Managing Rosacea: Facing Future Flare-ups

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Rosacea is a chronic inflammatory disorder characterized by erythema, facial flushing, telangiectasia (symmetric reddening) of the face, coarseness of the skin, small, red papules (solid bumps), pustules (pus-filled pimples), granulomatous nodules, phyma formation, and ocular changes and often resembles acne.^1-3 Rosacea affects an estimated 14 million individuals in the United States between the ages of 30 and 50 years of age, and it is found in women more than men at a ratio of 3:1.^2,4,5 Rosacea occurs mainly in the area of the cheeks, nose, forehead, around the mouth and the eyes, and if untreated, may extend to the scalp and palmar surfaces.^3,5

Ocular changes occur in more than 50% of patients and commonly cause mild dryness and irritation with blepharitis, conjunctivitis, and very rarely, sight-threatening keratitis.^4,6 Patients with rosacea may experience increased sensitivity of the facial skin and may have dry, flaking facial dermatitis, edema of the upper face, or persistent granulomatous papulonodules.⁴

Although rosacea is more common in women than men, men are more likely to develop phymas.^2,4 The course of the disease is typically chronic with episodes of remissions and flare-ups. Little is known about the inflammatory process that causes rosacea; however, several factors have been identified that may trigger or aggravate rosacea.^5-7 Common triggers for flare-ups include sun exposure, emotional stress, cold or hot weather, alcohol, spicy foods, exercise, wind, cosmetics, hot baths, or hot drinks.^5,6 The use of certain medications such as amiodarone, topical steroids, nasal steroids, and large doses of vitamins B6 and B12 may cause flare-ups for patients with rosacea.¹ The National Rosacea Society strongly recommends that patients keep a symptom diary to identify the specific triggers and track symptoms in order to see if a pattern of what worsens rosacea develops. Patients can then use this information to avoid future flare-ups.

Although not a life-threatening condition, rosacea can have a negative impact on a patient’s self-esteem and quality of life.⁷ In recent surveys by the National Rosacea Society, more than 76% of rosacea patients reported that having rosacea lowered their selfconfidence and self-esteem, and 52% reported that it caused them to avoid public contact or not attend social engagements. Nearly 70% of those with severe rosacea reported that the disorder had adversely affected their professional interactions, and nearly 30% said they were frequently absent from their jobs because of rosacea.^7,8

Classification of Rosacea

In 2002, the National Rosacea Society developed and published a classification system that is based on predominant lesion morphology.^1,9 Patients are classified as having 1 of 4 types of rosacea: erythematotelangiectatic, papulopustular, phymatous, or ocular, with a variant form referred to as granulomatous.^1,9

Some patients may exhibit characteristics of more than one subtype at the same time, and those often may develop in succession.^2,9 Because rosacea develops gradually, many patients may be unaware that they have this condition and may assume that the signs and symptoms they are experiencing are due to intermittent facial flushing and that the papules and pustules are related to adult acne, sun or wind burn, or normal effects of aging.⁷ It is important for patients to obtain early treatment, because, if left untreated, rosacea can lead to irreversible damage and vision loss.⁷

Treatment

Although rosacea is not curable, it can be managed with proper treatment. Primary initial treatment of rosacea involves avoidance of triggers and the routine use of sunscreen. Because some sunscreens can trigger cutaneous irritation and produce erythema, pharmacists should advise patients to use sunscreens that contain silicones (dimethicone or cyclomethicone) to minimize skin irritation, stinging, and erythema.¹⁰

Topical Treatments

Topical treatments approved by the FDA for rosacea include metronidazole (0.75% and 1%), sodium sulfacetamide 10% with 5% sulfur lotions and creams, and 15% azelaic acid gel. They are indicated for the management of papules, pustules, and erythema.¹⁰ Topical metronidazole, which is effective for stage I and stage II rosacea and avoids the toxicity of systemic treatment, is considered first-line therapy.⁷ Metronidazole is available in a twice-daily application of 0.75% cream or gel and in a once-daily 1% formulation.^4,7 Patients should be advised to cleanse the affected area prior to application of topical metronidazole. The most common adverse effects associated with the use of topical metronidazole include burning, skin irritation, dryness, transient redness, tingling, and nausea.

Sodium sulfacetamide 10% with sulfur 5% formulations are typically used twice a day. This formulation may be less irritating than topical metronidazole.⁷ The most common adverse effects associated with sodium sulfacetamide with sulfur include mild irritation, stinging, or burning of the skin.⁷

Azelaic acid is a naturally occurring, dicarboxylic acid possessing antibacterial activity and is available as a 20% cream to be used twice daily. The most common adverse effects include erythema, stinging, burning, and pruritus.

Other topical agents, which are not approved by the FDA, that have been used in the treatment of rosacea, include benzoyl peroxide, retinoids, clindamycin, and topical steroids.^10,11

Oral Antibiotics

Oral antibiotics have been used in the treatment of rosacea since the 1950s and are indicated for those patients with multiple papules or pustules, as well as those with ocular rosacea. In 2006, the FDA approved a controlled-release formulation of doxycycline monohydrate (Oracea) for the treatment of rosacea. It is available as 40-mg capsules, which are administered once daily, and it is the first and only oral agent approved for the treatment of the inflammatory lesions (papules and pustules) of rosacea in adult patients. Oracea is unique because, at its low dose, it has only anti-inflammatory and subantimicrobial effects; therefore, it does not have an increased incidence of antimicrobial resistance.^2,12 This controlled-release formulation of doxycycline monohydrate is expected to enhance patient adherence and efficacy.² Common adverse effects include sore throat, diarrhea, and sinus infections.¹² Oracea should not be used in women who are pregnant or those individuals of either sex planning to conceive a child.¹² Patients also should be advised that the use of this agent may decrease the effectiveness of low-dose oral contraceptives. ¹²

Since the approval of the once-daily, submicrobial dosing of doxycycline, oral therapy has become more commonly prescribed as first-line treatment for rosacea. In many cases, a combination of oral and topical antibiotics are used for a synergistic effect.² In some cases, the patient is converted to topical products only for maintenance therapy.²

Examples of other oral antibiotics commonly prescribed for rosacea include tetracycline and its derivatives– doxycycline and minocycline– as well as the macrolides (erythromycin, clarithromycin, and azithromycin). Second-generation macrolides, such as clarithromycin and azithromycin, have been shown to work faster and with less gastrointestinal distress than erythromycin. Once a beneficial response is achieved, the lowest possible dosages should be used to control symptoms.³ Patients should be advised to adhere to the prescribed regimen for the allotted duration of therapy.

In cases of rosacea that are not responsive to other treatments, oral isotretinoin has been used.^3,7 Due to the serious adverse effect profile, the use of isotretinoin is often limited. This agent is contraindicated in pregnancy due to its teratogenic effects.⁷

During counseling, pharmacists can reassure patients that, although no cure exists for rosacea, a variety of treatments are available to effectively manage this condition, as well as minimize the incidence of flare-ups. Patients should understand the importance of adhering to prescribed regimens, the regular use of a nonirritating sunscreen, and to immediately seek medical care if their condition shows any signs of worsening. Pharmacists should encourage patients exhibiting signs of rosacea, who have not been diagnosed, to consult their primary health care provider for medical evaluation to prevent further complications.

It also is important to remind patients to use only nonirritating and hypoallergenic facial cleansers, lotions, and cosmetics.¹⁰ Patients should be advised to avoid facial products that contain alcohol, witch hazel, menthol, peppermint, eucalyptus oil, or clove oil and to blot–not rub–the facial area when cleansing or drying skin.¹⁰

It is important to remind patients that a collaborative approach incorporating nonpharmacologic and pharmacologic measures will provide the best management of rosacea. The greatest defense in managing rosacea is providing the patient with a thorough understanding of this condition, the factors that trigger flare-ups, and the various treatment options available. â–