Managing rosacea: Practitioners discuss trends

I recently moderated numerous advisory panels during which we spoke to 226 practicing specialists in the field of dermatology on the topic of rosacea management. The panels were conducted across the United States and included dermatologists, nurse practitioners and physician assistants. We met in small groups, mixing didactic presentations with open-ended discussions. We discussed a wide array of topics, from the history of rosacea therapies in the United States to new frontiers for topical treatments.

The responses were compelling because they shed new light on trends in rosacea management and provided insight into some possible reasons for those trends.

Our first topic was the actual management of this chronic, recurring condition. Given the numerous hypotheses for the pathophysiology of rosacea, its management should involve four aspects: patient education, skincare management, the control of environmental (so-called trigger) factors, and pharmacologic intervention. Following are some of the questions posed and a summary of prescriber responses:

The overwhelming majority of prescribers discuss trigger factors with patients, but the identification of a trigger factor requires reflection by the patient, so a list of potential triggers to be reviewed later is provided.

Some patients may, however, mistakenly believe that simply avoiding trigger factors can prevent all recurrences. To address this, prescribers ask patients to think of rosacea as a chronic condition such as diabetes or heart disease, while still stressing avoidance of trigger factors in order to give the patients control.

Treatment compliance relies on many different aspects, such as patient education, a proper skincare regimen, the control of environmental factors and medical interventions. Most cited poor patient treatment compliance as the primary reason for therapy failure.

The main explanation was unrealistic patient expectations. Many patients expect symptoms to clear and remain clear without further treatment, and when symptoms persist, patients become discouraged and discontinue therapy.

Managing patient expectations takes many forms. Patient education is the key to realistic expectations and enhanced compliance. By setting realistic goals such as avoidance of trigger factors, and by emphasizing the chronic nature of rosacea, one can separate patient perception of treatment failure from actual failure and, ideally, enhance compliance.

Proper skincare also plays a vital role in the management of rosacea, as certain moisturizers and cleansers can help repair and/or maintain the skin barrier, while sunscreens can prevent or minimize UV-induced erythema and photosensitivity. In fact, many prescribers felt that skincare management was equal in importance to pharmacologic management.

Very few people use sulfacetamide/ sulfur as first-tier monotherapy for rosacea, unless a concomitant condition such as seborrheic dermatitis or acne is present. Nonetheless, sulfacetamide/ sulfur is widely used in therapy for rosacea, and is almost invariably used in combination with other medications.

The majority have prescribed metronidazole, in a range of formulations and strengths, usually in combination with either oral or topical products. The most common topical combinations are with sulfacetamide/sulfur and azelaic acid (AzA) 15 percent gel in order to achieve the desired effect when treating erythema.

With 69 percent of prescribers reporting little or no success in treating erythema with metronidazole, a comparative trial of metronidazole confirmed this by demonstrating a plateau in efficacy of metronidazole after eight weeks (for both lesions and erythema). Of prescribers, 51 percent had experienced a leveling-off in improvement in treating erythema when using metronidazole. This would seem to be the reason why the majority prescribes AzA 15 percent gel in combination with metronidazole for erythema and as maintenance therapy.

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