National report — Therapies in the investigational drug pipeline are joining existing treatment options for redness associated with rosacea, according to two clinicians.
Findings from a Cochrane Systematic Review show evidence of the effectiveness of topical azelaic acid, topical metronidazole and oral subantimicrobial dose doxycycline for the treatment of papulopustular rosacea (PPR). The use of brimonidine 0.33 percent topical gel (Mirvaso, Galderma), laser and light modalities, and various off-label pharmacologic treatments also serve as effective options for managing the facial erythema, telangiectasias and phymatous changes associated with this common disease, says Hilary E. Baldwin, M.D.
The Food and Drug Administration (FDA) in August 2013 approved topical brimonidine gel for the treatment of facial redness in adults with rosacea. Although there was some evidence from clinical trials that facial redness improved in patients using topical azelaic acid gel or subantimicrobial dose oral doxycycline to treat PPR, the change in skin color was predominantly due to a reduction in perilesional erythema rather than in the background redness that is mediated by vasodilation as well as inflammation, says Dr. Baldwin, associate professor and vice chair, department of dermatology, State University of New York at Brooklyn.
Brimonidine is an alpha-2 agonist that causes reversible vasoconstriction of the small blood vessels in the skin. When applied topically, redness is reduced within about 30 minutes, and the benefit persists for about 12 hours, after which there is a gradual return to the baseline state.
“Due to its temporary effect, I instruct patients to apply topical brimonidine in the morning on days when they care about reducing facial redness and to forego its use on the days when they are not concerned,” Dr. Baldwin says.
She notes that there is no “Cinderella phenomenon” with topical brimonidine use, wherein the medication effect wears off and the face suddenly becomes bright red again. In the pivotal clinical trials, topical brimonidine was not associated with rebound of facial erythema, i.e., worsening of erythema compared with baseline after treatment cessation.