New developments in rosacea call for dermatologists to place greater emphasis on addressing persistent facial redness (erythema), according to experts at a recent National Rosacea Society (NRS) roundtable to provide an update on this key aspect of the disorder. The roundtable participants discussed the new standard classification system,1 recent burden-of-illness study results, new standard management options and significant advances in medical therapy and patient care.
“Rosacea encompasses a multitude of possible combinations of signs and symptoms, and we now have an arsenal of medical therapies to address each of them directly,” noted Dr. Richard Gallo, chairman of dermatology at the University of California – San Diego. “It is more important than ever that patients are made to understand that effective treatment is more than simply ‘Take your medicine.’ The good news is that a combination of rosacea therapies may often offer a synergistic effect, and a clear and detailed explanation of how exactly to use the various oral and topical therapies can help provide results that will improve quality of life.”
Dr. Gallo noted that recent studies have shown that rosacea’s diverse features, from erythema to papules and pustules to phymatous changes, appear to be part of a consistent continuum of inflammation. As a result, medical therapies that work by reducing inflammation may be useful in treating not only papules and pustules, for instance, but also erythema.
The impact on quality of life of severe redness was illustrated in a recent burden of illness study.2 In the survey of 708 respondents, the mean scores on a validated Dermatology Life Quality Index (DLQI) were 5.2 overall, which is comparable to scores for acne patients. However, respondents with severe erythema scored a 13.4 — comparable to scores for eczema and psoriasis patients, noted Dr. Hilary Baldwin, associate professor of dermatology at Rutgers Robert Wood Johnson Medical School.
The doctors noted that two FDA-approved therapies exist specifically to treat erythema. Though both are alpha agonists, they act on different receptors and have different actions, said Dr. Linda Stein Gold, director of dermatology clinical research at the Henry Ford Health System.
“Brimonidine kicks in within 30 minutes and many patients see a dramatic reduction of their erythema,” Dr. Stein Gold said. Exacerbations of redness have also been reported, she explained, peaking at 3-6 hours and as the medication began wearing off at 10-12 hours. A possible remedy may be to apply one pea-sized amount rather than five, which is instructed in the package insert, to various areas of the face. Women who are flushers and blushers may be more likely to experience a rebound, she said.
Oxymetazoline, the other FDA-approved treatment, has a more gentle onset, Dr. Stein Gold noted, with some improvement evident in 1-3 hours and continued impact seen over the course of the day, while the return of redness can occur in a more subtle way. The exacerbation of redness seen in brimonidine was not seen with oxymetazoline clinical trials. For many patients, oxymetazoline results in normal-appearing skin tones and may be easier to use, leading to better compliance with therapy.
“One question we need to consider is whether we are modifying the disease in the long term,” she said. In long-term studies of alpha agonists, patients appeared to have improved baseline redness over time, though the drugs’ ability to inhibit disease progression is untested.
Though the quality of evidence is limited, intense pulsed light (IPL), pulsed dye and potassium titanyl phosphate (KTP) lasers have proven effective in removing visible blood vessels (telangiectasia) and diminishing redness. Dr. Stein Gold added that she was aware anecdotally of physicians using alpha agonists to clear redness in order to better identify telangiectasia for laser treatment.
While rosacea is still treated by many with a monotherapy approach, the doctors agreed that treating every present sign or symptom (phenotypes) with targeted therapies in cooperation with the patients will achieve the best overall outcome, both in terms of clear skin and quality of life.
Dr. Julie Harper of the Dermatology and Skin Care Center of Birmingham, added that a combination of phenotype-specific therapies may work better when taken together than when staggered. She cited a study by Dr. Stein Gold that found using brimonidine for erythema together with ivermectin for papules and pustules from the start resulted in clearer skin than using brimonidine only after several weeks had passed.3
In addition to a comprehensive treatment plan, educating patients on compliance — explaining the need for multiple medications and how they should be used — is necessary, Dr. Harper stressed. The time of day, frequency and areas of application should be clearly explained. A patient who applies oxymetazoline before bed won’t see the full benefit of treatment, for example.
1. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018 Jan;78(1):148-155. Epub 2017 Oct 28.
2. Baldwin HE, Harper J, Baradaran S, Patel V. Erythema of rosacea affects health-related quality of life: results of a survey conducted in collaboration with the National Rosacea Society. Dermatol Ther 2019;9(4):725–734.
3. Gold LS, Papp K, Lynde C, et al. Treatment of rosacea with concomitant use of topical ivermectin 1% cream and brimonidine 0.33% gel: a randomized, vehicle-controlled study. J Drugs Dermatol 2017;16(9):909–916.