
Sponsor: AOBiome LLC

Protocol Number: RB244-001 
Version 4.0; 07 JAN 2019 
 
 
 
Confidential |  Protocol: RB244-001  | Version No: 4.0 Amendment| Date:  07 JAN 2019 
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CLINICAL STUDY PROTOCOL 
A Vehicle-Controlled, Double-Blind, Randomized Phase II Study of B244 Delivered as a 
Topical Spray to Determine Safety and Efficacy in Subjects with Mild to Moderate 
Rosacea. 
Protocol Number: RB244-001 
 VERSION 4.0 DATE:  07 JAN 2019 
 
Sponsor: 
AOBiome, LLC 
125 Cambridgepark Drive 
Cambridge, MA 02140 
 
 
Any and all information presented in this document shall be treated as confidential and shall remain the 
exclusive property of AOBiome LLC (or any of its affiliated companies).  The use of such confidential 
information must be restricted to the recipient for the agreed purpose and must not be disclosed, published or 
otherwise communicated to any unauthorized persons, for any reasons, in any form whatsoever without the 
prior written consent of AOBiome LLC (or the concerned affiliated company) 
NCT03590366

 
Protocol Number: RB244-001 
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INVESTIGATOR SIGNATURE PAGE 
The signature below constitutes approval of this protocol and provides the necessary 
assurance that this study will be conducted at his/her investigational site according to all 
stipulations of the protocol including all statements of confidentiality and in accordance with 
ICH GCP and local regulatory requirements. 
Print Name 
 
Title 
 
Address of Institution / 
Site: 
__________________________________________________ 
__________________________________________________ 
__________________________________________________ 
__________________________________________________ 
Telephone Number: 
 
Investigator Signature: _______________________________ Date: _______________ 
 
 

 
Protocol Number: RB244-001 
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PROTOCOL AMENDMENT 3 SUMMARY OF CHANGES 
Section 
Description of Changes 
Synopsis 
Added Exploratory Endpoints: IGA treatment success 
and CEA treatment success defined as “clear” or “almost 
clear” with a 2-grade improvement in score from 
baseline to the end of treatment. 
Section 3 Study Endpoints 
Added Section 3.3 Exploratory Endpoints: IGA 
treatment success and CEA treatment success, defined 
as “clear” or “almost clear” with a 2-grade improvement 
in score from baseline to the end of treatment. 
Section 14 Statistical Analysis  
Added 14.3.3.1 Exploratory Endpoints: IGA treatment 
success and CEA treatment success defined as “clear” or 
“almost clear” with a 2-grade improvement in score 
from baseline to the end of treatment. 
 
Administrative changes: Minor changes involving grammar, wordsmithing, punctuation, and 
other editorial changes have been made throughout the document.  All are clearly identified in 
the track-changes version of the amendment. 
 
Additional formatting and stylistic adjustments have been made to facilitate the reading 
process. 
 
 
 
 

 
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TABLE OF CONTENTS 
SIGNATURE PAGE ............................................................................................................................................ 2 
INVESTIGATOR SIGNATURE PAGE ................................................................................................................... 3 
PROTOCOL AMENDMENT 3 SUMMARY OF CHANGES ..................................................................................... 4 
TABLE OF CONTENTS ....................................................................................................................................... 5 
GLOSSARY OF ABBREVIATIONS ....................................................................................................................... 9 
PROTOCOL SYNOPSIS .................................................................................................................................... 11 
STUDY FLOWCHART ...................................................................................................................................... 18 
SCHEDULE OF ACTIVITIES .............................................................................................................................. 19 
PRINCIPAL CONTACTS ................................................................................................................................... 21 
1 BACKGROUND AND RATIONALE ................................................................................................................. 22 
1.1 BACKGROUND ................................................................................................................................................ 22 
1.2 RATIONALE OF THE STUDY ................................................................................................................................. 23 
1.2.1 Clinical Experience .............................................................................................................................. 24 
1.2.2 Safety Profile ....................................................................................................................................... 25 
2 STUDY OBJECTIVES ..................................................................................................................................... 26 
2.1 STUDY OBJECTIVES .......................................................................................................................................... 26 
2.1.1 Primary Objective ................................................................................................................................ 26 
2.1.2 Exploratory Objectives ........................................................................................................................ 26 
3 STUDY ENDPOINTS ..................................................................................................................................... 26 
3.1 SAFETY & TOLERABILITY .................................................................................................................................... 26 
3.2 EFFICACY ....................................................................................................................................................... 26 
3.3 EXPLORATORY................................................................................................................................................. 27 
4 INVESTIGATIONAL PLAN ............................................................................................................................. 27 
4.1 STUDY DESIGN ................................................................................................................................................ 27 
4.2 NUMBER OF SUBJECTS AND SITES ....................................................................................................................... 28 
5 SELECTION AND WITHDRAWAL OF STUDY POPULATION ............................................................................ 28 
5.1 ELIGIBILITY CRITERIA ........................................................................................................................................ 28 
5.1.1 Inclusion Criteria ................................................................................................................................. 28 
5.1.2 Exclusion Criteria ................................................................................................................................. 29 
5.2 STUDY WITHDRAWAL ....................................................................................................................................... 31 
5.3 EARLY DISCONTINUATION ................................................................................................................................. 31 
6 INVESTIGATIONAL PRODUCT TREATMENT AND ADMINISTRATION ............................................................ 32 
6.1 IDENTITY OF INVESTIGATIONAL PRODUCT(S) .......................................................................................................... 32 
6.2 INVESTIGATIONAL PRODUCT .............................................................................................................................. 32 
6.3 PACKAGING AND LABELING................................................................................................................................ 33 
6.4 STORAGE OF THE INVESTIGATIONAL PRODUCT AT SITE ............................................................................................. 33 
6.5 TREATMENT ASSIGNMENT (RANDOMIZATION) ...................................................................................................... 33 
6.6 BLINDING/UNBLINDING PROCEDURES ................................................................................................................. 33 

 
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6.7 INVESTIGATIONAL PRODUCT DISPENSATION, APPLICATION, AND HOME STORAGE ........................................................ 34 
6.8 ACCOUNTABILITY, DESTRUCTION AND RETURN OF STUDY SUPPLIES ........................................................................... 35 
6.9 TREATMENT OF INVESTIGATIONAL PRODUCT OVERDOSE ......................................................................................... 36 
6.10 DOSE CHANGES ............................................................................................................................................ 36 
7 CONTRACEPTION REQUIREMENTS ............................................................................................................. 36 
7.1 CONTRACEPTION AND PREGNANCY AVOIDANCE MEASURES ..................................................................................... 36 
8 CONCOMITANT MEDICATIONS ................................................................................................................... 37 
8.1 PRIOR, CONCOMITANT AND PROHIBITED THERAPY ................................................................................................. 37 
8.2 PROHIBITED PROCEDURES ................................................................................................................................. 38 
9 LIFESTYLE RESTRICTIONS ............................................................................................................................ 39 
9.1 USE OF CLEANSER AND MOISTURIZER DURING THE TRIAL .......................................................................................... 39 
9.2 USE OF MAKEUP, MOISTURIZERS AND SUN SCREEN ................................................................................................. 39 
10 STUDY PROCEDURES AND SCHEDULE OF STUDY ACTIVITIES ..................................................................... 39 
10.1 ADMINISTRATIVE PROCEDURES ........................................................................................................................ 39 
10.1.1 Subject Informed Consent ................................................................................................................. 39 
10.1.2 Documentation of Screen Failures .................................................................................................... 39 
10.2 STUDY PROCEDURES ...................................................................................................................................... 40 
10.2.1 Visit 1- Screening Visit (Day -21 to -1) ............................................................................................... 40 
10.2.2 Washout Phase (-14 to -1) ................................................................................................................ 40 
10.2.3 Visit 2- Baseline visit (Day 1): ............................................................................................................ 40 
10.2.4 Visit 3- Week 1 (Day 7) ±2 days ........................................................................................................ 41 
10.2.5 Visit 4- Week 4 (Day 28) ±2 days ...................................................................................................... 41 
10.2.6 Visit 5- Week 8 (Day 56) ±2 days ...................................................................................................... 42 
10.2.7 Visit 6- End of Study Visit-Week 12 (Day 84) ±2 days ....................................................................... 42 
10.2.8 Unscheduled Visit .............................................................................................................................. 42 
10.2.9 Early Termination Visit ...................................................................................................................... 43 
11 METHODS OF ASSESSMENT ...................................................................................................................... 43 
11.1 CLINICAL EVALUATIONS .................................................................................................................................. 43 
11.1.1 Subject Demographics ...................................................................................................................... 43 
11.1.2 Medical history ................................................................................................................................. 44 
11.1.3 Concomitant Medication Recording ................................................................................................. 44 
11.1.4 Vital Signs ......................................................................................................................................... 44 
11.1.5 Physical examination ........................................................................................................................ 44 
11.1.6 Investigator’s Global Assessment (IGA) ............................................................................................ 44 
11.1.7 Clinician’s Erythema Assessment (CEA) ............................................................................................ 45 
11.1.8 Skindex 16 ......................................................................................................................................... 46 
11.1.9 Patient Self-Assessment (PSA) .......................................................................................................... 46 
11.1.10 Telangiectasia Evaluation ............................................................................................................... 46 
11.2 SAFETY ASSESSMENTS .................................................................................................................................... 47 
11.2.1 Assessment of Adverse Events .......................................................................................................... 47 
11.2.2 Pregnancy Test .................................................................................................................................. 47 
11.2.3 Laboratory Assessments ................................................................................................................... 47 
11.2.4 Biomarkers ........................................................................................................................................ 48 
11.2.5 Samples Shipment ............................................................................................................................. 48 
11.2.6 Treatment Adherence Evaluations .................................................................................................... 48 

 
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11.2.6.1 Study Diary Compliance Review ................................................................................................................. 48 
11.2.6.2 Treatment Compliance ............................................................................................................................... 48 
12 SAFETY DATA COLLECTION, RECORDING AND REPORTING ....................................................................... 49 
12.1 DEFINITIONS ................................................................................................................................................. 49 
12.1.1 Adverse Event ................................................................................................................................... 49 
12.1.2 Serious Adverse Events ..................................................................................................................... 49 
12.2 ADVERSE EVENT SEVERITY ............................................................................................................................... 50 
12.3 CAUSALITY OF ADVERSE EVENTS ....................................................................................................................... 51 
12.4 ADVERSE EVENT COLLECTION PERIOD ............................................................................................................... 51 
12.5 ADVERSE EVENT REPORTING ........................................................................................................................... 51 
13 MEDICAL MONITOR ................................................................................................................................. 52 
13.1 UNBLINDING DUE TO SAE ............................................................................................................................... 52 
14 DATA ANALYSIS ........................................................................................................................................ 53 
14.1 SUBJECT POPULATION/DATA SETS TO BE EVALUATED .......................................................................................... 53 
14.2 SAMPLE SIZE DETERMINATION ......................................................................................................................... 54 
14.3 STATISTICAL ANALYSES ................................................................................................................................... 54 
14.3.1 Subject Disposition and Demography ............................................................................................... 54 
14.3.2 Assessment of Safety ........................................................................................................................ 54 
14.3.3 Hypothesis Testing/ Assessment of Efficacy ..................................................................................... 55 
14.3.3.1 Exploratory Endpoints ................................................................................................................................ 55 
14.3.4 Handling of Missing Values & Sensitivity Analysis ............................................................................ 55 
14.3.5 Handling of Multiplicity .................................................................................................................... 56 
14.3.6 Primary Objective .............................................................................................................................. 56 
14.3.7 Exploratory Objectives ...................................................................................................................... 56 
14.3.7 Clinical Trial Protocol deviations ....................................................................................................... 56 
15 STUDY CONDUCT ...................................................................................................................................... 57 
15.1 ETHICAL CONDUCT OF THE STUDY ..................................................................................................................... 57 
15.2 OTHER REQUIRED APPROVALS ......................................................................................................................... 57 
15.3 INFORMED CONSENT...................................................................................................................................... 57 
15.4 SUBJECT CONFIDENTIALITY .............................................................................................................................. 57 
15.5 INSTITUTIONAL REVIEW BOARD (IRB) / INDEPENDENT ETHICS COMMITTEE (IEC) ...................................................... 58 
15.6 PUBLICATION ................................................................................................................................................ 58 
16 ADMINISTRATIVE OBLIGATIONS ............................................................................................................... 59 
16.1 CURRICULUM VITAE ....................................................................................................................................... 59 
16.2 SOURCE DOCUMENTATION FORMS ................................................................................................................... 59 
16.3 RECORD RETENTION ...................................................................................................................................... 59 
17 PUBLICATIONS ......................................................................................................................................... 60 
18 PROTOCOL ADHERENCE ........................................................................................................................... 60 
19 CLINICAL TRIAL PROTOCOL AMENDMENTS .............................................................................................. 61 
20 PROPERTY RIGHTS .................................................................................................................................... 61 
21 DATA PROTECTION ................................................................................................................................... 61 
22 SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES ........................................................... 61 

 
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22.1 QUALITY CONTROL (QC) AND QUALITY ASSURANCE (QA) .................................................................................... 62 
22.1.1 Study Site Monitoring Visits .............................................................................................................. 62 
22.1.2 Protocol Deviations ........................................................................................................................... 62 
22.2 TRIAL DISCONTINUATION/INVESTIGATIVE SITE TERMINATION ................................................................................ 63 
22.2.1 Criteria for Premature Termination or Suspension of the Study ....................................................... 63 
22.2.2 Criteria for Premature Termination or Suspension of Investigational Sites ...................................... 63 
22.2.3 Procedures for Premature Termination or Suspension of the Study or Investigational Site(s) ......... 63 
23 REFERENCES ............................................................................................................................................. 64 
24 APPENDICES ............................................................................................................................................. 65 
APPENDIX 1: INVESTIGATOR GLOBAL ASSESSMENT (IGA) ............................................................................................. 65 
APPENDIX 2: CLINICIAN ERYTHEMA ASSESSMENT (CEA) ............................................................................................... 66 
APPENDIX 3: PATIENT SELF-ASSESSMENT (PSA) ......................................................................................................... 67 
APPENDIX 4:  SKINDEX 16 ...................................................................................................................................... 68 
APPENDIX 5: FITZPATRICK SKIN ASSESSMENT ............................................................................................................. 70 
APPENDIX 6:  TELANGIECTASIA ASSESSMENT .............................................................................................................. 71 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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GLOSSARY OF ABBREVIATIONS 
ABBREVIATION 
MEANING 
AE 
Adverse Event 
AOB 
Ammonia-Oxidizing Bacteria 
BID 
Bis in Die (twice a day) 
BP 
Blood Pressure 
CEA 
Clinician Erythema Assessment 
CRA 
Clinical Research Associate 
CI 
Confidence Interval 
CRF 
Case Report Form 
CTMF 
Clinical Trial Master File 
CTP 
Clinical Trial Protocol 
eCRF 
Electronic Case Report Form 
EOS 
End of Study 
ET 
Early Termination 
ETR 
Erythematotelangiectatic rosacea 
GCP 
Good Clinical Practice 
IB 
Investigator’s Brochure 
ICH 
International Conference On Harmonization 
IEC 
Independent Ethics Committee 
IGA 
Investigator Global Assessment 
IGE 
Investigator’s Global Evaluation 
IP 
Investigational Product 
IPL 
Intense Pulsed Light 
IRB 
Institutional Review Board 
ISF 
Investigator Site File 
IUD 
Intrauterine Device 
IUS 
Intrauterine system 
IWRS 
Interactive Web Response System 
LOCF 
Last Observation Carried Forward 

 
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mITT 
Modified Intent-To-Treat 
NSAID 
Nonsteroidal Anti-inflammatory Drug 
OTC 
Over the Counter 
PP 
Per-Protocol 
PRN 
Pro Re Nada (as needed) 
PSA 
Patient Self-Assessment 
RR 
Relative Risk 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SI 
Simple Imputation 
SOP 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reactions 
TEAE 
Treatment Emergent Adverse Event 
ULN 
Upper Limit of Normal Range 
UPT 
Urine Pregnancy Test 
UV 
Ultraviolet  
WBC 
White Blood Cell Count 
WOCBP 
Women of Child Bearing Potential 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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PROTOCOL SYNOPSIS 
TITLE: 
A Vehicle-Controlled, Double-Blind, Randomized Phase II 
Study of B244 Delivered as a Topical Spray to Determine 
Safety and Efficacy in Subjects with Mild to Moderate 
Rosacea. 
INVESTIGATIONAL 
PRODUCT 
B244 
Topical application 
STUDY ARMS 
1. B244  
2. Vehicle  
PURPOSE: 
The aim of the study is to assess the safety and efficacy of 
B244 in the treatment of mild to moderate rosacea. 
STUDY OBJECTIVES: 
Primary Objective:  
• To assess the safety and tolerability of B244 applied 
twice daily (BID) to the face for 8 weeks in subjects 
with mild to moderate rosacea. 
Exploratory Objectives:  
To assess the efficacy of B244 in subjects with mild to 
moderate rosacea. 
• Proportion of subjects with IGA improvement at 
Week 8 relative to baseline 
• Proportion of subjects with CEA improvement at 
Week 8 relative to baseline 
• Change in IGA from Week 8 to Baseline  
• Change in CEA from Week 8 to Baseline 
• Proportion of Subjects with improvement in IGA or 
CEA at Week 1, Week 4, and Week 12. 
• Change in Skindex 16 patient reported outcome from 
Baseline to Week 1, Week 4, Week 8, and Week 12. 
• Proportion of subjects with change in PSA at Week 1, 
Week 4, Week 8 and Week 12 from Baseline. 
• 
Evaluation of Telangiectasia Score at Baseline/Day1 
and Week 8  

 
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STUDY DESIGN: 
This is a Prospective, Vehicle Controlled, Double Blind, 
Multicenter, Randomized Phase II trial, comparing the effect 
of twice daily B244 application for 8 weeks vs. vehicle 
application on treatment of mild to moderate rosacea.  
At Screening and Baseline: 
• All subjects must have diagnosis of mild to 
moderate Rosacea. 
• Subjects must have IGA score of 2-3 and CEA 
score of 2-3 in order to qualify for the study.  
• After screening and recruitment, participants will 
be randomized to active or vehicle application for 
8 weeks.  
• Subjects will apply a total of 4 pumps of IP per 
application to the face twice-a-day  
• Randomization will be 1:1 B244 to Vehicle.   
• Subjects will be provided with cleanser and 
moisturizer to use for the duration of the study 
• All B244 randomized subjects will be treated at 
the dose of 4x109 cells/ml via spray application 
• Screening period will occur at Days -21 to -1  
• Washout will occur after Screening visit (Days -
14 to -1) 
• Randomization will occur during the baseline 
visit for the study  
• Efficacy will be assessed using Investigator 
Global Assessment (IGA) score, Clinician’s 
Erythema Assessment (CEA) score, Patient Self-
Assessment (PSA) score and patient reported 
Skindex 16. 
• Clinical assessments of response to treatment will 
be made at Week 1(Day 7), Week 4 (Day 28), and 
Week 8 (Day 56) 
• At Baseline visit, subjects will receive a kit 
containing the drug product.  Each bottle will be 
used for 2 weeks.  At Week 4, subjects will return 
the used bottles from the kit and will be issued a 
new kit of drug product to be used from Week 4 
through Week 8.    
• Subjects will stop applying investigational 
product at Week 8 and will return investigational 
product at that visit. 
• Subjects will come back for a 4-week post-
treatment follow up visit at Week 12 (Day 84).  

 
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• Participant's safety will be monitored throughout 
the study.  Safety will be assessed by monitoring 
reported adverse events, vital signs, clinical 
chemistry and hematology and overall tolerability 
of the investigational product.   
• Subjects would be required to discontinue the 
investigational product under the following 
circumstances:  
o Development of an intercurrent illness 
that would jeopardize the safety, or 
significantly affect assessments of clinical 
status of a subject 
o Either at the discretion of the Investigator 
or at the participant’s request 
o Development 
of 
any 
investigational 
product-related SAE  
o Suspected 
or 
laboratory-confirmed 
pregnancy 
STUDY POPULATION: 
 
Inclusion Criteria 
In order to be eligible for the study, subjects must have 
fulfilled all of the following criteria. 
 
1. 
Male and female subjects ≥18.  
2. 
A clinical diagnosis of mild to moderate facial 
rosacea.  
3. 
In good general health as determined by a thorough 
medical history, physical examination, clinical 
chemistry and hematology. 
4. 
Presence of 3 to 20 inflammatory lesions on the face 
(i.e. papules/pustules). 
5. 
A Clinician Erythema Assessment (CEA) score of 2-
3 at Screening and at Baseline Visits (prior to the 
investigational product application). 
6. 
Mild to Moderate IGA score of 2-3 at Screening and 
at Baseline Visits (prior to the investigational 
product application).  
7. 
Willing to refrain from using any topical or systemic 
treatments for the treatment of rosacea, other than 
the investigational product. 
8. 
Females of childbearing potential with a negative 
urine pregnancy test (UPT) at Screening and 

 
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Baseline/Day 1 (prior to the investigational product 
application).  
9. 
Ability to comprehend and comply with study 
procedures. 
10. Agree to commit to participate in the current 
protocol. 
11. Provide written informed consent prior to any study 
procedure being performed. 
STUDY POPULATION: 
 
Exclusion Criteria 
Any subject who meets one or more of the following criteria 
is excluded from this study:  
1. Female subjects who are pregnant, lactating or who 
are trying to conceive will be excluded from 
participation in this study. 
2. Any uncontrolled chronic or serious disease or 
medical condition that would normally prevent 
participation in a clinical trial, or, in the judgment of 
the Investigator, would put the subject at undue risk, 
or might confound the study assessments (e.g., other 
dermatological diseases), or might interfere with the 
subject’s participation in the study, (e.g., planned 
hospitalization during the study). 
3. Particular forms of rosacea (e.g., rosacea conglobata, 
rosacea fulminans, isolated rhinophyma, isolated 
pustulosis of the chin, Ocular rosacea Phymatous 
rosacea, Steroid-induced rosacea, severe rosacea 
including pyoderma faciale) or other concomitant 
facial dermatoses that are similar to rosacea such as 
peri-oral dermatitis, demodicidosis, facial keratosis 
pilaris, 
seborrheic 
dermatitis, 
acute 
lupus 
erythematosus, or actinic telangiectasia.   
4. Presence of more than two (2) nodulocystic lesions on 
the face. 
5. Presence of less than 3 and more than 20 inflammatory 
lesions on the face (i.e. papules/pustules). 
6. Severe papulopustular rosacea requiring systemic 
treatment. 
7. Participation at the time of eligibility assessment 
(Screening) in any other investigational  drug or 
device study or may have participated within 30 days 
prior to Screening.  

 
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8. Commencement of new hormonal therapy or dose 
change to hormonal therapy within 30 days prior to 
baseline.  Dose and frequency of use of any hormonal 
therapy started more than 30 days prior to baseline 
must remain unchanged throughout the study.  
Hormonal therapies include, but are not limited to, 
oral, injected or implanted hormonal methods of 
contraception or placement of an intrauterine device 
(IUD) or intrauterine system (IUS) or other forms of 
hormonal contraception that have comparable efficacy 
(e.g. 
vaginal 
ring 
or 
transdermal 
hormone 
contraception) 
9. Presence of beard or excessive facial hair at Screening 
which would interfere with the study treatments or 
study assessments and refusal to remove for duration 
of study.   
10. Carcinoid, Pheochromocytoma or other systemic 
causes of flushing.  
11. Known sensitivity to B244 or its components.  
12. Refusal to submit to blood and urine sampling for 
laboratory analysis.  
13. Treatment with the following: 
 
Prohibited Topical Treatments: 
Topical Treatment 
Prohibited Time Frame prior to Baseline 
Astringents or abrasives 
2 days 
RHOFADE™ (oxymetazoline HCl) Cream, 1% 
1 week 
Bleach baths 
1 week 
Mirvaso (brimonidine) topical cream 
1 week 
Vinegar  
1 week 
Topical Prescription/OTC medications for 
treatment of acne 
2 weeks  
Soolantra (Ivermectin 1%) topical cream 
1 week 
Topical Antibiotic 
2 weeks 
Use of over the counter antimicrobial  
2 weeks 
Benzoyl Peroxide  
2 weeks 
Immunomodulators  
4 weeks 
Oracea (doxycycline) topical cream  
2 weeks 
Corticosteroids  
4 weeks 
Electrocoagulation, Dermabrasion; Facial peels 
4 weeks 
Dermatologic/surgical procedure on the face 
4 weeks 

 
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Topical Prescription medications for the 
treatment of rosacea (e.g. azelaic acid, 
metronidazole, etc.) 
4 weeks 
Laser, Phototherapy, Photodynamic Therapy or 
IPL (intense pulsed light) treatment 
4 weeks 
Over the counter topical retinoid use on the face  
4 weeks 
 
Prohibited Systemic Treatments:  
Systemic Treatment  
Prohibited Time Frame prior to Baseline 
Exposed to excessive ultraviolet (UV) radiation 
and/or subject was unwilling to refrain from 
excessive exposure to UV radiation during the 
course of the study 
1 week 
Prescription anti inflammatory 
2 weeks 
Prescription/OTC anti-inflammatory 
medications (excludes low dose aspirin) 
2 weeks 
Systemic Antibiotics 
4 weeks 
Systemic medications for the treatment of 
rosacea (e.g. doxycycline, tetracycline, 
macrolides) 
4 weeks 
 
Prescription medications for treatment of acne 
4 weeks 
Corticosteroids (oral or injectable) 
4 weeks 
Immunomodulators 
12 weeks 
Oral retinoid use (e.g., isotretinoin), vitamin A 
supplements greater than 10,000 units/day 
6 months 
 
STATISTICAL ANALYSIS: 
Analysis Populations: 
• 
Safety Population: The safety population includes 
all randomized subjects who received investigational 
product. 
• 
Modified Intent-to-Treat (mITT) Population: A 
modified intent-to-treat population includes all 
subjects who are randomized, applied at least one 
dose of assigned product, and returned for at least one 
post-baseline evaluation visit. 
• 
Per Protocol (PP) Population: The PP population 
includes all randomized subjects who met all 
inclusion/exclusion criteria, were compliant with the 
assigned study treatment, returned to the study site 
for the primary endpoint visit within the specified 
window (±2 days) OR discontinued from the study as 

 
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a treatment failure, and did not have any major 
protocol violations.  Subjects who administered at 
least 50 % of IP, have at least one baseline and post 
baseline in clinic visit and did not have any major 
protocol violations.  
Efficacy Analysis: 
• IGA score at Baseline to Week 1, Week 4, Week 8 and 
Week 12 
• CEA score at Baseline to Week 1, Week 4, Week 8 and 
Week 12. 
• Skindex 16 patient reported outcome from Baseline to 
Week 1, Week 4, Week 8 and Week 12 
• PSA score at Baseline to Week 1, Week 4, Week 8 and 
Week 12. 
Safety & Tolerability Analysis:  
Safety and tolerability endpoints will consist of all adverse 
events reported during the study duration. 
Exploratory Endpoints: 
IGA treatment success, defined as “clear” or “almost clear” 
with a 2-grade improvement in IGA score from baseline to the 
end of treatment. 
CEA treatment success, defined as “clear” or “almost clear” 
with a 2-grade improvement in CEA score from baseline to the 
end of treatment. 
 
 
 

 
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STUDY FLOWCHART 
Figure 1.  Study Flowchart 
 
STUDY SCHEMA 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Male and Female subjects with clinical diagnosis of mild to 
moderate rosacea 
Randomized 
Vehicle 
Treatment 
Clinical Assessments at: 
Baseline, Weeks 1,4, 8 
End of Study visit/Clinical Assessment at Week 12 
B244 
Treatment 
Screening visit 
-21 to -14 
Washout phase 
-14 to -1 
Baseline visit 1 

 
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SCHEDULE OF ACTIVITIES  
Table 1: Schedule of Study Activities  
 
 
 
Visit Name 
Screening 
Baseline/ 
DAY 1 
Week 1 
Week 4 
Week 8 
Week 12/ End 
of Study Visit 
Early 
Termination 
Visit 
Visit number 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
 
Visit window in days 
-21 to -1 
1 
7+/-2 
28 +/- 2 
56 +/- 2 
84 +/- 2 
 
Informed Consent 
X 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
Physical Exam 
X 
X 
 
 
 
X 
X 
 BP & Pulse2 
X 
X 
X 
X 
X 
X 
X 
Urine pregnancy test for WOCBP1 
X 
X 
X 
X 
X 
X 
X 
Clinical chemistry and hematology and urinalysis3 
X 
X 
 
X 
X 
 
X 
Biomarkers4 
 
X 
 
 
X 
 
X 
CEA 
X 
X 
X 
X 
X 
X 
X 
IGA 
X 
X 
X 
X 
X 
X 
X 
Skindex 16 
X 
X 
X 
X 
X 
X 
X 
PSA score 
X 
X 
X 
X 
X 
X 
X 
Telangiectasia Evaluation 
 
X 
 
 
X 
 
X 
Fitzpatrick skin type 
X 
 
 
 
 
 
 
IWRS 
 
X 
 
X 
 
 
 
Dispense Investigational product to Subject 5/6 
 
X 
 
X 
 
 
 
Collect Investigational product from Subject5 
 
 
 
X 
X 
 
X 

 
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1. Urine pregnancy test for WOCBP will be done at every visit. 
2. Blood pressure readings will be obtained at every visit.  Subject should be allowed to rest for more 
than 5 minutes sitting, then BP measurements and pulse (x3) will be performed, using the non-
dominant arm with a calibrated electronic sphygmomanometer.  The average of the second and third 
readings will be documented. 
3. Subjects should fast for at least 8 hours before the test.  Laboratory work includes: hematology and Lipid 
Panel, Albumin, Alkaline Phos, ALT, AST, Total Bilirubin, BUN, BUN: Creatinine ratio, Calcium, 
Chloride, Creatinine, eGFR, Glucose, Potassium, Sodium, Uric Acid, and urinalysis.  HIV Ab, HCV Ab, 
HBsAg. will only be done at screening. 
4. Subjects should fast for at least 8 hours before the test.   
5. Weight of the investigational product kit will be obtained at the Baseline visit.  Study staff will be 
asked to weigh all dispensed bottles without the carton box PRE- FIRST DOSE.  Weight will be 
recorded in grams.  
6. Subjects will be asked to bring all dispensed bottles back for the Week 4 and Week 8 visits.  Upon 
return for the study visit, all bottles will be weighed again without the carton box.  Subjects will be 
asked to apply the investigational product twice daily.  First investigational product application will 
happen at the site under medical supervision.  
7. Subjects will be counseled on the use of study medication and answer any questions subject may have. 
8. Subjects will be asked to fill out study diary for the duration of the study. 
9. Cleanser and moisturizer will be dispensed at the Baseline visit.  Subjects will be asked to refrain, if 
possible, from using any other cleanser and/or moisturizer on their face and apply the provided product 
while they are participating in the trial.  Any left over moisturizer /cleanser will be collected at Week 8 
visit, at which point subjects will be asked to go back to their regular routine. 
 
 
Visit Name 
Screening 
Baseline 
Week 1 
Week 4 
Week 8 
Week 12/End 
of Study Visit 
Early 
Termination 
Visit 
Visit number 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
 
Visit window in days 
-21 to -1 
1  
7+/-2 
28 +/- 2 
56 +/- 2 
84 +/- 2 
 
Investigational product Compliance5 
 
X 
 
X 
X 
 
X 
Study Cleanser and moisturizer dispensation9 
 
X 
 
X 
 
 
 
Study Cleanser and moisturizer collection 
 
 
 
 
X 
 
X 
Study Diary8 
 
X 
X 
X 
X 
 
X 
Study Counseling7 
 
X 
X 
X 
X 
 
 
AE Collection and Assessment 
X 
X 
X 
X 
X 
X 
X 

 
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PRINCIPAL CONTACTS 
 
Clinical Protocol and Conduct 
Inquiries 
AOBiome 
Masha Gaber 
Clinical Operations 
mgaber@aobiome.com 
Sponsor’s Medical Expert for the 
Trial 
Name: Larry Weiss, MD 
Title: Chief Medical Officer 
Email: lweiss@aobiome.com 
Reporting of Serious Adverse 
Events (SAEs) 
Biorasi Safety and Pharmacovigilance 
19495 Biscayne Blvd., Suite #900 
Aventura, FL 33180 
Fax: +1 (786) 221-3531 
RB244-001-safety@biorasi.com 
 
 

 
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1 BACKGROUND AND RATIONALE 
1.1 Background  
Rosacea is a chronic dermatologic disorder that primarily affects convexities of the central face 
with skin lesions located on the cheeks, chin, nose, and central forehead.  An estimated 14 
million Americans have rosacea.1 Rosacea prevalence is highest (between 2.7 and 10%) in 
patients with  northern European or Celtic heritage.2 Rosacea is more common among female 
patients, and incidence peaks between the ages of 30 and 50 years. In 2002, National Rosacea 
Society Expert Committee established a standard classification system of rosacea subtypes 
based on the clinical characteristics.  The four basic stages of the disease are 
erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), phymatous rosacea, 
ocular rosacea and one variant rosacea, granulomatous rosacea (GR) 3.  
Diagnostic criteria of rosacea include primary features such as flushing, persistent central facial 
erythema, pustules, papules in the central facial distribution, thickened skin with irregular 
contours overlying the ears, cheeks, chin (gnathophyma), forehead (metophyma), and nose 
(rhinophyma), watery, burning, dry, itchy, and light sensitive ocular sensation with a bloodshot 
appearance.3 
Men are more prone to the phymatous skin changes associated with rosacea.  Rosacea patients 
experience periods of relapses and remissions.  There are trigger factors that can lead to a 
relapse such as: sun exposure, stress, hot weather, alcohol, spicy foods, exercise, wind, hot 
baths, cold weather, hot drinks and certain skin care products and medications.4 
Pathogenic mechanisms that lead to the development of the skin lesions have not yet been fully 
elucidated.  However, the pathology of rosacea may be multifactorial:  abnormal vascular and 
immune system responses; hair follicle mite Demodex folliculorum and Demodex brevis; 
bacteria such as H. pylori and Bacillus oleronius; prolonged steroid use and other aggravating 
trigger factors like sun and stress.5,6  Gallo and colleagues found an abnormally high level of 
the naturally occurring antimicrobial peptide cathelicidins upon histopathological staining in 
the skin of patients with rosacea.7 Over the years, there have been numerous attempts to 
connect etiopathogenesis of rosacea with the presence of some microorganisms, specifically 
Demodex mite and bacteria. It has been well documented, that people with rosacea have higher 
density of Demodex mites on their skin compared to controls8,9. 
In addition, presence of Demodex mite on facial skin has also been associated with itching, 
with or without erythema10.  
Bacillus bacteria found in the Demodex mite stimulate immune response and produce an 
antigen that could be responsible for the tissue inflammation11.  
Epidermal cells and sebum components are the main food sources for the Demodex mites, 
therefore these ecto-parasites are found in the areas rich in sebaceous glands, such as the face, 
including cheeks, nose, chin and forehead12.  

 
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It is thought that Demodex mites may carry the bacteria into areas of the face most susceptible 
to rosacea changes, which in turn may produce higher density of bacteria and thus create an 
inflammatory response11.  
In the process of destroying epithelial cells, Demodex penetrates the dermis, stimulating Toll 
Like receptors (TLR) leading to increased skin inflammation and hyperreactivity to 
environmental stimuli.  
1.2 Rationale of the Study  
The proposed study is aimed to evaluate the safety and efficacy of B244 topical spray.  A 
Vehicle-Controlled, Double-Blind, Multicenter, Randomized Study Design has been Selected 
in Order to Evaluate the Safety and Efficacy of the B244 Investigational product in the 
Treatment of Mild-to-Moderate Rosacea.  
There is no cure for rosacea and treatment is aimed at alleviating the symptoms.  Topical or 
oral medications are generally prescribed for mild to moderate papulopustular rosacea.  These 
topical medications include: metronidazole, azelaic acid, sodium sulfacetamide and sulfur, 
erythromycin, and tretinoin8.  Currently these approved topical medications may cause local 
irritation to the skin.  The oral medications prescribed for severe disease include tetracycline, 
doxycycline, minocycline, erythromycin and metronidazole.  The systemic therapies may 
result in systemic adverse events such as gastrointestinal upset and photosensitivity.  
It is believed, that topical application of Ammonia-Oxidizing Bacteria (AOB) will reduce 
survival of pathogenic bacteria present on the skin and thus improve rosacea symptoms in those 
affected by it.  
AOBs are essential for the initial step in environmental nitrification processes, specifically the 
oxidation of ammonia (NH3) to nitrite (NO2-).  Nitrosomonas are Gram-negative 
chemolithoautotrophic betaproteobacteria that obtain energy solely from NH3 oxidation, while 
fixing CO2 for their carbon needs13.  Oxidation of NH3 proceeds in two steps (Figure 2) leading 
to sequential generation of hydroxylamine (NH2OH) and NO2- that require two enzyme 
complexes: the membrane-bound ammonia monooxygenase (AMO) comprised of subunits 
AmoA, AmoB and AmoC; and the periplasmic NH2OH oxidoreductase (HAO).  In addition to 
high NO2- levels, NH3 oxidation leads to nitric oxide (NO) and N2O production through two 
independent pathways downstream of NH2OH production: nitrifier denitrification and NH2OH 
oxidation14. 
 
 

 
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Figure 2 
Nitrifier Denitrification Pathway 
 
B244 is a purified strain of Nitrosomonas eutropha, designated D23, originally isolated from 
soil samples.  Sequencing of the B244 genome revealed a distinct genetic profile from that of 
other published Nitrosomonas strains and AOB genomes.  Based on in vitro co-culture studies, 
B244 was able to reduce survival of pathogenic bacteria.  Nitrite generation from ammonia 
concurrently with medium acidification by B244 led to strong antibacterial effects and a 
marked reduction (~100-fold) in viable counts of methicillin-resistant Staphylcoccus aureus 
and Pseudomonas aeruginosa, two pathogens frequently isolated from infected skin and 
wound sites.  In contrast, control cultures with B244 in the absence of ammonium or with heat-
killed B244 supplemented with ammonium, had no antibacterial effects.  The unique metabolic 
and antimicrobial activity of Nitrosomonas, in combination with their lack of virulence render 
these bacteria as attractive candidates for topical delivery of nitrite and nitric oxide on human 
skin with potential to improve health in both normal and abnormal skin conditions or wound 
sites.  NO-releasing drugs or NO donors have also shown activity against Propionibacterium 
acnes and other pathogenic bacteria, anti-inflammatory activity, and inhibition of lipogenesis 
by insulin-stimulated immortal sebocytes15, 16. 
 
1.2.1 Clinical Experience 
B244 is being developed as a ‘live topical’ to provide a natural source of AOB and NO/NO2 
to the human skin.  A phase 1b/2a clinical trial entitled A Double Blind, Vehicle-Controlled, 
Single Center, Randomized, Sequential, Ascending 14-Day Multiple Dose Study in Subjects 
with Acne Vulgaris to Evaluate the Safety, Tolerability and Preliminary Efficacy of B244 
Delivered as a Topical Spray was completed in 2016 where 36 participants with clinical 
diagnosis of facial acne vulgaris were randomized to receive ascending doses of investigational 
product (IP) over 14 days. Safety analyses have been completed and there have been no 
attributable drug related SAEs reported.  In addition, a Phase 2b/3 clinical trial entitled A 
Randomized, Double Blinded, Phase IIb/III, Decentralized Study of B244 Delivered as a 
Topical Spray to Determine Safety and Efficacy in Participants with Mild to Moderate Acne 
Vulgaris in 372 patients with clinical diagnosis of facial acne has been completed.  B244 was 
safe and well tolerated with no attributable drug related SAEs.  Efficacy was supported by 
statistically significant 2-point reduction in IGA with B244 and a trend in the reduction of the 
number of inflammatory lesions compared to vehicle.  

 
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Additionally, other topical development programs with B244 include hypertension and atopic 
dermatitis.  A study titled, “A Prospective, Controlled, Double Blinded, Multicenter, 
Randomized, Vehicle controlled, Phase II Study of B244 delivered as a topical spray to 
Determine Safety and Efficacy in Subjects with elevated blood pressure” has been completed.  
Safety data indicated that B244 was safe and well tolerated.  Overall, 16% subjects experienced 
at least 1 TEAE during the study with comparable incidence in the B244 and Vehicle groups.  
The most commonly reported types of events in the study were nervous system disorders (5% 
incidence) and investigations (4% incidence).  No TEAE was reported in more than 1 subject 
in the B244 group.  There was no apparent increase in the incidence of TEAEs with increasing 
dose in either treatment group.  All TEAEs were Grade 1 or Grade 2 in severity.  There were 
no deaths in the study.  Overall, there were no unexpected safety signals observed following 
treatment with B244. 
A study titled, “A Prospective, Vehicle Controlled, Double Blind, Multicenter, Randomized, 
Phase II Study of B244 Delivered as a Topical Spray to Determine Safety and Efficacy in 
Subjects with Mild to Moderate Atopic Dermatitis” is currently enrolling subjects.  
 
 
Furthermore, a nasal spray of B244 is being developed for treatment of allergic rhinitis and 
migraines.  A rat toxicology study performed by intranasal administration of B244 twice daily 
for 28 days found that B244 was safe and well tolerated in rats at levels of up to the maximum 
dose 8x109 cell/mL.  A study titled, “A Prospective, Controlled, Double Blinded, Single 
Center, Randomized, 3 arm, Phase 1b/2a Study to Assess the Safety, Tolerability, and 
Preliminary Efficacy of B244 Delivered as an Intranasal Spray in Healthy Volunteers and 
Subjects with Seasonal Allergic Rhinitis” has been initiated.  In addition, a study titled “A 
Prospective, Randomized, Vehicle-Controlled, Double-Blind, Phase 2 Study to Assess the 
Safety, Tolerability, and Efficacy of B244 Delivered as an Intranasal Spray for Preventive 
Treatment in Subjects with Episodic Migraine” is being initiated.  
 
1.2.2 Safety Profile 
To date, there have been no reported infections or health risks associated with topical 
application or ingestion of Nitrosomonas species.  The absence of any illnesses attributed to 
these bacteria despite our widespread exposure indicates that they pose a minimal health risk, 
if any at all.  Infection or tissue damage by Nitrosomonas is unlikely, because the sequenced 
genomes of several Nitrosomonas and other AOB lack genes encoding cytotoxins, or other 
known bacterial virulence factors.  Further, AOB are slow growing, as compared to most 
heterotrophic bacteria, with optimum doubling times of 8 hours or higher.  In particular, 
Nitrosomonas growth is rate limited by the availability of ammonia requiring the oxidation of 
27 moles NH3/mole CO2 fixed.  Due to their dependence on ammonia for their growth, the 
numbers of Nitrosomonas on the skin will be necessarily limited and naturally regulated by the 
amount of ammonia produced in sweat.  This would ensure that the amount of nitrite and NO 
generated would be relatively low, without any adverse effects. 
 
 

 
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2 STUDY OBJECTIVES  
2.1 Study Objectives 
2.1.1 Primary Objective 
• 
To assess the safety and tolerability of B244 applied twice daily (BID) to the 
face for 8 weeks in subjects with mild to moderate rosacea. 
2.1.2 Exploratory Objectives 
• To assess the efficacy of B244 in subjects with mild to moderate rosacea. 
o Proportion of subjects with IGA improvement at Week 8 relative to 
baseline. 
o Proportion of subjects with CEA improvement at Week 8 relative to 
baseline. 
o Change in IGA from Week 8 to Baseline.  
o Change in CEA from Week 8 to Baseline. 
o Proportion of Subjects with improvement in IGA or CEA at Week 1, 
Week 4, and Week 12. 
o Change in Skindex 16 patient reported outcome from Baseline to Week 
1, Week 4, Week 8, and Week 12. 
o Proportion of subjects with change in PSA at Week 1, Week 4, Week 8 
and Week 12 from Baseline. 
o Evaluation of Telangiectasia Score at Baseline/Day 1 and Week 8  
 
3 STUDY ENDPOINTS 
3.1 Safety & tolerability 
• Safety and tolerability endpoints will consist of all adverse events reported during the 
study duration. 
3.2 Efficacy 
• IGA score at Baseline to Week 1, Week 4, Week 8 and Week 12. 
• CEA score at Baseline to Week 1, Week 4, Week 8 and Week 12. 
• Skindex 16 patient reported outcome from Baseline to Week 1, Week 4, Week 8 and 
Week 12. 
• PSA score at Baseline to Week 1, Week 4, Week 8 and Week 12. 

 
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3.3 Exploratory  
• IGA treatment success, defined as “clear” or “almost clear” with a 2-grade 
improvement in IGA score from baseline to the end of treatment. 
• CEA treatment success defined as “clear” or “almost clear” with a 2-grade 
improvement in CEA score from baseline to the end of treatment. 
 
4 INVESTIGATIONAL PLAN 
4.1 Study Design 
• 
This is a Prospective, Vehicle Controlled, Double Blind, Multicenter, Randomized 
Phase II trial, Comparing the effect of twice daily B244 application for 8 weeks vs. 
vehicle application on treatment of mild to moderate rosacea.  
• 
We will enroll approximately 130 subjects and complete 104 subjects. 
• 
At Screening and Baseline: 
• All subjects must have clinical diagnosis of mild to moderate rosacea. 
• Subjects must have IGA score of 2-3 and CEA score of 2-3 in order to qualify for 
the study.  
• After screening and recruitment, participants will be randomized to active or vehicle 
application for 8 weeks.  
• Subjects will apply a total of 4 pumps of IP per application to the face twice-a-day.  
• Randomization will be 1:1 B244 to Vehicle.   
• Subjects will be provided with cleanser and moisturizer to use for the duration of the 
study. 
• All B244 randomized subjects will be treated at the dose of 4x109 cells/ml via spray 
application. 
• Screening will occur at Days -21 to -1. 
• Washout will occur after Screening visit (Days -14 to -1). 
• Randomization will occur during the baseline visit for the study (Day 1). 
• Efficacy will be assessed using Investigator Global Assessment (IGA) score, Clinician’s 
Erythema Assessment (CEA) score, Patient Self-Assessment (PSA) score and patient 
reported Skindex 16. 
• Clinical assessments of response to treatment will be made at Week 1(Day 7), Week 4 
(Day 28), and Week 8 (Day 56). 
• At Baseline visit, subjects will receive a kit containing the drug product.  Each bottle 
will be used for 2 weeks.  At Week 4, subjects will return the used bottles from the kit 
and will be issued a new kit of drug product to be used from Week 4 through Week 8.    
• Subjects will stop applying investigational product at Week 8 and will return 
investigational product at that visit. 

 
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• Subjects will come back for a 4-week post-treatment follow up visit at Week 12 (Day 
84).  
• Participant's safety will be monitored throughout the study.  Safety will be assessed by 
monitoring reported adverse events, vital signs, clinical chemistry and hematology and 
overall tolerability of the investigational product.   
• Subjects would be required to discontinue the investigational product under the 
following circumstances:  
o Development of an intercurrent illness that would jeopardize the safety, or 
significantly affect assessments of clinical status of a subject 
o Either at the discretion of the Investigator or at the participant’s request 
o Development of any investigational product-related SAE  
o Suspected or laboratory-confirmed pregnancy 
4.2 Number of Subjects and Sites  
Approximately 130 subjects are planned to be enrolled, and assuming a 20% drop out rate, the 
planned overall sample size for this clinical trial is approximately 104 adult male and female 
subjects, 18 years of age and older with mild to moderate rosacea.  Subjects will be randomized 
at a 1:1 ratio (B244: Vehicle) at about 8 clinical research centers in the United States.   
 
5 SELECTION AND WITHDRAWAL OF STUDY POPULATION 
5.1 Eligibility Criteria 
Subjects who satisfy ALL of the following inclusion and have NONE of the following 
exclusion criteria may be enrolled in the study: 
 
5.1.1 Inclusion Criteria 
1. 
Male and female subjects ≥18.  
2. 
A clinical diagnosis of mild to moderate facial rosacea.  
3. 
In good general health as determined by a thorough medical history, physical 
examination, clinical chemistry and hematology. 
4. 
Presence of 3 to 20 inflammatory lesions on the face (i.e. papules/pustules). 
5. 
A Clinician Erythema Assessment (CEA) score of 2-3 at Screening and at Baseline 
Visits (prior to the investigational product application). 
6. 
Mild to Moderate IGA score of 2-3 at Screening and at Baseline Visits (prior to the 
investigational product application).  
7. 
Willing to refrain from using any topical or systemic treatments for the treatment of 
rosacea, other than the investigational product. 
8. 
Females of childbearing potential with a negative urine pregnancy test (UPT) at 
Screening and Baseline/Day 1 (prior to the investigational product application).  

 
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9. 
Ability to comprehend and comply with study procedures. 
10. Agree to commit to participate in the current protocol. 
11. Provide written informed consent prior to any study procedure being performed. 
 
5.1.2 Exclusion Criteria 
Any subject who meet one or more of the following criteria are excluded from this study.  
1. Female subjects who are pregnant, lactating or who are trying to conceive will be 
excluded from participation in this study. 
2. Any uncontrolled chronic or serious disease or medical condition that would normally 
prevent participation in a clinical trial, or, in the judgment of the Investigator, would 
put the subject at undue risk, or might confound the study assessments (e.g., other 
dermatological diseases), or might interfere with the subject’s participation in the study, 
(e.g., planned hospitalization during the study). 
3. Particular forms of rosacea (e.g., rosacea conglobata, rosacea fulminans, isolated 
rhinophyma, isolated pustulosis of the chin, Ocular rosacea Phymatous rosacea, 
Steroid-induced rosacea, severe rosacea including pyoderma faciale) or other 
concomitant facial dermatoses that are similar to rosacea such as peri-oral dermatitis, 
demodicidosis, facial keratosis pilaris, seborrheic dermatitis, acute lupus 
erythematosus, or actinic telangiectasia.   
4. Presence of more than two (2) nodulocystic lesions on the face. 
5. Presence of less than 3 and more than 20 inflammatory lesions on the face (i.e. 
papules/pustules). 
6. Severe papulopustular rosacea requiring systemic treatment. 
7. Participation at the time of eligibility assessment (Screening) in any other 
investigational  drug or device study or may have participated within 30 days prior to 
Screening.  
8. Commencement of new hormonal therapy or dose change to hormonal therapy within 
30 days prior to baseline.  Dose and frequency of use of any hormonal therapy started 
more than 30 days prior to baseline must remain unchanged throughout the study.  
Hormonal therapies include, but are not limited to, oral, injected or implanted hormonal 
methods of contraception or placement of an intrauterine device (IUD) or intrauterine 
system (IUS) or other forms of hormonal contraception that have comparable efficacy 
(e.g. vaginal ring or transdermal hormone contraception) 
9. Presence of beard or excessive facial hair at Screening which would interfere with the 
study treatments or study assessments and refusal to remove for duration of study.   
10. Carcinoid, Pheochromocytoma or other systemic causes of flushing.  
11. Known sensitivity to B244 or its components.  
12. Refusal to submit to blood and urine sampling for laboratory analysis.  
13. Treatment with the following: 
 
Prohibited Topical Treatments: 

 
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Topical Treatment 
Prohibited Time Frame prior to Baseline 
Astringents or abrasives 
2 days 
RHOFADE™ (oxymetazoline HCl) Cream, 
1% 
1 week 
Bleach baths 
1 week 
Mirvaso (brimonidine) topical cream 
1 week 
Vinegar  
1 week 
Topical Prescription/OTC medications for 
treatment of acne 
2 weeks 
Soolantra (Ivermectin 1%) topical cream 
1 week 
Topical Antibiotic 
2 weeks 
Use of over the counter antimicrobial  
2 weeks 
Benzoyl Peroxide  
2 weeks 
Immunomodulators  
4 weeks 
Oracea (doxycycline) topical cream  
2 weeks 
Corticosteroids  
4 weeks 
Electrocoagulation, Dermabrasion; Facial 
peels 
4 weeks 
Dermatologic/surgical procedure on the face 
4 weeks 
Topical Prescription medications for the 
treatment of rosacea (e.g. azelaic acid, 
metronidazole, etc.) 
4 weeks 
Laser, Phototherapy, Photodynamic 
Therapy or IPL (intense pulsed light) 
treatment 
4 weeks 
Over the counter topical retinoid use on the 
face 
4 weeks 
 
Prohibited Systemic Treatments:  
Systemic Treatment  
Prohibited Time Frame prior to Baseline 
Exposed to excessive ultraviolet (UV) 
radiation and/or subject was unwilling to 
refrain from excessive exposure to UV 
radiation during the course of the study 
1 week 
Prescription anti inflammatory 
2 weeks 
Prescription/OTC anti-inflammatory 
medications (excludes low dose aspirin) 
2 weeks 
Systemic Antibiotics 
4 weeks 
Systemic medications for the treatment of 
rosacea (e.g. doxycycline, tetracycline, 
macrolides) 
4 weeks 
 
Prescription medications for treatment of 
acne 
4 weeks 

 
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Corticosteroids (oral or injectable) 
4 weeks 
Immunomodulators 
12 weeks 
Oral retinoid use (e.g., isotretinoin), vitamin 
A supplements greater than 10,000 units/day 
6 months 
 
5.2 Study Withdrawal  
A subject may voluntarily withdraw from the study at any time and for any reason without 
prejudice to his or her future medical care.  The Investigator, Sponsor, or Medical Monitor 
may also withdraw a subject at any time if it is medically necessary or in the interest of 
subject’s safety.  Additional reasons for premature discontinuation of investigational product 
may include adverse events and major non-compliance with study procedures, as described 
below.  The withdrawal of a subject from investigational product by the Investigator will be 
discussed with the Medical Monitor before the subject stops investigational product, whenever 
possible. 
A subject will be discontinued from this study if any of the following criteria are met: 
• Withdrawal of consent by the subject is received. 
• In the opinion of the Investigator, Medical Monitor or Sponsor, it is not in the 
subject’s best interests to continue in the study. 
• Significant non-compliance with study procedures that would interfere with the study 
results or increase the subject’s risks in the study, as determined by the Investigator.  
• Development of an intercurrent illness that would jeopardize the safety, or 
significantly affect assessments of clinical status of a subject. 
• Development of any investigational product-related SAE.  
• Suspected or laboratory-confirmed pregnancy. 
Subjects who discontinued early from the study due to lack of treatment effect after completing 
at least four weeks of treatment (Day 28) will be included in the mITT and PP population as 
treatment failures and the change in IGA and CEA from the baseline visit to the last completed 
visit prior to discontinuation due to lack of efficacy will be carried forward in the primary 
endpoint analysis. Subjects discontinued early for other reasons will be excluded from the PP 
population.  
5.3 Early Discontinuation 
If a subject discontinues prematurely, the Investigator will perform Early Termination (ET) 
visit, capturing the reason for discontinuation.   
If a subject does not return for a scheduled visit, every effort will be made to contact the subject 
and document the End of Study visit assessments.  The Investigator must document the primary 
reason for discontinuation of a study subject in the source document and on the appropriate 
electronic case report form (eCRF). 

 
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Randomized subjects who discontinue due to an adverse event will have all events documented 
and followed to satisfactory resolution, as detailed in Section 12. 
6 INVESTIGATIONAL PRODUCT TREATMENT AND ADMINISTRATION 
6.1 Identity of Investigational product(s) 
The term investigational product is used to refer to the B244 and vehicle drug products.  Please 
see the study Pharmacy Manual for full details. 
6.2 Investigational Product 
Under normal conditions of handling and administration, IP is not expected to pose significant 
safety risks to site staff.  A Material Safety Data Sheet describing the occupational hazards and 
recommended handling precautions will be provided to site staff if required by local laws or 
will otherwise be available from the Sponsor upon request. 
 
Investigational product must be stored in a secure area under the appropriate physical 
conditions for the product.  Access to and administration of the IP will be limited to the 
Investigator and authorized site staff.  Investigational product must be dispensed or 
administered only to participants enrolled in the study and in accordance with the protocol. 
 
The Investigator is responsible for study treatment accountability, reconciliation, and record 
maintenance.  The Investigator or designated site personnel must maintain study treatment 
accountability records throughout the course of the study.  The responsible person(s) will 
document the amount of study treatment received from and returned to the Sponsor and the 
amount administered to participants.  The required accountability unit for this study will be the 
bottle.  Discrepancies are to be reconciled or resolved.  
 
Product name: 
B244, 30ml/bottle 
Vehicle, 30ml/bottle 
Dosage form: 
B244 suspension 
Vehicle solution 
Unit dose strength: 
4x109 cfu/ml 
50nM Na2HPO4-2mM 
MgCl2 (pH 7.6) 
Route/administration/duration: Topical application BID 
for 8 weeks 
Topical application BID 
for 8 weeks 
Dosing instruction: 
4 pumps of spray to 
saturate the entire face 
applied BID.  
Applications should 
occur in the morning and 
at night for 8 weeks. 
4 pumps of spray to 
saturate the entire face 
applied BID.  
Applications should 
occur in the morning and 
at night for 8 weeks. 
Physical description: 
Odorless, cloudy, light 
pink suspension 
Odorless, clear, and 
colorless solution 

 
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Manufacturer/source of 
procurement: 
AOBiome, LLC 
AOBiome, LLC 
6.3 Packaging and Labeling 
The investigational product bottles to be dispensed to the subject will be packaged and labeled 
in accordance with Good Manufacturing Practice.  Each individual bottle of the investigational 
product will be provided in a subject’s kit.  The contents of the label will be in accordance with 
all applicable regulatory requirements.  B244 and matching vehicle will be packaged in 
identical 30 ml white bottles.  
6.4 Storage of the Investigational product at Site 
All investigational drug supplies in the study will be stored in a secure, refrigerated (2-8oC) 
safe place, under the responsibility of the Investigator or other authorized individual.  
The Investigator will maintain temperature monitoring of the investigational product with daily 
temperature readings.  All temperature excursions must be reported to the Sponsor using the 
Temperature Excursion log.  If the investigational product was exposed to the temperature 
excursion outside the range of 2-8oC, but for the period greater than 24 hours, the 
investigational product must be quarantined until the Sponsor’s approval on future use.  Please 
refer to the Pharmacy Manual for additional detail on the Temperature Excursions and 
temperature monitoring during the shipment and storage at the site pharmacy.  
6.5 Treatment Assignment (Randomization) 
Randomization will be performed using an Interactive Web Response System (IWRS) at the 
time the subject has met all eligibility criteria and is ready for enrollment.  Subjects will be 
randomized in a 1:1 ratio to receive either B244 or vehicle and will be stratified by site. 
Interactive Web Response System (IWRS) will assign subjects to the treatment arm and specify 
the kit number to be dispensed.  
The randomization scheme will be generated and held by the independent third party 
throughout the conduct of the study and will not be available to the Sponsor, Investigator, or 
study staff, or to clinical staff who could have an impact on the outcome of the study. 
6.6 Blinding/Unblinding Procedures 
This is a double-blind study, thus Sponsor, CRO, site staff, study monitors, and subjects will 
be blinded to the randomization scheme.  The packaging of the investigational product 
products will be identical in appearance to make difference in treatment less obvious to the 
subjects.  
The blinding scheme for each set of the investigational product will be available to the FDA 
or other regulatory agency investigators at the time of site inspection to allow for verification 
of the treatment identity of each subject. 

 
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The blinding code must not be broken except in emergency situations for which the 
identification of the study treatment of a subject is required by the Investigator to complete a 
serious adverse event report.  In such situations, the Investigator will use the IWRS system in 
order to unblind the treatment for the individual subject.  Unblinded information will be held 
by designated individual(s), and the date and reason for breaking the blind must be recorded 
and reported appropriately to the IRB.  
 
As the study is blinded, the Investigator should promptly document and explain to the Sponsor 
and Medical Monitor any premature unblinding (e.g., accidental unblinding, unblinding due to 
a serious adverse event) of the investigational product(s). 
The Investigator may unblind a participant’s treatment assignment only in the case of 
emergency or in the event of a serious medical condition when knowledge of the study 
treatment is essential for the appropriate clinical management or welfare of the participant, as 
determined by the Investigator.  It is preferred (but not required) that the Investigator first 
contacts the Medical Monitor to discuss options before unblinding the participant’s treatment 
assignment.  The Investigator must notify the Sponsor as soon as possible when a participant’s 
treatment assignment is unblinded without revealing the treatment assignment of the unblinded 
participant unless that information is deemed important for the safety of participants currently 
in the study.  The date and reason for the unblinding must be documented in the participant’s 
study record.  
The Investigator may unblind the treatment assignment for any participant with an SAE.  If the 
SAE requires that an expedited regulatory report be sent to one or more regulatory agencies, a 
copy of the report, identifying the participant’s treatment assignment, may be sent to clinical 
Investigators in accordance with local regulations and/or Sponsor policy. 
6.7 Investigational product Dispensation, Application, and Home Storage 
At Baseline visit, Subjects will receive a kit containing two 30 ml white bottles.  Each bottle 
will be used for 2 weeks.  At Week 4, subjects will return the used bottles from the kit and will 
be issued a new kit of two 30mL white bottles to be used from Week 4 through Week 8.   
Subjects will store the unused bottle in the refrigerator until utilized.  The bottle which is being 
used for treatment at a given week may be kept at ambient temperature to be used during the 
treatment period. 
 
Subjects will be asked not to expose the treatment kit to conditions which are unnatural or 
harmful to the product, such as excessive heat (temperatures over 77°F (25°C) and freezing 
temperatures (at 0oC).  Subjects may travel with their study medication but should not leave it 
in the hot car, outside in the cold temperatures etc.  Subjects will also be asked not to tamper 
or cause damage to investigational product bottle. 
 
Each subject will be instructed by the Investigator on proper application technique.  The 
following application instructions will be provided to the subject: 
• Subjects will apply 4 pumps of investigational product to saturate their face in the 

 
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morning and 4 pumps of investigational product at night. 
• Subject should saturate the application area well. 
• Subjects will be asked to let the product air dry. 
• Subjects may not wash their face for 2 hours post morning application of the 
investigational product.  
• Participants may not bathe, shower or wash their face until morning post evening 
application of IP. 
• While in use, one spray bottle may be stored at ambient temperature.  The bottle that 
is not in current use by the subject, must be stored in the refrigerator.   
• DO NOT FREEZE. 
6.8 Accountability, Destruction and Return of Study Supplies 
In accordance with federal and local regulatory requirements, the Investigator and designated 
site personnel must document the amount of investigational product dispensed to study 
Subjects, the amount returned by study Subjects, and amount received and returned to the 
Sponsor, when applicable.  Product accountability records must be maintained throughout the 
course of the trial.  Any quality issue noticed with the receipt or use of an investigational 
product (deficient investigational product in condition, appearance, pertaining documentation, 
labeling, expiry date, etc.) should be promptly reported to the Sponsor, who will initiate a 
complaint procedure.  
All investigational product must be stored in a secure locked room with access limited to the 
Investigator and designated site personnel.  Study product is to be stored in a refrigerator 
between 2-8º C. Maintenance of a temperature log is required. 
Under no circumstances will the Investigator allow investigational product to be used other 
than as directed by this Clinical Trial Protocol, or dispose of investigational product without 
Sponsor direction.  
The Sponsor will supply sufficient quantities of the investigational product for the completion 
of this study. 
The study pharmacist or designated study personnel will maintain an Investigational Materials 
Accountability Record and a Subject Investigational Product Accountability Log itemizing all 
investigational product received, dispensed to and returned from each subject during the study.  
All dispensed bottles must be accounted for, and any discrepancies explained.  Study site 
should contact site Clinical Research Associate (CRA) or designee in case of any dispensing 
errors or if discrepancies are discovered. 
Prior to site closure and at appropriate intervals during the study, site CRA will perform 
investigational product accountability and reconciliation.  At the end of the study, the 
Investigator will retain all the original documentation regarding investigational product 
accountability, return, and copies will be sent to the Sponsor. 

 
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All unused and used investigational product tubes will be returned to the Sponsor or its 
designee for destruction at the end of the study. 
6.9 Treatment of Investigational Product Overdose 
The Sponsor does not recommend specific treatment for an overdose.  Washing with 
conventional cleanser and water will remove the product.  The Investigator will use clinical 
judgment to treat any overdose.  
6.10 Dose Changes  
No dose changes are anticipated. 
 
7 CONTRACEPTION REQUIREMENTS 
7.1 Contraception and Pregnancy Avoidance Measures 
Effective contraception is required for all women of childbearing potential (WOCBP) during 
study participation.  
Female subjects must be post-menopausal OR surgically sterile or using highly effective birth 
control methods (note below) with a negative urine pregnancy test at the Baseline Visit.  Male 
subjects must be willing to not attempt to conceive a child during the participation in the study. 
Acceptable forms of contraception include: 
Total abstinence; oral (birth control pills), intravaginal (e.g. NuvaRing®), implantable (e.g. 
Norplant®), injectable (e.g. Depo-Provera®) or transdermal (e.g. Ortho Evra®) contraception, 
intrauterine device (IUD), double-barrier (diaphragm or condom with spermicidal gel or foam) 
for one month prior to study enrollment or a vasectomized partner (6 months status post 
vasectomy). 
In case of use of oral contraception women should have been stable on the same pill for a 
minimum of 30 days before the baseline visit. 
If a subject, or female partner of male subject becomes pregnant during the participation in the 
study, the Investigator will immediately discontinue the Subject from the study and contact the 
Medical Monitor and the Sponsor.  Diligent efforts will be made to determine the outcome for 
all pregnancy exposures in the clinical trial.  Information on the status of the mother and the 
child will be forwarded to the Sponsor’s Safety Team using the Pregnancy Data Collection 
Form.  Generally, follow-up will occur within 6 to 8 weeks following the estimated delivery 
date.  Any premature termination of the pregnancy will be reported.  Detailed guidance on the 
reporting of Pregnancies will be provided in SAE and Pregnancy Reporting Guidance. 
Payment for all aspects of obstetrical care, child-or related care will be the study participant’s 
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8 CONCOMITANT MEDICATIONS 
8.1 Prior, Concomitant and Prohibited Therapy  
Current medications and any medications taken within the 30 days prior to the start of the study 
will be recorded as prior/concomitant medications (using their generic name, if known) with 
the corresponding indication, start and stop dates.  The medications to be recorded include 
prescription, all over-the-counter (OTC) medications and all dietary supplements.  All 
medications taken on a regular basis should be recorded prior to commencing the use of the 
investigational product.  Any medications started during the study (including “as needed” 
medications) will be recorded in the concomitant medication list as soon as the Investigational 
Site will become aware of the medication being added. 
Prohibited Therapies are those medicinal products and treatment methods that are not 
allowed during the study period and within the timeframes specified in Table 2. 
 
Table 2.  List of Prohibited Medication and Treatment Methods 
 
Prohibited Topical Treatments: 
Topical Treatment 
Prohibited Time Frame prior to Baseline 
Astringents or abrasives 
2 days 
RHOFADE™ (oxymetazoline HCl) 
Cream, 1% 
1 week 
Bleach baths 
1 week 
Mirvaso (brimonidine) topical cream 
1 week 
Vinegar  
1 week 
Topical Prescription/OTC medications for 
treatment of acne 
2 weeks 
Soolantra (Ivermectin 1%) topical cream 
1 week 
Topical Antibiotic 
2 weeks 
Use of over the counter antimicrobial  
2 weeks 
Benzoyl Peroxide  
2 weeks 
Immunomodulators  
4 weeks 
Oracea (doxycycline) topical cream  
2 weeks 
Corticosteroids  
4 weeks 
Electrocoagulation, Dermabrasion; Facial 
peels 
4 weeks 
Dermatologic/surgical procedure on the 
face 
4 weeks 
Topical Prescription medications for the 
treatment of rosacea (e.g. azelaic acid, 
metronidazole, etc.) 
4 weeks 

 
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Laser, 
Phototherapy, 
Photodynamic 
Therapy or IPL (intense pulsed light) 
treatment 
4 weeks 
Over the counter topical retinoid use on the 
face  
4 weeks 
 
Prohibited Systemic Treatments:  
Systemic Treatment  
Prohibited Time Frame prior to Baseline 
Exposed to excessive ultraviolet (UV) 
radiation and/or subject was unwilling to 
refrain from excessive exposure to UV 
radiation during the course of the study 
1 week 
Prescription anti inflammatory 
2 weeks 
Prescription/OTC anti-inflammatory 
medications (excludes low dose aspirin) 
2 weeks 
Systemic Antibiotics 
4 weeks 
Systemic medications for the treatment of 
rosacea (e.g. doxycycline, tetracycline, 
macrolides) 
4 weeks 
 
Prescription medications for treatment of 
acne 
4 weeks 
Corticosteroids (oral or injectable) 
4 weeks 
Immunomodulators 
12 weeks 
Oral retinoid use (e.g., isotretinoin), vitamin 
A supplements greater than 10,000 units/day 
6 months 
8.2 Prohibited procedures 
Participants will be asked refrain from cosmetic facial procedures for the possible treatment of 
rosacea or acne, such as chemical peels, micro or dermabrasion, comedone extraction, 
electrocautery, Phototherapy, Photodynamic Therapy or IPL (intense pulsed light) treatment 
laser peels or laser light therapy (including ThermaClear TM, blue light, tanning devices or 
photodynamic therapy), steroid injections throughout the study until the final follow-up visit.   
 
If the Investigator becomes aware of a subject having taken a prohibited medication or 
performed prohibited procedure, they will report the incident to the Medical Monitor within 
24 hours, and the Medical Monitor and/or Sponsor will provide written approval of the 
subject’s continuation or discontinuation from the study. 
 

 
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9 LIFESTYLE RESTRICTIONS 
9.1 Use of cleanser and moisturizer during the trial  
At the beginning of the trial, subjects will be provided with cleanser and moisturizer to use for 
the duration of the trial as needed.  The subject may choose not to use a moisturizer, as it is not 
required.  If moisturizer is used, subject should be advised to apply it 10 minutes after the 
application of the IP.  
 
Subjects may use other cleansers to wash other parts of their body not treated during the study.  
 
At Week 8 (End of Investigational product application) subjects will be asked to return cleanser 
and moisturizer that was provided to them by the Sponsor and will be asked to go back to their 
regular regimen and use their preferred cleanser and moisturizer. 
9.2 Use of makeup, moisturizers and sun screen 
• Use of anti-aging, anti-acne or rosacea treatment products or procedures on the face 
will be prohibited during the study. 
• Subjects will be encouraged not to use other topical products on the face, such as 
emollients, sunscreen, moisturizers, etc.  These should be used minimally or used 
sparingly while in the active phase (Baseline-Week 8) of the trial.  
• Participants will be advised to use minimally or use sparingly liquid or powder makeup 
during the active phase (Baseline-Week 8) of the study. 
 
10 STUDY PROCEDURES AND SCHEDULE OF STUDY ACTIVITIES 
The following sections describe the procedures to be completed during the study.  Subjects are 
to be assessed by the same Investigator or site personnel whenever possible. 
10.1 Administrative Procedures  
10.1.1 Subject Informed Consent 
A signed and dated, study-specific, approved by 
Institutional Review 
Board 
(IRB)/Independent Ethics Committee (IEC) and applicable regulatory authorities Informed 
Consent Form must be obtained from each subject prior to performing any study related 
procedures.  No study related procedures or activities may be performed until each subject is 
fully informed and the consent form is signed and dated. 
10.1.2 Documentation of Screen Failures 
Investigators must account for all subjects who sign informed consent and will maintain an 
Subject Screening and Enrollment Log capturing subjects screened and indicating who was 

 
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enrolled or excluded and the reason why.  If the subject is found not to be eligible prior to 
enrollment, the reason(s) for ineligibility must be documented by the Investigator.  Subject 
Numbers assigned to subjects who fail screening will not be re-used. 
10.2 Study Procedures 
10.2.1 Visit 1- Screening Visit (Day -21 to -1) 
• Informed Consent 
• Inclusion/Exclusion Criteria 
• Demographics 
• Medical History 
• Concomitant and Prohibited Therapies review and documentation 
• Physical examination 
• Collection of Vital Signs 
• Urine pregnancy test for WOCBP 
• Venipuncture for Laboratory Assessment & Urinalysis 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex-16 
• Patient Self-Assessment (PSA) 
• Fitzpatrick skin type 
• Start AE collection and assessment 
 
10.2.2 Washout Phase (-14 to -1) 
Washout phase may be initiated after Screening procedures have been completed.  
 
10.2.3 Visit 2- Baseline visit (Day 1):  
Baseline visit will include the following procedures and assessments: 
• Review of inclusion/exclusion criteria 
• Review of Medical History 
• Concomitant and Prohibited Therapies review and documentation 
• Physical examination 
• Collection of Vital Signs 
• Urine pregnancy test for WOCBP 
• Venipuncture for Laboratory Assessment & Urinalysis 
• Blood for biomarkers 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 

 
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• Telangiectasia Evaluation 
• Randomization 
• IP dispensation 
• IP compliance  
• IP application under medical supervision 
• Study cleanser and moisturizer dispensation 
• Study counseling 
• Study Diary 
• Adverse Events collection and assessment  
 
10.2.4 Visit 3- Week 1 (Day 7) ±2 days 
The following procedures will be performed: 
• Concomitant and Prohibited Therapies review  
• Collection of Vital Signs 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 
• Study Counseling 
• Study Diary 
• Urine pregnancy test for WOCBP 
• Adverse Event collection and assessment 
 
10.2.5 Visit 4- Week 4 (Day 28) ±2 days 
The following procedures will be performed: 
• Concomitant and Prohibited Therapies review  
• Collection of Vital Signs 
• Venipuncture for Laboratory Assessment & Urinalysis 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 
• Urine pregnancy test for WOCBP 
• Study cleanser and moisturizer dispensation 
• IP compliance  
• IP collection 
• IP dispensation 
• Study Counseling 
• Study Diary 

 
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• Adverse event collection and assessment 
 
10.2.6 Visit 5- Week 8 (Day 56) ±2 days 
The following procedures will be performed: 
• Concomitant and Prohibited Therapies review  
• Collection of Vital Signs 
• Venipuncture for Laboratory Assessment & Urinalysis 
• Blood for biomarkers 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 
• Telangiectasia Evaluation 
• Urine pregnancy test for WOCBP 
• IP collection 
• IP compliance 
• Study cleanser and moisturizer collection 
• Study Counseling 
• Study Diary 
• Adverse event collection and assessment 
 
10.2.7 Visit 6- End of Study Visit-Week 12 (Day 84) ±2 days 
The following procedures will be performed: 
• Concomitant and Prohibited Therapies review  
• Physical Exam 
• Collection of Vital Signs 
• Urine Pregnancy Test for WOCBP 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 
• Adverse event collection and assessment 
 
10.2.8 Unscheduled Visit 
If an event arises that requires subject to come in to the research center, subjects should be 
scheduled for the Unscheduled visit and assessments are performed based on investigator 
discretion. 

 
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Subjects will be encouraged to report any complications or adverse effects during their 
participation.  Investigator may evaluate the subject at an unscheduled visit, if subject’s 
condition will be considered as worsening. 
 
10.2.9 Early Termination Visit 
Every attempt should be made to complete all visits during the defined window periods.  
Subjects who do not complete all required study visits and withdraw from the study before 
Week 12 final visit, will be asked to complete the Early Termination Visit. 
 
During the visit, the following will be obtained: 
• Concomitant and Prohibited Therapies review  
• Physical Exam 
• Collection of Vital Signs 
• Urine Pregnancy Test for WOCBP 
• Venipuncture for Laboratory Assessment & Urinalysis 
• Blood for biomarkers 
• Investigator’s Global Assessment [IGA] 
• Clinician’s Erythema Assessment [CEA] 
• Skindex 16 
• Patient Self-Assessment (PSA) 
• Telangiectasia Evaluation 
• IP collection 
• IP compliance 
• Study cleanser and moisturizer collection 
• Study diary  
• Adverse event collection and assessment 
 
11 METHODS OF ASSESSMENT 
11.1 Clinical Evaluations 
Study activities will take place according to the Schedule of Study Activities table.  The 
following clinical evaluations will be conducted during the course of the study. 
 
11.1.1 Subject Demographics 
Basic demographic information, including date of birth, Fitzpatrick skin type (classification of 
skin type (or phototype) depending on the amount of melanin pigment in the skin), gender, 
ethnicity, and race will be recorded at the Screening Visit. 
 

 
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11.1.2 Medical history 
Medical history will be collected at the Screening Visit.  Relevant medical history, including 
past history of rosacea will be documented.  
 
11.1.3 Concomitant Medication Recording 
All medications (both prescription and nonprescription, and including vitamins, herbals, 
topicals, inhaled, and intranasal) taken within 30 days prior to the start of the investigational 
product and through the final study visit will be recorded on the appropriate eCRF (using their 
generic and brand name, if known) with the corresponding indication, start and stop dates.  At 
each study visit, subjects will be asked whether they have started or discontinued any 
medication since their previous study visit.  This includes single use or PRN (as needed) 
medication use. 
Previous treatment of rosacea must be recorded irrespectively of the term it was given.  
Corresponding condition shall be captured in the subject’s Medical History. 
 
11.1.4 Vital Signs 
Vital signs will be collected at each visit.  Blood pressure readings will be obtained at every 
visit as described in the Schedule of Study Activities.  Subject should be asked to remove all 
clothing that covers the location of cuff placement.  The individual should be comfortably 
seated in the chair, with the legs uncrossed, and the back and arm supported, such that the 
middle of the cuff on the upper arm is at the level of the right atrium (the mid-point of the 
sternum).  Neither the subject nor the observer should talk during the measurement.  After 5 
minutes sitting, serial clinic BP measurements and heart (x3) rate will be performed, using the 
non-dominant arm with a calibrated electronic sphygmomanometer.  The average of the second 
and third readings will be documented. 
Any abnormal characteristics will be evaluated by the Investigator based on their significance.  
Abnormal vital signs will be considered AEs if they require therapeutic medical intervention, 
and/or if the Investigator considers them to be AEs based on his/her clinical judgement. 
 
11.1.5 Physical examination 
Physical examination, including height, weight, and evaluation of organs and systems (General 
Appearance, Heart/Cardiovascular, Lungs, Gastrointestinal, Ears / Nose / Throat, Extremities, 
and Skin) will be assessed at the Screening, Baseline and EOS/ET visits. 
Clinically significant abnormalities other than presence of rosacea lesions will disqualify 
subject from participation.  
 
11.1.6 Investigator’s Global Assessment (IGA) 
An Investigator’s Global Assessment (IGA) will be evaluated at each study visit (Table 3).  
This scale should not be a reflection of treatment response, but should describe the condition 

 
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at each visit.  Therefore, no reference should be made to baseline in the evaluation.  The 
Investigator will grade the severity of facial erythema, lesions, papules, pustules, and nodules 
from 0 to 4.  0=none, 1=almost clear, 2=mild, 3=moderate, 4=severe.   
 
Table 3.  Investigator’s Global Assessment (IGA) scale 
 
Score Grade 
Definition 
0 
Clear 
No inflammatory lesions present; at most, mild erythema 
1 
Almost Clear Very mild erythema present.  Very few small papules/pustules 
2 
Mild 
Mild erythema.  Several small papules/pustules 
3 
Moderate 
Moderate erythema.  Several small or large papules/pustules, and up to 2 
nodules 
4 
Severe 
Severe erythema.  Numerous small and/or large papules/pustules, up to 
several nodules 
Questionnaire can be found in Appendix 1. 
 
11.1.7 Clinician’s Erythema Assessment (CEA) 
Clinician’s Erythema Assessment (CEA) will be will be evaluated at each study visit.  The 
Investigator will assess the extent of rosacea based on the 5-point severity scale summarized 
below.  
The Investigator will perform a static (“snap-shot”) evaluation of erythema severity using the 
CEA, and report the one integer that best describes the overall severity beginning from the 
Baseline Visit (Table 4).  Although inflammation (papules, pustules, plaques) or dry 
appearance may obscure the level of erythema, underlying redness should be evaluated 
disregarding this effect.  Inflammation or dry appearance may be noted, but perilesional 
erythema should not be included in this assessment.  Transient erythema (flushing) will also 
not be included. 
 
Table 4.  Clinician Erythema Assessment 
 
Score 
Severity 
Description 
0 
Clear 
Clear skin with no signs of erythema 
1 
Almost clear 
Almost clear, slight redness 
2 
Mild 
Mild erythema; definite redness  
3 
Moderate 
Moderate erythema; marked redness  
4 
Severe 
Severe erythema; fiery redness  
Questionnaire can be found in Appendix 2. 
 
 

 
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11.1.8 Skindex 16  
Skindex-16 instrument will be evaluated at each study visit.  The participant will answer a 
questionnaire examining the relationship between the patient’s skin health and quality of life.  
Skindex16 questionnaire can be found in Appendix 4. 
 
11.1.9 Patient Self-Assessment (PSA) 
Subjects will be asked to perform static (“snap-shot”) evaluations of their rosacea-associated 
facial erythema severity using the Patient Self Assessment scale (PSA) at each study visit, and 
report the one integer that best describes the overall severity of their facial redness as seen in 
a mirror at the time of the evaluation.  
 
Table 5: Patient Self-Assessment 
 
Circle the number that best describes your rosacea-related facial redness RIGHT NOW. 
Score Severity 
Description 
0 
No redness 
Clear of unwanted redness 
1 
Very mild redness 
Nearly clear of unwanted redness 
2 
Mild redness 
Somewhat more redness than I prefer 
3 
Moderate redness 
More redness than I prefer  
4 
Severe redness 
Completely unacceptable redness 
Questionnaire can be found in Appendix 3. 
 
11.1.10 Telangiectasia Evaluation 
Telangiectasia evaluation will be performed at Baseline and Week 8 visit as indicated in the 
Schedule of Study Activities.  The Investigator will assess the extent of telangiectasia based 
on the 4-point severity scale summarized below.  
The Investigator will perform a static (“snap-shot”) evaluation of telangiectasia severity using 
the below scoring system. 
 
Table 6: Telangiectasia Evaluation 
Score 
Grade 
Definition 
0 
Clear 
No telangiectasia 
1 
Mild 
Only few fine vessels discernible, involves 10% or less of the 
facial area 
2 
Moderate 
Multiple fine vessels and/or few large vessels discernible, 
involves > 10% - 30% of the facial area 
3 
Severe 
Many fine vessels and/or large vessels discernable, involves > 
30% of the facial area 
Questionnaire can be found in Appendix 6. 

 
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11.2 Safety Assessments 
11.2.1 Assessment of Adverse Events 
Beginning with the screening visit and through the EOS/ET visit, the Investigator and study 
personnel will review each subject’s clinical evaluation findings and query the subject directly 
regarding AEs (see Section 12, Safety Data Collection, Recording and Reporting). Subjects 
must be followed for AEs until 30 days post study conclusion or until the PI determines AEs 
are stable, whichever is later. 
 
11.2.2 Pregnancy Test 
A urine pregnancy test will be performed at all visits for females of childbearing potential.  The 
baseline result must be available and must be negative before the subject apply the first 
application of investigational product.  Positive pregnancy test will disqualify the subject from 
the participation.  
 
11.2.3 Laboratory Assessments 
Blood samples will be taken at the times indicated in the Schedule of Study Activities. 
Blood samples should be taken using standard venipuncture techniques.  Blood sampling will 
be performed according to the site SOPs. 
The following routine clinical chemistry, hematology and Lipid Panel will be performed 
according to the Schedule of Study Activities.  Albumin, Alkaline Phos, ALT, AST, Total 
Bilirubin, BUN, BUN:Creatinine ratio, Calcium, Chloride, Creatinine, eGFR, Glucose, 
Potassium, Sodium, Uric Acid. 
Lipid Panel: HDL Cholesterol, LDL cholesterol, Total Cholesterol, Triglycerides, VLDL 
Cholesterol, LDL/HDL Cholesterol Ratio, Non HDL Cholesterol. 
Hematology: WBC, RBC, Hemoglobin, Hematocrit, Platelets, WBC Differential (Neutrophils, 
Lymphocytes, Monocytes, Eosinophils, Basophils), HbA1C. 
Serology will only be done at Screening: HIV Ab, HCV Ab, HBsAg. 
Urinalysis will be performed according to the Schedule of Study Activities.  
 
Patients will be asked to fast for at least 8 hours before all blood tests are done.  
 
The total blood volume collected for clinical labs for Screening visit will be approximately 20 
ml of whole blood.  Volume collected for subsequent visits would be approximately 10 ml of 
whole blood.  
Any value outside the normal range will be flagged for the attention of the Investigator or 
designee at the site.  The Investigator or designee will indicate whether or not the value is of 
clinical significance.  If the result of the clinical chemistry test from the samples taken during 
the screening phase is indicated as clinically significant, the study subject will NOT be allowed 
into the study.  
 

 
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11.2.4 Biomarkers 
In addition to the blood drawn for the safety laboratory assessments, additional blood will be 
collected for the biomarker analysis at the times indicated in the Schedule of Activities.  
Samples will be processed on site and aliquots stored in the -80○ C freezer. 
Approximately 20 ml of whole blood will be drawn for biomarkers at each visit.  Subjects will 
be asked to fast for at least 8 hrs. before blood for biomarkers is drawn.  
Biomarkers will be evaluated for cytokines, chemokines, inflammatory markers and immune 
response.  
 
11.2.5 Samples Shipment 
All clinical chemistry samples are to be shipped to the central laboratory where samples will 
be analyzed.  
Biomarker samples are to be shipped frozen monthly on dry ice to the central laboratory. 
Shipments should be made only on Mondays and Tuesdays to ensure receipt of the specimens 
by Friday. 
 
11.2.6 Treatment Adherence Evaluations 
11.2.6.1 Study Diary Compliance Review 
The subject will be given a Study Diary at each study visit of the treatment period to record 
date and time of applications, any adverse events, quality of life assessments, of the 
investigational product.  Subjects will record every application during the treatment period and 
will bring the Subject Diary to each of the post-baseline study visits for compliance review.  
The Investigator will verify that the subject complied with the application requirements and 
will file the completed Subject Diary in the study files at each study visit until the EOT/ET 
visit.  Any missed application notations will be clarified with the subject and documented in 
the subject’s CRF.  
 
11.2.6.2 Treatment Compliance 
Each site participating in the trial will be instructed to assess subject’s compliance by weighing 
the investigational product and obtaining the weight of the bottles in grams pre- and post-
application.  Study personnel will be asked to take out the bottles from the carton, weigh both 
bottles and record the weight pre-first application.  At the Day 28 and Day 56 visit, study 
personnel will need to weigh both bottles without the carton and record the weight.  This 
procedure should be followed every time study medication is dispensed and returned.  Sites 
will be provided scales, which will be calibrated prior to each use.  Study personnel will be 
instructed to record measurements into the eCRF.  

 
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12 SAFETY DATA COLLECTION, RECORDING AND REPORTING 
The Investigator will monitor each subject for clinical evidence of adverse events on a routine 
basis throughout the study.  The Investigator will assess and record any Adverse Event (AE) 
in detail including the date of onset, description, severity, time course, duration and outcome, 
relationship of the adverse event to investigational product, an alternate etiology for events not 
considered “related” or “probably related” to investigational product, final diagnosis, if known, 
and any action(s) taken. For AEs to be considered intermittent, the events must be of similar 
nature and severity and each intermittent AE will be reported separately.  AEs and SAEs, 
whether in response to a query, observed by site personnel, or reported spontaneously by the 
subject will be recorded, monitored and followed-up until the resolution (or until the 
Investigator deems the event to be stable/chronic). 
12.1 Definitions 
12.1.1 Adverse Event 
An AE is defined as any untoward medical occurrence in a Subject or clinical investigation 
subject administered a pharmaceutical product and which does not necessarily have a causal 
relationship with this treatment.  An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with 
the use of a medicinal (investigational) product, whether or not the event is considered causally 
related to the use of the investigational product. 
Such an event can result from use of the drug as stipulated in the protocol or labeling, as well 
as from accidental or intentional overdose, drug abuse, or drug withdrawal.  Any worsening of 
a pre-existing condition or illness is considered an AE.  If a new rosacea signs or symptom or 
worsening of a rosacea sign or symptom was believed by the investigator to be related to the 
investigational product and not the disease, then it will be recorded as an AE.  Clinically 
significant abnormalities are to be followed to resolution (i.e., become stable, return to normal, 
return to baseline, or become explainable).  Laboratory abnormalities and changes in vital signs 
are considered to be AEs only if they necessitate therapeutic medical intervention, and/or if the 
Investigator considers them to be AEs. 
 
12.1.2 Serious Adverse Events 
If an AE meets any of the following criteria, it is to be reported to the Sponsor’s Safety 
department and Pharmacovigilance as a Serious Adverse Event (SAE) using SAE report form 
within 24 hours of occurrence or notification to the study site: 
 
Death of Subject 
An event that results in the death of a subject. 
Life-Threatening 
An event that, in the opinion of the Investigator, would have 
resulted in immediate fatality if medical intervention had not been 

 
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taken.  This does not include an event that would have been fatal 
if it had occurred in a more severe form. 
Hospitalization 
An event that results in an admission to the hospital for any length 
of time.  This does not include an emergency room visit or 
admission to an out-patient facility. 
Prolongation of 
Hospitalization 
An event that occurs while the study subject is hospitalized and 
prolongs the subject's hospital stay. 
Congenital 
Anomaly/birth defect 
An anomaly detected at or after birth or any anomaly that result 
in fetal loss. 
Persistent or 
Significant 
Disability/Incapacity 
An event that results in a condition that substantially interferes 
with the activities of daily living of a study subject.  Disability is 
not intended to include experiences of relatively minor medical 
significance such as headache, nausea, vomiting, diarrhea, 
influenza, and accidental trauma (e.g., sprained ankle). 
Other Important 
Medical Event 
An important medical event that may not be immediately life-
threatening or result in death or hospitalization, but based on 
medical judgment may jeopardize the subject and may require 
medical or surgical intervention to prevent any of the outcomes 
listed above (i.e., death of subject, life- threatening, 
hospitalization, prolongation of hospitalization, congenital 
anomaly, or persistent or significant disability/incapacity).  
Examples of such events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug 
abuse. 
12.2 Adverse Event Severity 
The Investigator will use the following definitions to rate the severity of each AE and SAE: 
Mild 
The event is transient and easily tolerated by the subject. 
Moderate 
The event causes the subject discomfort and interrupts the subject's 
usual activities. 
Severe 
The event causes considerable interference with the subject's usual 
activities and may be incapacitating or life-threatening. 

 
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12.3 Causality of Adverse Events 
The Investigator will use the following definitions to assess the relationship of the AE/SAE 
to the use of investigational product: 
Related 
The event occurred within a reasonable time after drug administration 
or drug concentration and body fluids demonstrated that the 
investigational product was present: the event could not be reasonably 
explained by known characteristics including concomitant therapies; 
the adverse event abated after discontinuing the investigational 
product. 
Probably Related 
The event has a strong temporal relationship to investigational product 
or recurs on re-challenge and another etiology is unlikely or 
significantly less likely. 
Possibly Related 
The event has a strong temporal relationship to the investigational 
product and an alternative etiology is equally or less likely compared 
to the potential relationship to investigational product. 
Probably Not 
Related 
The event has little or no temporal relationship to the investigational 
product and/or a more likely alternative etiology exists. 
Not Related 
The event is due to an underlying or concurrent illness or effect of 
another drug and is not related to the investigational product (e.g., has 
no temporal relationship to investigational product or has a much more 
likely alternative etiology). 
If an Investigator's opinion of possibly, probably not, or not related to investigational product 
is given, an alternate etiology must be provided by the Investigator for the AE. 
12.4 Adverse Event Collection Period 
Adverse Event Collection Period starts with the Screening visit once the ICF has been signed 
through the follow-up visit (week 12).  Any AE/SAE prior to the Screening visit will be 
considered past medical history (PMH).  
SAE(s) that are observed or spontaneously reported during the subject’s participation in the 
trial will be captured and monitored until the Investigator deems the event to be chronic or not 
clinically significant or the subject to be stable.  
12.5 Adverse Event Reporting 
In the event of a SAE, whether related to investigational product or not, the Investigator or 
representative must make an accurate and adequate report consisting of at least the minimum 
criteria (Site and Subject ID, Date site became aware of the event, SAE Term, Seriousness 
criteria, investigational product, Investigator/Reporter and site address) within 24 hours by 
email, fax, or telephone to the Sponsor’s Safety and Pharmacovigilance team. Sponsor’s Safety 

 
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and Pharmacovigilance team will complete the SAE report for further evaluation and review 
by the Medical Monitor and Sponsor designee.  
Copies of each report with the associated documentation received (i.e., queries, medical 
records, lab records, IRB/IEC communications and all source documents) will be kept in the 
site’s study file. 
 
Primary Contact for AE/SAE Reports and Queries 
Email: RB244-01-safety@biorasi.com 
Medical Monitor:  Dr. Jeffrey Sugarman 
Email: pediderm@yahoo.com 
Phone: 707-280-0283 
 
13 MEDICAL MONITOR  
13.1 Unblinding due to SAE 
Subjects, Investigators, site staff, AOBiome, and the Medical Monitor will be blinded to 
treatment assignment.  
Reasons to unblind Subject should be clearly documented in subject notes, and the monitoring 
site visit report.  In the event of an emergency necessitating unblinding the PI/site staff will 
make every effort to contact and discuss the event with the Medical Monitor prior to 
unblinding. 
Treatment assignment for an individual subject should be unblinded only in an emergency by 
the Investigator, when knowledge of the treatment assignment is urgently needed for the 
clinical management or welfare of the subject.  Treatment should be provided in accordance 
with the medical condition and with regard to the information provided in the Investigator’s 
Brochure. 
According to the FDA guidance Safety Assessment for IND Safety Reporting IND safety 
reports submitted should be unblinded.  If the blind is broken and a subject with an adverse 
event that would meet the criteria for reporting as a single event was receiving vehicle, the 
event will not be reported in an IND safety report because there is a reasonable possibility that 
the drug did not cause the adverse event but in the event of an SAE determined to be as a result 
of drug exposure reporting to the FDA will take place.  
The Investigator must document the breaking of the code, and the reasons for doing so on the 
eCRF, in the site file, and in the medical notes. 

 
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The Investigator must notify the IRB and the Sponsor in writing as soon as possible following 
the code break detailing the necessity of the code break, all other members of the research team 
should remain blinded. 
14 DATA ANALYSIS 
The data analysis will be conducted on all participant data when the trial ends.  Data will be 
presented by treatment group and overall.   
Categorical variables will be summarized by frequency distributions (number and percentages 
of subjects) and continuous variables will be summarized by descriptive statistics (mean, 
standard deviation, etc.). 
Adverse events will be summarized by treatment group using the Medical Dictionary for 
Regulatory Activities (MedDRA) system organ class and preferred term.  Separate tabulations 
will be produced for all treatment-emergent AEs (TEAEs), treatment-related AEs (those 
considered by the Investigator as at least possibly drug related), SAEs, discontinuations due to 
AEs, and AEs ≥Grade 3 severity.  By-subject listings will be provided for any deaths, SAEs, 
and AEs leading to discontinuation. 
Descriptive statistics for each treatment group will be provided for clinical laboratory values 
(e.g., hematology, serum chemistry, and urinalysis) and vital signs data, presented as both 
actual values and changes from baseline relative to each on-study evaluation.  Abnormal 
clinical laboratory values will be listed.  
All data will be provided in by-subject listings. 
14.1 Subject Population/Data Sets to Be Evaluated 
The subject populations are defined as follows: 
• 
Safety Population: The safety population includes all randomized subjects who 
received investigational product. 
• 
Modified Intent-to-Treat (mITT) Population: A modified intent-to-treat 
population includes all subjects who are randomized, applied at least one dose of 
assigned product, and returned for at least one post-baseline evaluation visit. 
• 
Per Protocol (PP) Population: The PP population includes all randomized subjects 
who met all inclusion/exclusion criteria, were compliant with the assigned study 
treatment, returned to the study site for the primary endpoint visit within the specified 
window (±2 days) OR discontinued from the study as a treatment failure, and did not 
have any major protocol violations.  Subjects who administered at least 50 % of IP, 
have at least one baseline and post baseline in clinic visit and did not have any major 
protocol violations.  
Subjects who discontinued early from the study due to lack of treatment effect after completing 
at least eight weeks of treatment should be included in the mITT and PP population as treatment 

 
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failures and the change in IGA and CEA from the baseline visit to the last completed visit prior 
to discontinuation due to lack of efficacy should be carried forward in the primary endpoint 
analysis.  Subjects discontinued early for other reasons should be excluded from the PP 
population, but included in the mITT population.  
The results in the mITT population will be considered definitive for superiority of each active 
treatment to vehicle with those in the PP population considered supportive.  Safety analyses 
will be performed using the Safety population. 
14.2 Sample Size Determination 
Sample size of 104 randomized 1:1 Active to Vehicle based on 80% power to detect 33% IGA 
response in Active group versus 10% in the Vehicle group, with two-sided test and alpha =0.05. 
14.3 Statistical Analyses 
14.3.1 Subject Disposition and Demography 
A tabulation of the disposition of subjects will be presented, including the number enrolled, 
the number randomized, the number treated, and the reasons for study discontinuation.  
Summaries of the number in each analysis set will be presented.  Entry criteria violations and 
protocol deviations will be listed. 
 
Demographic and baseline characteristic data summarization will be performed in order to 
descriptively assess the comparability of treatment groups.  Data to be tabulated will include 
age, race, ethnicity, height, weight, and BMI, as well as baseline characteristics related to 
medical history. 
 
14.3.2 Assessment of Safety 
The reporting of safety data is descriptive, and will include all subjects who receive at least 
one dose of investigational product.  The variables for safety endpoints are AEs, Local 
Application Site Reactions, vital signs measurements, clinical chemistry and hematology.  AEs 
will be summarized based on the frequency of AEs and their severity for all treated subjects.  
All AEs will be coded using Medical Dictionary for Regulatory Activities (MedDRA) and 
summarized by treatment group.  Data will be summarized using preferred term and primary 
system organ class. 
If a subject experiences multiple events that map to a single preferred term, the greatest severity 
and strongest Investigator assessment of relation to investigational product will be assigned to 
the preferred term for the appropriate summaries.  Should an event have a missing severity or 
relationship, it will be classified as having the highest severity and/or strongest relationship to 
investigational product. 
Summaries of AEs will include any AEs reported beginning with the first dose of 
investigational product on Day 1.  The occurrence of adverse events will be summarized by 

 
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treatment group using preferred terms, system organ classifications, and severity.  Separate 
summaries of serious adverse events, adverse events related to investigational product, and 
events leading to the discontinuation of investigational product will be generated.  All adverse 
events reported will be listed for individual subjects showing both verbatim and preferred 
terms. 
Concomitant medications will be coded using the World Health Organization (WHO) 
dictionary.  This data will be summarized by treatment group.  Previous and concomitant 
medications will be presented in a data listing. 
 
14.3.3 Hypothesis Testing/ Assessment of Efficacy 
Further details of the planned statistical methods presented below will be provided in the study 
Statistical Analysis Plan (SAP).  The purpose of the SAP is to further elaborate the statistical 
methods described in the protocol and describe analysis conventions to guide the statistical 
programming work.  Any changes to the final SAP will be documented.  Unless otherwise 
specified, the hypothesis testing will be conducted by the difference of means for a two-sample 
two-sided test with a significance level of 0.050. 
The Evaluable Period for the outcome variables will be weeks 1, 4, 8 and 12. During each 
Evaluable Period an ordinal value based on IGA, CEA, PSA scores will be collected.  The 
probability of improving will be the criteria to assess the superiority of the drug over the 
vehicle.  The null and alternative statistical hypotheses for the primary effectiveness endpoints 
are given by: 
(Ho) : The null hypothesis is that the probability of inproving (across the scale) with drug T 
(PrT)is less than or equal to the probability of inproving with vehicle (PrV) 
Ho: PrT ≤ PrV; PrT – PrV ≤ 0  
(Ha): The alternative hypothesis  is that the probability of inproving with drug T (PrT) is 
greater than to the probability of inproving with vehicle (PrV).  
Ha: PrT > PrV; PrT – PrV > 0 
The change from baseline score of Skindex-16 will be compared among treatment at weeks 1, 
4, 8 and 12 by a repeated measure analysis. 
 
14.3.3.1 Exploratory Endpoints 
IGA treatment success, defined as “clear” or “almost clear” with a 2-grade improvement in 
IGA score from baseline to the end of treatment. 
 
CEA treatment success defines as “clear” or “almost clear” with a 2-grade improvement in 
CEA score from baseline to the end of treatment. 
 
14.3.4 Handling of Missing Values & Sensitivity Analysis 

 
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For the primary and secondary analysis no missing values will be imputed.  A sensitivity 
analysis will be performed by Multiple Imputation Regression Analysis using the following 
factors: treatment, age, gender, baseline IGA, baseline CEA, baseline PSA and the results of 
the same variable from previous visits. 
 
14.3.5 Handling of Multiplicity 
No correction for multiplicity will be made. 
 
14.3.6 Primary Objective 
Assess the safety and tolerability of B244 applied twice daily to the face for 8 weeks in 
subjects with mild to moderate rosacea. 
 
14.3.7 Exploratory Objectives 
To assess the efficacy of B244 in subjects with mild to moderate rosacea. 
• Proportion of subjects with IGA improvement at Week 8 relative to baseline. 
• Proportion of subjects with CEA improvement at Week 8 relative to baseline. 
• Change in IGA from Week 8 to Baseline.  
• Change in CEA from Week 8 to Baseline. 
• Proportion of Subjects with improvement in IGA or CEA at week 1, week 4, and week 
12. 
• Change in Skindex 16 patient reported outcome from Baseline to week 1, week 4, 
week 8, and week 12. 
• Proportion of subjects with change in PSA at Week 1, Week 4, Week 8 and Week 12 
from Baseline. 
• Evaluation of Telangiectasia score at Baseline/Day1 and week 8. 
 
14.3.7 Clinical Trial Protocol deviations  
At minimum, the following deviations will be summarized on the ITT population:  
 
• 
Inclusion or exclusion criteria not satisfied.  
• 
Deviations related to the investigational product administration  
• 
Not permitted concomitant medications.  
 

 
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15 STUDY CONDUCT 
15.1 Ethical Conduct of the Study  
The study will be conducted according to the protocol, GCP, as outlined in the ICH Guidelines 
and Code of Federal Regulations.  Written informed consent for the study must be obtained 
from all subjects before protocol specific procedures are performed.  Subjects must be 
informed of their right to withdraw from the study at any time and for any reason.  
15.2 Other Required Approvals 
In addition to IRB/IEC approval, all other required approvals (e.g. approval from local 
Research and Development Board or Scientific Committee) required by the individual site for 
participating in this study will be obtained by the Investigator prior to recruitment of subjects 
into the study and shipment of the investigational product(s).  It is the responsibility of the 
Investigator to notify the Sponsor and the CRO of the requirement of such approvals prior to 
participating in the study. 
15.3 Informed Consent 
It is the responsibility of the Investigator to give each subject (or the subject’s acceptable 
representative), prior to inclusion in the trial, full and adequate verbal and written information 
regarding the objective and procedures of the trial and the possible risks involved.  The subjects 
must be informed about their right to withdraw from the trial at any time. 
Furthermore, it is the responsibility of the Investigator, or a person designated by the 
Investigator, to obtain signed informed consent from each subject or the subject’s legally 
acceptable representative prior to inclusion in the trial.  The Investigator will retain the original 
of each subject's signed consent form. 
The informed consent form will be in compliance with ICH GCP, local regulatory, and legal 
requirements.  The informed consent form used in this study, and any changes made during 
the course of the study, must be prospectively approved by both the IRB/IEC and the Sponsor 
before use. 
15.4 Subject Confidentiality 
All parties will ensure protection of subject personal data and will not include subject names 
on any Sponsor forms, reports, publications, or in any other disclosures, except where required 
by law.  In case of data transfer, the Sponsor will maintain high standards of confidentiality 
and protection of subject personal data. 
The Sponsor and designees affirm and uphold the principle of the subject’s right to protection 
against invasion of privacy.  Throughout this study, a subject’s source data will only be linked 
to the Sponsor’s clinical study database or documentation via a unique identification number.  
As permitted by all applicable laws and regulations, limited subject attributes, such as gender, 

 
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age, or date of birth, and subject initials may be used to verify the subject and accuracy of the 
subject’s unique identification number. 
To comply with ICH Guidelines for GCP and to verify compliance with this protocol, the 
Sponsor requires the Investigator to permit its monitor or designee’s monitor, representatives 
from any regulatory authority (e.g., FDA), the Sponsor’s designated auditors, and the 
appropriate IRBs and IECs to review the subject’s original medical records (source data or 
documents), including, but not limited to, laboratory test result reports, ECG reports, admission 
and discharge summaries for hospital admissions occurring during a subject’s study 
participation, and autopsy reports. Access to a subject’s original medical records requires the 
specific authorization of the subject as part of the informed consent process. 
Copies of any subject source documents that are provided to the Sponsor must have certain 
personally identifiable information removed (i.e., subject name, address, and other identifier 
fields not collected on the subject’s CRF). 
15.5 Institutional Review Board (IRB) / Independent Ethics Committee (IEC) 
It is the responsibility of the Investigator to have prospective approval of the study protocol, 
protocol amendments, informed consent forms, and other relevant documents, (e.g., 
recruitment advertisements, subject’s diaries, if applicable) from the IRB/IEC.  All 
correspondence with the IRB/IEC will be retained in the Investigator File.  Copies of IRB/IEC 
approvals should be forwarded to the Sponsor or its designee. 
The only circumstance in which an amendment may be initiated prior to IRB/IEC approval is 
where the change is necessary to eliminate apparent immediate hazards to the subjects.  In case 
of such an event, the Investigator must notify the IRB/IEC and the Sponsor in writing 
immediately after the implementation. 
15.6 Publication 
No publication or disclosure of study results will be permitted, except under the terms and 
conditions of a separate, written agreement between Sponsor and the Investigator and/or the 
Investigator’s institution.  The Sponsor must have the opportunity to review and approve all 
proposed abstracts, manuscripts, or presentations regarding this study prior to submission for 
publication/presentation.  Any information identified by the Sponsor as confidential must be 
deleted prior to submission. 
 
 
 
 
 

 
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16 ADMINISTRATIVE OBLIGATIONS 
16.1 Curriculum Vitae 
An updated, signed, and dated copy of the curriculum vitae with the experience, qualification 
and training for each Investigator and/or Sub-Investigator(s) will be provided to the Sponsor 
prior to the beginning of the Clinical Trial.  
16.2 Source Documentation Forms 
The Investigator/institution will permit study-related monitoring, audits/inspections, IRB/IEC 
review and regulatory inspection providing direct access to source documents, including all 
medical records or pertinent data relevant to the audit/inspection.  Source documents will 
represent a record of the raw data.  Source document templates may be provided by either the 
clinical site or the Sponsor.  The source documents will become part of the subject's permanent 
medical record maintained by the clinical site.  If computerized systems are used to create, 
modify, maintain, archive, retrieve or transmit source data, they must comply with the 
applicable regulatory regulations and/or guidances (ex. 21 CFR Part 11 and 312). 
eCRFs will be used in this study.  eCRFs are required and should be completed for each subject 
participating in the study.  eCRFs will contain data captured from subject source documents 
and results of laboratory tests.  In most cases, the source documents are contained in the 
subject’s chart at the hospital or the physician's office.  In these cases, data collected on the 
CRFs must match the data in those charts.  Data must be transcribed from the source documents 
(e.g. physical exam report, associated medical records, date and version of informed consent 
form) onto the CRF by clinical site personnel prior to data monitoring.  
Any corrections to entries made in the source documents must be dated, initialed and explained 
(if necessary) and should not obscure the original entry.  The Investigator has ultimate 
responsibility for the accuracy, authenticity, and timely collection and reporting of all clinical, 
safety, and laboratory data entered on the CRFs and any other data collection forms.  
Investigator will sign eCRFs electronically after completion of data entry, to attest that the data 
contained on the CRFs is complete and accurate.  Completed eCRFs are the sole property of 
the Sponsor and should not be made available in any form to third parties, except for authorized 
representatives of the Sponsor or appropriate regulatory authorities, without written permission 
from the Sponsor. 
16.3 Record Retention 
To enable evaluations and/or audits from regulatory authorities or the Sponsor, the Investigator 
agrees to keep records, including the identity of all participating subjects (sufficient 
information to link records, e.g., CRFs and hospital records), all original signed Informed 
Consent Forms, copies of all CRFs, SAE forms, source documents, detailed records of drug 
disposition, and adequate documentation of relevant correspondence (e.g., letters, meeting 
minutes, telephone calls reports).  

 
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The records will be retained by the Investigator according to the International Conference on 
Harmonization (ICH), local regulations, or as specified in the Clinical Study Agreement, 
whichever is longer. 
If the Investigator becomes unable for any reason to continue to retain study records for the 
required period (e.g., retirement, relocation), the Sponsor will be prospectively notified.  The 
study records must be transferred to a designee acceptable to the Sponsor, such as another 
Investigator, another institution, or to the Sponsor.  The Investigator must obtain Sponsor’s 
written permission before disposing of any records, even if retention requirements have been 
met. 
17 PUBLICATIONS 
All data generated from this study are the property of AOBiome LLC and shall be held in strict 
confidence along with all information furnished by AOBiome.  Independent analyses and/or 
publication of these data by the Investigator or any member of his/her staff is not permitted 
without prior written consent of AOBiome.   
Any formal presentation or publication of data from this trial will be considered as a joint 
publication by the Investigator(s) and appropriate Sponsor personnel.  Authorship will be 
determined by mutual agreement.  Written permission to the Investigator will be contingent on 
the review by the Sponsor of the methodology and statistical analysis and any publication or 
presentation will provide for nondisclosure of AOBiome confidential or proprietary 
information.  In all cases, the parties agree to submit all manuscripts or abstracts to all other 
parties at least 30 days prior to submission.  This will enable all parties to protect proprietary 
information and to provide comments based on information that may not yet be available to 
other parties.   
18 PROTOCOL ADHERENCE 
This protocol defines the study objectives, the study procedures and the data to be collected on 
study participants.  Additional assessments required to ensure safety of participants should be 
administered as deemed necessary on a case by case basis.  Under no circumstances is an 
Investigator allowed to collect additional data or conduct any additional procedures for any 
research related purpose involving any investigational drugs under the protocol. 
Investigators ascertain they will apply due diligence to avoid protocol deviations.  If an 
Investigator feels a protocol deviation would improve the conduct of the study this must be 
considered a protocol amendment, and unless such an amendment is agreed upon by the 
Sponsor and approved by the IRB/IEC and health authorities, where required, it cannot be 
implemented. 

 
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19 CLINICAL TRIAL PROTOCOL AMENDMENTS 
Any protocol amendments will be added as stand-alone documents.  In addition, any and all 
revisions dictated by the amendments will be made in the protocol.  Each time a protocol is 
amended, a new amended version date will be added to the cover page. 
The Investigator should not implement any deviation from, or changes of the Clinical Trial 
Protocol without agreement by the Sponsor and prior review and documented 
approval/favorable opinion from the IRB/EC of an amendment. The Investigator is expected 
to take any immediate action required for the safety of any participant included in this study, 
even if this action represents a deviation from the protocol. In such cases, the reporting 
requirements identified in Section 12 must be followed by the Study Lead. 
20 PROPERTY RIGHTS  
All information, documents and investigational product provided by the Sponsor or its 
designee are and remain the sole property of the Sponsor.  The Investigator shall not mention 
any information or the Product in any application for a patent or for any other intellectual 
property rights.  All the results, data, documents and inventions, which arise directly or 
indirectly from the Clinical Trial in any form, shall be the immediate and exclusive property 
of the Sponsor.  The complete verified database will be shared with the Operations Committee, 
which shall have full access to all data.  The Sponsor may use or exploit all the results at its 
own discretion, without any limitation to its property right (territory, field, continuance).  The 
Sponsor shall be under no obligation to patent, develop, market or otherwise use the results of 
the Clinical Trial.  As the case may be, the Investigator and/or the Sub-Investigators shall 
provide all assistance required by the Sponsor, at the Sponsor's expense, for obtaining and 
defending any patent, including signature of legal documents.  
21 DATA PROTECTION  
The subject’s personal data and Investigator's personal data which may be included in the 
Sponsor database shall be treated in compliance with all applicable laws and regulations; 
When archiving or processing personal data pertaining to the Investigator and/or to the 
subjects, the Sponsor shall take all appropriate measures to safeguard and prevent access to 
this data by any unauthorized third party.  
22 SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES  
For the purpose of ensuring compliance with the Clinical Trial Protocol, Good Clinical Practice 
and applicable regulatory requirements, the Investigator should permit auditing by or on the 
behalf of the Sponsor and inspection by applicable regulatory authorities.  

 
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The Investigator agrees to allow the auditors/inspectors to have direct access to his/her study 
records for review, being understood that this personnel is bound by professional secrecy, and 
as such will not disclose any personal identity or personal medical information.  
The Investigator will make every effort to help with the performance of the audits and 
inspections, giving access to all necessary facilities, data, and documents.  As soon as the 
Investigator is notified of a future inspection by the authorities, he will inform the Sponsor and 
authorize the Sponsor to participate in this inspection.  
The confidentiality of the data verified and the protection of the subjects should be respected 
during these inspections.  
Any result and information arising from the inspections by the regulatory authorities will be 
immediately communicated by the Investigator to the Sponsor.  
The Investigator shall take appropriate measures required by the Sponsor to take corrective 
actions for all problems found during the audit or inspections.  
22.1 Quality Control (QC) and Quality Assurance (QA) 
22.1.1 Study Site Monitoring Visits 
During study conduct, the Sponsor or its designee will conduct periodic monitoring visits to 
ensure that the protocol and Good Clinical Practice (GCP) are being followed.  The 
Investigator/institution will allow the Sponsor’s monitors or designees and appropriate 
regulatory authorities direct access to source documents to perform this verification. 
The study site may also be subject to quality assurance audits performed by the Sponsor or 
companies working with or on behalf of the Sponsor, and/or review by the IRB/IEC, and/or to 
inspection by appropriate regulatory authorities 
It is important that the Investigator(s) and their relevant personnel are available during the 
monitoring visits and possible audits or inspections, and that sufficient time is devoted to the 
process. 
22.1.2 Protocol Deviations 
The Investigator should not deviate from the protocol, except where necessary to eliminate an 
immediate hazard to study subjects.  The site should document all protocol deviations in the 
subject’s source documents.  In the event of a significant deviation, the site will notify the 
Sponsor or its designee (and IRB or IEC, as required).  Significant deviations include, but are 
not limited to, those that involve fraud or misconduct, increase the health risk to the subject, 
or confound interpretation of primary study assessments.  Deviations from the 
inclusion/exclusion criteria will not be permitted unless written approval by the Sponsor has 
been obtained.  Should other unexpected circumstances arise that will require deviation from 
protocol-specified procedures, the Investigator will contact the Sponsor or designee at the 
below mentioned address to determine the appropriate course of action.  
Site will be responsible for proper maintaining and filing of all PD related documentation in 
the site files. 

 
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22.2 Trial Discontinuation/Investigative Site Termination 
The Sponsor reserves the right to discontinue the trial prior to inclusion of the intended number 
of subjects.  
After such a decision, the Investigator must contact all participating subjects within a time 
period specified by the Sponsor to inform them of the decision to discontinue the trial. 
 
22.2.1 Criteria for Premature Termination or Suspension of the Study 
The following criteria may result in either temporary suspension or early termination of the 
study: 
• New information regarding the safety or efficacy of the investigational product that 
indicates a change in the known risk/benefit profile for the compound, such that the 
risk/benefit is no longer acceptable for subjects participating in the study. 
• Significant violation of GCP that compromises the ability to achieve the primary study 
objectives or compromises subject safety. 
The Sponsor reserves the right to discontinue the trial for other valid administrative reasons. 
 
22.2.2 Criteria for Premature Termination or Suspension of Investigational Sites 
A study site may be terminated prematurely or suspended if the site (including the Investigator) 
is found to be in significant violation of GCP, protocol, contractual agreement, or is unable to 
ensure adequate performance of the study. 
 
22.2.3 Procedures for Premature Termination or Suspension of the Study or 
Investigational Site(s) 
In the event that the Sponsor and or a regulatory authority elects to terminate or suspend the 
study or the participation of an investigational site, a study-specific procedure for early 
termination or suspension will be provided by the Sponsor; the procedure will be followed by 
applicable investigational sites during the course of termination or study suspension.

 
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23 REFERENCES 
1. Prevalence and Incidence of Rosacea - rosecea statistics. 
http://www.whathealth.com/rosacea/incidence.html. 
2. Steinhoff M, Buddenkotte J, Aubert J, et al. Clinical, cellular, and molecular aspects in 
the pathophysiology of rosacea. J Investig Dermatol Symp Proc. 2011;15(1):2-11. 
doi:10.1038/jidsymp.2011.7. 
3. Weinkle AP, Doktor V, Emer J. Update on the management of rosacea. Clin Cosmet 
Investig Dermatol. 2015;8:159-177. doi:10.2147/CCID.S58940. 
4. Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am 
Fam Physician. 2002;66(3):435-440. http://www.ncbi.nlm.nih.gov/pubmed/12182520. 
Accessed October 26, 2016. 
5. Nally JB, Berson DS. Topical therapies for rosacea. J Drugs Dermatol. 2006;5(1):23-26. 
http://www.ncbi.nlm.nih.gov/pubmed/16468288. Accessed October 26, 2016. 
6. Lindow KB, Warren C. Understanding rosacea. A guide to facilitating care. Am J Nurs. 
2001;101(10):44-51; quiz 52. http://www.ncbi.nlm.nih.gov/pubmed/11680344. Accessed 
October 26, 2016. 
7. Muto Y, Wang Z, Vanderberghe M, Two A, Gallo RL, Di Nardo A. Mast cells are key 
mediators of cathelicidin-initiated skin inflammation in rosacea. J Invest Dermatol. 
2014;134(11):2728-2736. doi:10.1038/jid.2014.222. 
8. Vance, J. (1986). Demodicidosis – do Demodex mites cause disease? Curr Conc Skin 
Disorder, 10–18.  
9. Bonnar, E., Eustace, P. & Powell, F. C. (1993). The Demodex mite population in rosacea. 
J Am Acad Dermatol 28, 443–448).  
10. Karincaoglu Y, Bayram N, Aycan O, Esrefoglu M. The clinical importance of Demodex 
folliculorum presenting with nonspecific facial signs and symptoms. J Dermatol 
2004;31:618-26.) 
11. (Lacey N, Delaney S, Kavanagh K, Powell FC. Mite-related bacterial antigens stimulate 
inflammatory cells in rosacea.British Journal of Dermatology 2007;157:474-481).  
12. Demodex folliculorum and Demodex brevis in cutaneous biopsies. Aylesworth R, Vance 
JC. J Am Acad Dermatol. 1982 Nov; 7(5):583-9). 
13. Arp DJ, Sayavedra-Soto LA, Hommes NG (2002) Molecular biology and biochemistry of 
ammonia oxidation by Nitrosomonas europaea. Arch Microbiol 178: 250-255 
14. Chandran K, Stein LY, Klotz MG, van Loosdrecht MCM (2011) Nitrous oxide 
production by lithotrophic ammonia-oxidizing bacteria and implications for engineered 
nitrogen-removal systems. Biochem Soc Trans 39: 1832-1837. 
15. Weller, R., Price, R. J., Ormerod, A. D., Benjamin, N., & Leifert, C. (2001). 
Antimicrobial effect of acidified nitrite on dermatophyte fungi, Candida and bacterial 
skin pathogens. Journal of Applied Microbiology, 90(4), 648-652. 
16. Rico, J., Quiring, J., Hollenbach, S., Enloe, C., & Stasko, N. (2014, August). Phase 2 
study of efficacy and safety of SB204 in the treatment of acne vulgaris. In Journal Of 
Investigative Dermatology (Vol. 134, No. 8, pp. S8-S8). 75 Varick St, 9th Floor, New 
York, NY 10013-1917 USA: Nature Publishing Group. 

 
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24 APPENDICES 
Appendix 1: Investigator Global Assessment (IGA) 
 
Score Grade 
Definition 
0 
Clear 
No inflammatory lesions present; at most, mild erythema 
1 
Almost Clear Very mild erythema present.  Very few small papules/pustules 
2 
Mild 
Mild erythema.  Several small papules/pustules 
3 
Moderate 
Moderate erythema.  Several small or large papules/pustules, and up to 2 
nodules 
4 
Severe 
Severe erythema.  Numerous small and/or large papules/pustules, up to 
several nodules 
 
 
 

 
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Appendix 2: Clinician Erythema Assessment (CEA)  
 
 Score 
Severity 
Description 
0 
Clear 
Clear skin with no signs of erythema 
1 
Almost clear 
Almost clear, slight redness 
2 
Mild 
 Mild erythema; definite redness  
3 
Moderate 
Moderate erythema; marked redness  
4 
Severe 
Severe erythema; fiery redness  
 
 
 

 
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Appendix 3: Patient Self-Assessment (PSA) 
 
Score 
Severity 
Description 
0 
Absent redness 
Clear of unwanted redness 
1 
Very mild redness 
Nearly clear of unwanted redness 
2 
Mild redness 
Somewhat more redness than I prefer 
3 
Moderate redness 
More redness than I prefer  
4 
Severe redness 
Completely unacceptable redness 
 
 
 
Circle the number that best describes your rosacea-related facial redness RIGHT NOW. 

 
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Appendix 4:  Skindex 16 
 
 

 
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Appendix 5: Fitzpatrick Skin Assessment  
Score 
 
0 
1 
2 
3 
4 
 
What is the 
natural color of 
your hair? 
Sandy red 
Blond 
Chestnut, 
dark blond 
Dark 
brown  
Black 
 
What is the eye 
color? 
Light blue, 
Gray, 
Green 
Blue, 
Gray, 
Green 
Blue 
Dark 
Brown 
Brownish 
Black 
 
What is the color 
of sun unexposed 
skin areas? 
Reddish 
Very pale Pale with 
beige tint 
Light 
brown 
Dark 
brown 
 
How many 
freckles on 
unexposed skin 
areas? 
Many 
Several 
Few 
Incidental 
None 
 
What happens 
when you are in 
the sun TOO long 
without 
sunblock? 
Painful 
redness, 
blistering, 
peeling 
Blistering 
followed 
by 
peeling 
Burns, 
sometimes 
followed 
by peeling 
Rarely 
burns 
Never 
had a 
problem 
 
How well do you 
turn brown? 
Hardly or 
not at all 
Light 
color tan 
Reasonable 
tan 
Tan very 
easily 
Turn dark 
very 
quickly 
 
Do you turn 
brown within one 
day of sun 
exposure? 
Never 
Seldom 
Sometimes 
Often 
Always 
 
How does your 
face respond to 
the sun? 
Very 
sensitive 
Sensitive 
Normal 
Very 
resistant 
Never 
had a 
problem 
 
When did you last 
expose yourself to 
the sun or 
artificial sun 
treatments? 
More than 
3 months 
ago 
2-3 
month 
ago 
1-2 months 
ago 
Less than 
1 month 
ago 
Less than 
2 weeks 
ago 
 
Do you expose 
the area to be 
treated to the sun? 
Never 
Hardly 
ever 
Sometimes 
Often 
Always 
• 00-07 points = Skin type I 
• 08-16 points = Skin type II 
• 17-25 points = Skin type III 
• 25-30 points = Skin type IV 
• 30-40 points = Skin type V & VI 

 
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Appendix 6:  Telangiectasia Assessment  
  
Score 
Grade 
Definition 
0 
Clear 
No telangiectasia 
1 
Mild 
Only few fine vessels discernible, involves 10% or less of the 
facial area 
2 
Moderate 
Multiple fine vessels and/or few large vessels discernible, 
involves > 10% - 30% of the facial area 
3 
Severe 
Many fine vessels and/or large vessels discernable, involves 
> 30% of the facial area