April has been designated Rosacea Awareness Month by The National Rosacea Society (NRS) in an effort to educate the public on the impact of this chronic and widespread facial disorder.
The standard management options for rosacea were updated in 2020 and published in the Journal of the American Academy of Dermatology. The updated guidelines were developed to provide clinicians with a detailed summary of available treatment options for rosacea patients.1
Every April is designated Rosacea Awareness Month by the National Rosacea Society. Zoe Diana Draelos, MD, and editor in chief of Dermatology Times® offered insights into her practices and individualized methods for treating rosacea in her patients.
Zoe Draelos, MD: Hello, my name is Zoey Diana Draelos. I'm a clinical and research dermatologist with Dermatology Consulting Services, which is a freestanding laboratory developing and testing, cosmetic and pharmaceutical products.
Dermatology Times®: What is the importance of patient adherence?
Draelos: I think it's important to recognize that rosacea is a chronic disease and because it's a chronic disease, it requires continued treatment. And one of the goals of treatment is to prevent rosacea from worsening; from going from the erythematous stage to the inflammatory papulopustular stage and avoiding the rhinophyma stage. So adherence is really important because it's different than treating an acute infection. For example, you may get pneumonia, you take an antibiotic, and it's done. Rosacea isn't like that, it requires continued attention and continued maintenance.
Dermatology Times: Do you customize treatment plans for patients?
Draelos: I don't think you can have a set management program because each individual's needs are different. And some people are comfortable with cream and some people want to take pills. There are males or females. There are people who work in different occupations because we know many of the triggers for rosacea are temperature, going from hot to cold, cold to hot, very humid environments, and sweaty environments. For the peri-menopausal woman with rosacea versus someone who's in their 30s and 40s with rosacea. Customization, I think, is a must, because rosacea affects people of all different ages, and both sexes, and has many different manifestations. So for the first stage of rosacea where people just get some redness of the face, the erythema part of rosacea can be very nicely treated with 2 products we currently have which are brimonidine and oxymetazoline. Brimonidine is an interesting topical agent; it induces vasoconstriction very quickly, and then it wears off very quickly, boom, and the redness comes back. Oximetazoline, on the other hand, takes longer for it to take effect, and then it wears off slower as well. So one of the tricks that I have learned is to use a little bit of brimonidine, and a little bit of oxymetazoline, and use them together. And that way you get immediate effect of brightness reduction, but on the other end, you get more slow release. So I like to use both of those creams together, then to that,I add topical ivermectin or an oral antibiotic, so you could use low-dose doxycycline, low-dose minocycline, or seracycline, which is a new antibiotic. It is only approved for the treatment of rosacea, but it can be used off -label quite effectively for rosacea, but it's basically used for acne. That's what seracycine's current indication is. The other thing with topical ivermectin is, many times when people have an inflammatory papular pustular component, topical ivermectin, which is an anti-parasitic that destroys the demodex mites on the face, is very effective as well. So either orals or topicals. And then once people get better, you either can take them off the oral antibiotic and keep them on ivermectin or add ivermectin, or once they get very stable, ivermectin instead of being used every day, you can use it during the maintenance phase. Again, this is off label again, but you can use it twice a week, once a week and find out the minimum amount of application that keeps the inflammatory state of the disease under control. So those are a couple of little pointers that I use in my practice to try and customize treatment for my patients.
Dermatology Times: What are some common comorbidities seen in rosacea patients?
Draelos: Rosacea can also affect the eyes, actually to the point of severe corneal scarring, which can result in blindness. So ocular rosacea should not be overlooked. So when is a dermatologist you're looking at their skin, you have to remember that the eyelashes are hair and the eyelids are skin and if you notice injection blepharitis you need to address that as well. Oral antibiotics work quite well and better eye hygiene like using baby shampoo to wash the eyelid margin to keep the Demodex count down is very very important.
Dermatology Times: What are your skin care recommendations for rosacea patients?
Draelos: Cleansing is really important for rosacea patients. Some of your cream to foam cleansers are good. And then a moisturizer is key because many of the medications are slightly drying. A good non-comedogenic hypoallergenic moisturizer, used day and night, can also help reduce the redness of rosacea. So successful treatment is pharmaceutical and cosmetic skincare products combined together to yield a much better outcome for the patient.
Transcript edited for clarity
1. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020 Jun;82(6):1501-1510. doi: 10.1016/j.jaad.2020.01.077.