To see successful outcomes with brimonidine, patients need to apply it optimally, offers Dr. Baldwin. "There is a learning curve to the application of the product," says Dr. Baldwin. "If you put it on helter skelter, you will get red streaks of red where you didn't put it and streaks of white where you did. You can also experience overwhitening if you apply too much (brimonidine)."
There is a phenomenon of rebound that clinicians say occurs occasionally with topical brimonidine, a vasoconstrictor that addresses the background redness of rosacea, but this phenomenon has not turned patients away from the therapy in most cases, notes Dr. Fowler.
"Some patients use the product, their face looks good, but the next morning they are redder compared to when they started out," says Dr. Fowler. "Most people don't find this to be a major issue. They continue to use the medication."
Even with new topical options available, patients may continue to choose systemic therapies like Apprilon because it does not pose any potential to irritating the skin the way topical products can. "The sensitivity of skin of rosacea patients is much greater [than individuals without rosacea]," says Dr. Fowler, a past president of the American Contact Dermatitis Society. Patients with rosacea “may want to choose systemic therapies instead of topical agents because they have found many topical agents sting, burn, and irritate."
A recent study1 suggests that patients who have had rosacea for longer periods of time may be more difficult to treat, according to Dr. Baldwin.
In this study, clinical response to Apprilon (anti-inflammatory doxycycline) was evaluated in conjunction with biomarker levels obtained from tape-strip and 2mm punch biopsies.
“The patients who did the best on Apprilon were the same people who had a larger decrease in MMP9 protease activity and down regulation of surface cathelicidin protein levels," says Dr. Baldwin, in an interview with Dermatology Times.
When stratified by duration of disease (less than or more than five years), patients who had their disease for a shorter amount of time did better clinically and had more significant decreases in the biomarker levels.
"One piece of information to glean from the study is that there may be a window of opportunity [to successfully treat rosacea], and when the window closes, patients may not be as responsive to therapy."
While it is not indicated for ocular rosacea, Apprilon or modified-release doxycycline has demonstrated success in treating the symptoms of ocular rosacea, such as decreasing redness and itchiness, explains Dr. Baldwin.