Emerging therapies for rosacea have a favorable side effect profile and address specific symptoms of the condition; brimonidine, for example, addresses background erythema while ivermectin addresses the papules and pustules.
Greater understanding of the pathophysiology of rosaceais leading to the emergence of newer therapies to address the chronic condition, say leading dermatologists who frequently treat the condition.
"People with rosacea tend to have more demodex mites on the skin, but we all have those," says Joseph F. Fowler, Jr., M.D., FAAD, a dermatologist in Louisville, Ky. and a Clinical Professor of Dermatology at the University of Louisville and Assistant Clinical Professor in the Division of Occupational Medicine at the University of Kentucky.
Topical option: ivermectin
The approval by the Food and Drug Administration of ivermectin represents an advance in topical treatment of a chronic and inflammatory condition, according to Dr. Fowler.
It appears to be at least as effective as our standard treatments," explains Dr. Fowler. "In addition to killing the demodex mites, ivermectin has an anti-inflammatory effect. What we don't know is if the product is working
because it is killing the demodex mites, or is it because of an anti-inflammatory effect on the skin, or is it because of both?"
Experience with ivermectin is still early, but data from various clinical trials suggest the topical therapy is well-tolerated, safe, and as or more effective in decreasing inflammatory lesions compared to other topical therapies like azelaic acid or metronidazole, says Hilary Baldwin, M.D., a board-certified dermatologist in private practice in Brooklyn, N.Y. and an Associate Professor at the State University of New York, Downstate in Brooklyn, N.Y.
"It will likely be my first choice of topical therapy for rosacea," says Dr. Baldwin. "It is offering really good response."
Topical option: brimonidine
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."
Topical & systemic therapies
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.
Rosacea skin care essentials
Regardless of the use of new additions to the rosacea therapeutic armamentarium or the use of existing therapies, patients with rosacea need to practice good skin care, a practice that is vital to temper the symptoms of rosacea that patients can find distressing.
"It is skin that is inflamed, red, and very sensitive," says Diane Berson M.D., a dermatologist in private practice in New York, N.Y. and Associate Professor of Dermatology at Weill Cornell Medical College in New York. "We recommend that patients use mild cleansers, moisturizers, and avoid using products that exacerbate the redness.”
"In addition to the release of inflammatory mediators and vascular hypersensitivity, we see a compromised epidermal barrier in patients with rosacea," says Dr. Berson. "We recommend that our patients use moisturizers with barrier-repairing ingredients. These include epidermal lipids such as ceramides and the humectants glycerin and hyaluronic acid. By restoring the barrier, you can improve the inflammation and sensitivity."
If patients want to camouflage the redness associated with rosacea, mineral makeup is a wise choice, notes Dr. Berson. Patients with rosacea also often have co-existing photo-damage and, as sunlight is a trigger that exacerbates rosacea flares, inorganic sun-blocking agents are appropriate for these patients.
Dr. Fowler has been a consultant and/or investigator for Galderma and Bayer. Dr. Baldwin is an advisor and speaker for Galderma. Dr. Berson is a consultant for Galderma, Allergan, and Valeant.
Gottschalk, Preston. Poster presented at: Fall Clinical Conference, October 2013; Las Vegas, NV.