Topical and Systemic Treatments for Rosacea-Associated Erythema: Weighing Your Options

Medications used to reduce the erythema and flushing associated with rosacea may provide temporary relief, but they do not alter the chronic nature of the disorder, according to the results of a systematic analysis of a variety of therapies used to treat the condition. The finding were published in Dermatologic Clinics.¹

With limited treatment options available for the medical management of facial erythema, telangiectases, and flushing associated with rosacea, the investigators sought to review the various topical and systemic treatments currently in use to help facilitate decision making in clinical practice. 

It is unlikely that a single treatment modality will result in total and permanent resolution of symptoms in those with the condition, but when tailored to the appropriate clinical scenarios, certain treatments will yield good results in certain patients. 

Topical medications, administered either as monotherapy or as part of a combination treatment regimen, are the first-line choice and are often sufficient to treat mild to moderate erythematotelangiectatic rosacea or papulopustular rosacea (PPR). Telangiectases are not likely to improve with the use of topical agents and are best managed with light-based therapies.

Brimonidine 0.33% topical gel has been approved for the treatment of persistent facial erythema of rosacea.² Adverse events associated with use of brimonidine are usually dermatologic in nature and mild or moderate in intensity. Oxymetazoline 1% cream was approved by the US Food and Drug Administration in 2017 to reduce persistent facial erythema associated with rosacea in adults, based on the results of 2 randomized trials.³ 

Although available data are limited, a number of topical agents that are not approved by the US Food and Drug Administration are available for the treatment of rosacea-associated erythema. Among these agents are calcineurin inhibitors, including tacrolimus and pimecrolimus; permethrin; crotamiton; ivermectin; and topical retinoids. Although therapeutic benefits have been reported with some of these agents, data are limited to only a few studies and only a small number of patients have received treatment with these alternative topical therapies.

If erythema is extensive or is not well controlled with topical agents, oral medications, such as tetracyclines or beta-blockers may be recommended.⁴ Orally administered treatments may initially be combined with topical agents. Limited data are available on the use of oral agents for the treatment of erythematotelangiectatic rosacea compared with PPR.

Although isotretinoin is used primarily for the treatment of severe, refractory, inflammatory acne, oral isotretinoin doses from 0.5 to 1.0 mg/kg per day are an effective treatment for patients with severe PPR.⁵

The investigators concluded that there have been few effective treatments for erythema in rosacea, with patients often being advised to avoid triggers. The welcome addition of topical brimonidine and oxymetazoline is a hopeful indication that new therapies will soon be available for the reduction of rosacea-associated erythema. The need exists for high-quality, well-designed, rigorously reported studies of treatments for rosacea. 

References

1. Cline A, McGregor SP, Feldman SR. Medical management of facial redness in rosacea.  Dermatol Clin. 2018;36(2):151-159.
2. Fowler J Jr, Jackson M, Moore A, et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013;12(6):650-656.
3. Allergan. Allergan Announces FDA Approval of RHOFADE™ (Oxymetazoline Hydrochloride) Cream, 1% for the Topical Treatment of Persistent Facial Erythema Associated With Rosacea in Adults [news release]. https://www.allergan.com/news/news/thomson-reuters/allergan-announces-fda-approval-of-rhofade-oxymet.aspx. January 19, 2017. Accessed May 30, 2018.
4. Elewski BE, Draelos Z, Dreño B, Jansen T, Layton A, Picardo M. Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group. J Eur Acad Dermatol Venereol. 2011;25(2):188-200.
5. van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262.