The management of rosacea, a chronic and relapsing inflammatory dermatosis, has been historically challenged by the complexities involved in its pathogenesis. In a comprehensive review, a team of researchers describe the treatment modalities currently available to manage rosacea, including oral and topical agents, laser and light therapies, as well as skincare. The review was published online in the Journal of Cosmetic Dermatology.
To date, topical therapies approved by the US Food and Drug Administration for rosacea are:
· Azelaic acid (15%) gel: The researchers explain that azelaic acid 15% gel is indicated for mild to moderate rosacea. Azelaic acid reduces erythema and inflammatory lesions via inhibition of NADPH oxidase on the neutrophil cell membrane, which ultimately results in decreased reactive oxygen species (ROS). In addition, the researchers state that previous investigations have found that azelaic acid 15% gel and 20% cream are equally effective in the management of the papulopustular subtype of rosacea.
· Metronidazole (0.75%) in a gel, cream, and lotion, as well as 1% cream and gel: The authors of the review note that topical metronidazole features an anti-inflammatory effect that is mediated through reduced release of ROS from neutrophils. The researchers added that metronidazole 1% cream, when applied once daily, is associated with significant reductions in erythema and inflammatory lesions.
· Sodium sulfacetamide/sulfur (10%/5%) in a gel, cleanser, lotion, suspension, and cream: Similar to azelaic acid and metronidazole, sodium sulfacetamide/sulfur exert therapeutic effects through anti-inflammatory actions. The researchers note that this combination approach is contraindicated in patients who have renal disease and known drug hypersensitivity. According to the researchers, there are newer wash-off formulations comprising sodium sulfacetamide and sulfur that have better absorption and produce less irritation and odor.
· Brimonidine tartrate (0.33%) gel: This α-adrenergic receptor agonist also features anti-inflammatory effects, yet these effects occur via vasoconstriction of small subcutaneous vessels that leads to edema inhibition. The researchers note that this formulation has a rapid onset of action, and they state that many patients experience a 1-grade improvement of their condition within 30 minutes of application.
· Oxymetazoline hydrochloride (1%) cream: Considered a potent α-1 agonist, oxymetazoline hydrochloride features an onset of action that occurs within 1 to 3 hours fafter application with effects that last up to 10 hours.
· Ivermectin (1%) cream: The researchers wrote that ivermectin is effective for the papulopustular rosacea subtype.
Second-line agents for rosacea include calcineurin inhibitors tacrolimus and pimecrolimus, topical antibiotics clindamycin and erythromycin, as well as benzoyl peroxide.
According to the researchers, several factors should be considered in selecting topical therapies for rosacea, including:
· Skin type
· Predominant signs and symptoms
· Mechanism of action
· Efficacy and tolerability of the drug
· Prior treatment
Isotretinoin at 0.5 to 1 mg/kg/day is often used in the treatment of refractory and nodulocystic acne, but the researchers note that the oral agent can also be used to treat erythematotelangiectatic rosacea and papulopustular rosacea subtypes that are recalcitrant to other therapies.
Tetracyclines show clinical efficacy in the treatment of rosacea, which the researchers mainly attribute to the anti-inflammatory effects of this drug class. According to the researchers, the papulopustular rosacea subtype often responds well to 250 mg to 1000 mg/day tetracycline, 100 mg to 200 mg/day doxycycline or 40 mg once daily of a modified-release formulation, and 100 mg to 200 mg/day minocycline. The researchers added that doxycycline and minocycline feature increased bioavailability, longer half-life, and low gastrointestinal-related adverse effects compared with first-generation molecules.
Macrolides – including azithromycin, clarithromycin, and erythromycin – are effective and safe options for the treatment of papulopustular rosacea. The researchers noted that these therapies are particularly effective in patients who are not deemed good candidates for tetracyclines.
Metronidazole is effective for reducing the number of inflammatory lesions in papulopustular rosacea, the researchers noted. Previous research, cited by the investigators of the review, indicates that twice daily 200 mg metronidazole features similar efficacy as twice daily 250 mg oxytetracycline for improving rosacea as early as 6 weeks and after 12 weeks of treatment.
Laser and Light Therapy
The researchers point to several different laser and light therapy modalities that have shown efficacy in the treatment of rosacea. These modalities include:
· Intense pulsed light (500−1,200 nm)
· Pulsed dye laser (585−595 nm)
· Potassium titanyl phosphate (532 nm) laser
· Long-pulsed neodymium:yttrium-aluminum-garnet laser (1,064 nm)
Ablative lasers used in the treatment of phymatous rosacea include carbon dioxide and erbium:yttrium-aluminum-garnet lasers. According to the investigators, light-based treatments are particularly useful in the management of varied vascular manifestations of rosacea, including flushing, erythema, and telangiectasia.
Skincare and Patient Education
In addition to oral and topical therapies, dermatologists and other clinicians should provide education to patients about their rosacea and the potential triggers for the disorder. The researchers noted that while patient education is part of comprehensive management of rosacea, this education should be tailored to the individual patient’s aggravating factors. All patients, however, should be advised to reduce their sun exposure and improve their photoprotection efforts.
Physical sunscreens that contain zinc oxide, titanium dioxide, and iron oxide should be worn daily, even indoors given that ultraviolet A radiation can penetrate clouds and glass. Skin care should include mild soap-free cleanser and use of moisturizing agents to reduce skin irritation and maintain the epidermal barrier function. The researchers added that patients should also be counseled to avoid heavy makeup foundations, astringents, alcohol-based toners, waterproof cosmetics, and products that contain sodium lauryl sulfate.
Sharma A, Kroumpouzos G, Kassir M, et al. Rosacea management: A comprehensive review. J Cosmet Dermatol. Published online February 1, 2022. doi:10.1111/jocd.14816