Recent Advances in Understanding and Managing Rosacea

New evidence suggests mechanisms of neurovascular dysregulation and a heightened autoimmune response that may be triggered by both environmental and genetic factors.^1,2 Transcript receptor potential (TRP) subfamilies ankrin (A1) and vanilloid (V1 and V4) have particularly been implicated in cellular responses to triggers that result in aggravation and continuation of underlying neurogenic inflammation in rosacea.²

Rosacea Treatment Strategies

Therapy for rosacea includes basic general skin care, trigger avoidance, and pharmacologic and non-pharmacologic treatments based on symptoms. General skin care for rosacea involves regular cleansing with nonirritating products, moisturizing, and regular use of sunscreen. Beyond this, treatment for individual symptomatic patterns usually involves combinations of topical agents with laser therapies and systemic treatments.²

Novel Therapies

In recent years, several therapies have improved the management of different symptoms of rosacea.^2,4 Brimonidine, a highly selective α-adrenergic receptor agonist, is recommended by most guidelines for the treatment of transient and persistent erythema and telangiectasia.⁶ Brimonidine is a topical agent with anti-inflammatory properties that cause contraction of vascular smooth muscle and constriction of the local blood vessels.^4,6 Another anti-inflammatory agent is 1% metronidazole cream, approved for treatment of erythema and inflammatory lesions associated with rosacea.^2,4 A gel, 15% azelaic acid, has also demonstrated efficacy for treating the papulary pustules and erythema of PPR, but not other types of erythema.^2,4 Oxymetazoline hydrochloride 1% cream is a vasoconstrictive agent used for flushing and erythema.⁴

Effective treatments for mild to moderate papules and pustules include topical agents metronidazole, azelaic acid, sodium sulfacetamide sulfur, or ivermectin 1%, as well as a number of off-label therapies with agents such as erythromycin (2%) topical or oral, doxycycline, minocycline, permethrin, isotretinoin, or clindamycin.^2,6 Tetracycline has been used successfully for phymatous changes.^2,4

The anti-inflammatory and anti-parasitic action of ivermectin has shown efficacy in reducing the density of demodex mites, as well as in the treatment of ocular rosacea.⁴ Ivermectin combined with bromonidine has been beneficial in reducing facial redness and erythema.⁴

Changes to Procedural Therapies

Dual frequency ultrasound (DFU) is the latest addition to laser therapies for rosacea, following its initial success as an anti-aging therapy. Fractional microneedling radiofrequency (FMR) therapy represents a new device that has shown some promise in the treatment of rosacea, although to date studies have shown only moderate improvement.⁴

In a 2019 review of updates in the treatment of rosacea, Brittany Feaster, MHS, Center for Dermatology Research, department of dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina,  and colleagues, observed that the overall growth of therapies in this field has been slow, resulting in relatively small improvement in rosacea outcomes.⁴ “Given the somewhat limited novel treatments for rosacea management, it is unlikely that a single modality will result in complete and permanent resolution,” the investigators wrote.

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References

1. Rainer B, Kang S, Chien A. Rosacea: epidemiology, pathogenesis, and treatment. Dermatoendocrinol. 2017;9(1):e1361574.

2.  Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000Res. 2018; 7. pii: F1000 Faculty Rev-1885.

3. Alinia H, Tuchayi SM, Patel NU, et al.  Rosacea triggers: Alcohol and smoking. Dermatol Clin. 2018;36(2):123-126.

4. Feaster B, Cline A, Feldman SR, Taylor S. Clinical effectiveness of novel rosacea therapies. Curr Opin Pharmacol. 2019;46:14-18.

5. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):584-587.

6 Juliandri J, Wang X, Liu Z, Zhang J, Xu Y, Yuan C. Global rosacea treatment guidelines and expert consensus points: The differences [published online February 26, 2019]. J Cosmet Dermatol.doi:10.1111/jocd.12903