Topical Rosacea Treatment

Topical Rosacea Treatment
Acne Rosacea patients have a skin that is unusually vulnerable to chemical and physical insults. All sources of local irritation, such as soaps, alcoholic cleansers, tinctures, astringents, abrasives, and peeling agents must be avoided. Only mild soaps or cleansers are advised. Protection against sunlight must be emphasized.
Antibiotics, as used in acne, are sometimes effective. Topical tetracyclines, clindamycin, and erythromycin, usually in concentrations from 0.5% to 2.0%, are commercially available. Erythromycin and clindamycin seem to be superior. Tetracycline is effective orally, but a disappointment topically. An inhibition of chemotaxis or inflammatory cells or a direct effect on vascular endothelium may be responsible for its action.
Metronidazole has become an important addition to the Anti-Rosacea repertoire. The observation that topical metronidazole was comparable in its effects to oral tetracycline (250 mg bid) led to placebo-controlled double-blind clinical studies demonstrating its effectiveness. In many countries throughout the world there is a 0.75% gel, cream, or lotion, as well as a 1% cream available. It is applied once or twice daily and has its greatest effect on papules and pustules, and reduces erythema to a lesser degree. It does not alter telangiectases or flushing. Topical metronidazole may be used as monotherapy or, in more severe forms, in combination with oral antibiotics. One study found that 0.75% metronidazole gel rapidly reduced inflammatory lesions during the first 3 weeks of treatment, potentially allowing quick tapering and discontinuation of oral medication. Long-term use of 0.75% metronidazole gel has been shown to keep Acne Rosacea in remission. A study involving 88 patients whose Acne Rosacea was initially controlled with a combination of oral tetracycline and metronidazole found that more than 80 percent of those patients given metronidazole remained in remission after 6 months, while 40 percent of those patients given placebo relapsed. The mechanism by which metronidazole ameliorates the inflammatory lesions and erythema of Acne Rosacea may be related to anti-inflammatory or immunosuppressive actions of the drug.
Imidazoles are also gaining popularity with the treatment of Acne Rosacea. Best results are with ketoconazole cream applied once or twice daily. The imidazoles are anti-inflammatory agents, affect gram-positive bacteria, and, above all, are well tolerated by most Acne Rosacea patients with sensitive skin.
Old-time remedies should not be forgotten, even though their use is not supported by evidence-based trials. Drying lotions fall into this category, with a very thin application at night recommended. Lotions with 2% to 5% sulfur have been used successfully. Because they are messy, we no longer use them. Other topical medications proven effective for treating Acne Rosacea include sulfacetamide sodium 10% lotion, as well as sulfacetamide sodium 10% and sulfur 5% lotion, which may be tinted or tint free. They are used in a similar fashion and for the same purpose as metronidazole.
Retinoids are worth a trial. In an uncontrolled clinical study, women with Acne Rosacea used 0.025% tretinoin cream over a period of several months. After a predictable early exacerbation of symptoms, the patients then appeared to develop hardening and side effects diminished. Gratifying long-term results were reported, including a reduction in erythema. Alternative topical retinoids may prove easier to use. There is preliminary evidence that 0.2% isotretinoin in a bland cream is helpful. It is less irritating than tretinoin, and suppresses inflammatory lesions in stage II and III Acne Rosacea. No data exist for adapalene, which seems to be the least irritating of all topical retinoids.
In a clinical study, 20% azelaic acid cream was more effective than its vehicle cream in reducing the number of inflammatory lesions and degree of erythema associated with Acne Rosacea. In a recent study, 20% azelaic acid cream gave results comparable to 0.75% metronidazole cream with the added benefit of increased patient satisfaction. The efficacy of azelaic acid in Acne Rosacea may be due to the anti-inflammatory properties of this compound.
As stated earlier, Demodex folliculorum mites are not considered to play a causative role in Acne Rosacea, although massive infestation of Demodex folliculorum mites may sometimes aggravate the condition. Nevertheless, it is good to check for mites. This is best done with the skin-surface biopsy technique of placing a drop of cyanoacrylate on a glass slide that is covered with immersion oil and analyzed with the 10 or 20 × objective in the light microscope. The mites are hard to control with any of the antiparasitic drugs such as lindane (hexachlorocyclohexane), crotamiton, permethrin, or benzyl benzoate. The effect of treatment on the mite population can be monitored by cyanoacrylate skin-surface biopsies.
Sunscreens, preferably of the broad spectrum UVA plus UVB and infrared type, with a skin protection factor (SPF) of 15 or higher are always recommended to Acne Rosacea patients and should be used every day of the year. The sunscreens with a base of micronized zinc oxide or titanium oxide are nonirritating and work well for anyone with the sensitive skin of Acne Rosacea, but they leave sometimes an opaque hue on the skin, especially in the spacious facial pores. For this reason patients often turn away from these products.
Glucocorticoids should never be used. The only exception is with Acne Rosacea conglobata and Acne Rosacea fulminans. In these patients, short courses of oral and topical glucocorticoids are a reasonable option because of their anti-inflammatory properties.