The most recent evidence and understanding of rosacea therapeutic targets is discussed in a review published in the Annales de Dermatologie et de Vénéréologie.
An investigator at the Université de Strasbourg in France evaluated rosacea literature published during the past 15 years. The review author focused on 9 potential treatment targets: vascular changes, erythema and telangiectasia, flushing, innate immunity, neurovascular components, Demodex mites, microbiota, sebaceous glands, and external factors.
For permanent erythema, flushing, telangiectasia, and rhinophyma, it was acknowledged that pulsed-dye laser (PDL) and potassium titanyl phosphate laser and intense pulsed light (IPL) therapies have been shown to be effective at treating the vascular component of rosacea. Some patients with rosacea may require multiple laser treatments to achieve desired results. In addition, the novel treatment photodynamic therapy (PDT) has been shown to improve erythema and telangiectasias, however, the effects may be temporary.
Botulinum toxin has been shown to improve symptoms of flushing for several months. The review author cautioned that only a few case studies or small comparative trials have been published to date, calling into question quality of evidence.
Antihypertensive drugs, such as beta-blockers, have been used for the treatment of flushing and the neurovascular component of rosacea. Despite the wide use of beta-blockers to address flushing, the review author failed to find a clinical trial demonstrating its efficacy. Before beta-blocker use, patients should be evaluated by electrocardiogram and consult with a cardiologist.
Azelaic acid, topical ivermectin, metronidazole, and doxycycline have been used to treat the innate immunity component of rosacea. Anti-inflammatory, antioxidant, and antienzyme attributes of treatments have shown efficacy for treating symptoms.
There is robust evidence that Demodex folliculorum plays a role in rosacea, however, the physiopathological role of Demodex in disease remains poorly understood. Furthermore, both medications with no anti-parasitic effects and anti-parasitic effects have been shown to improve symptomology. The most common treatment targeting Demodex is 1% ivermectin which has been shown to improve symptoms and quality of life.
More recently, sebaceous glands have been of interest in rosacea with several studies finding sebaceous secretion abnormalities in patients with rosacea. Although additional study into the role of sebaceous glands in rosacea is needed, isotretinoin has been shown to have a positive result in edematous rosacea.
The review author concluded, “Treatment of rosacea has evolved considerably over the last 15 years, along with the publication of many new physiopathological findings. Clinical trials have progressed significantly with regard to a disease in which standard treatments long had an empirical basis. Current management recommendations are based on a phenotypic approach: each symptom is subject to more or less specific management, depending on patients’ individual goals. The definition of different therapeutic targets is made possible by new data on the mechanisms of the disease. Rosacea is becoming increasingly complex, with various intertwining elements, including inflammation, a vascular component, Demodex mites, microbiota, and the environment, not to mention progress in genetics.”
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Cribier B. Rosacea: Treatment targets based on new physiopathology data. Ann Dermatol Venereol. 2022;149(2):99-107. doi:10.1016/j.annder.2021.11.001