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Rosacea: Expert recommends treating erythema, papules/pustules simultaneously


 

EXPERT ANALYSIS FROM THE COASTAL DERMATOLOGY SYMPOSIUM

 

The results of a recently published trial helps answer one of the toughest questions in rosacea treatment: when patients present with both papules/pustules and erythema, which problem do you treat first?

In the past, Hilary Baldwin, MD, tended to target papules and pustules first, usually with ivermectin cream (Soolantra) and, when warranted, anti-inflammatory doses of doxycycline. Going after the erythema first and making the skin paler could make the cherry red inflammatory lesions stand out even more, she said.

Woman with rosacea on her face. Courtesy National Rosacea Society
But the new 12-week study of patients with rosacea, with moderate to severe persistent erythema and inflammatory lesions, suggests that treating both problems at once might be the best, she said in a presentation on rosacea at the 13th Annual Coastal Dermatology Symposium, sponsored by the Global Academy for Medical Education.

In the study, one group was put on ivermectin for 12 weeks, with the vasoconstrictor brimonidine 0.33% (Mirvaso topical gel) added after 4 weeks to help with the erythema; and another group was treated with both ivermectin 1% cream and brimonidine daily for the entire 12 weeks. The third group received vehicles of both applied every day for 12 weeks (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16).

“What they found was that both the combinations worked better than ivermectin alone,” and that treatment with both agents for the full 12 weeks worked best, with no increased risk of irritation or worsening of erythema than when brimonidine was brought in after 4 weeks of ivermectin, said Dr. Baldwin, a clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., said in an interview. The vasoconstriction might have somehow helped with the papules and pustules, she noted.

The lesions might have looked more prominent “for the week or two it took for the ivermectin to kick in, but the patients didn’t care. They were happier campers by virtue of treating both aspects of their rosacea at the same time,” she added.

The new kid on the block for vasoconstriction – oxymetazoline (Rhofade cream) – appears to be gentler than brimonidine. “It takes a little bit longer to reach peak effect, and the peak doesn’t give you quite as much vasoconstriction as brimonidine, which for some people is a good thing,” she said. “Perhaps they’re a little bit too white with brimonidine. For other people who are bright red, oxymetazoline might not be enough. I think there’s a place for both drugs.”

Both vasoconstrictors might actually make erythema temporarily worse; it’s a known side effect. Dr. Baldwin has her patients try them for the first time when they’re at home and don’t have any important impending social engagements, just in case. “I like to give a tube of each one and say, ‘use one on one side of your face and the other on the other side and see which makes you happier.’ ”

Dr. Hilary Baldwin
Dr. Hilary Baldwin
Isotretinoin is an option that is often forgotten in rosacea treatment and “works amazingly well for rosacea” when anti-inflammatory doxycycline and topical treatments aren’t getting the job done, Dr. Baldwin said. “The papules and pustules absolutely melt away. It can reduce the size of existing phymas and halt the progression of phymas.”

Some patients can get away with “a really low dose and be completely cleared,” she commented. “I have some fully controlled on 10 mg twice weekly. As long as there’s no pregnancy risk, there’s no reason you can’t do this almost indefinitely.”

This publication and the Global Academy for Medical Education are both owned by Frontline Medical News. Dr. Baldwin is a speaker and advisor for Allergan, Galderma, and Valeant; and is an investigator for Dermira, Galderma, Novan, and Valeant.
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