Optimizing the management of rosacea

Written by Louise Gagnon, Correspondent, The Chronicle

The rosacea toolbox is growing thanks to emerging agents and expanded use of existing therapies, a development that is welcome news to Canadian dermatologists.

Physicians underline that therapies should tackle the four subtypes of rosacea which include erythematotelangiectatic rosacea,
papulopustular rosacea, phymatous rosacea, and ocular rosacea. An emerging topical therapy is microencapsulated benzoyl peroxide a formulation that is designed to minimize the irritation often associated with benzoyl peroxide. It can decrease the papules and pustules of rosacea as well as erythema and is better tolerated than standard benzoyl peroxide. 

 
“It [microencapsulated benzoyl peroxide] is made to gradually release the benzol peroxide into the skin", said Dr. Lisa Kellett, a Toronto dermatologist. When you wrap it up in these tiny capsules, they allow for the gradual release of the benzoyl peroxide.
This would be an interesting therapy because I think that it could be used in rosacea as well as in acne vulgaris.”

Dr. Michal Martinka, a dermatologist in Calgary, agreed that microencapsulated benzoyl peroxide would be an appealing therapeutic option for patients with rosacea. “If this is something that helps with tolerability, then I think that would definitely be a good option,” said Dr. Martinka. “For patients who have rosacea, adding more options is always beneficial. Right now, we do
have several good options, but sometimes even those options may not lead to the efficacy that we want.”

Poster research presented in late March at the 2023 American Academy of Dermatology sessions in New Orleans revealed the percentage of subjects who were “not bothered” by the side effects of treatment was similar between those treated with  microencapsulated benzoyl peroxide (67.0%) and vehicle (66.8%) at 12 weeks.

Combination approaches important

Rosacea treatment can involve various strategies, noted Dr. Jaggi Rao, Founder and Medical Director, Alberta DermaSurgery
Centre, and Clinical Professor of Medicine, Division of Dermatology at the University of Alberta, Edmonton. “I treat erythematotelangiectatic rosacea with vascular laser alone,” explained Dr. Rao. “I treat papulopustular rosacea with anti-inflammatory therapy, which typically consists of topical ivermectin with or without oral doxycycline or minocycline. Once the inflammation is controlled, I will then treat the background erythema with vascular laser.”

Other combination approaches have also demonstrated success and tolerability, such as treatment with oxymetazoline hydrochloride cream 1% in conjunction with one of four energy-based therapies, which has been shown to be able to decrease moderate-to-severe facial erythema in patients with rosacea (Lasers in Surgery and Medicine 2021; 53:55–65). Emerging medical devices, such as the Etherea-MX multi-platform laser, can treat multiple symptoms of rosacea, including redness and broken blood vessels, noted Dr. Kellett.

“It is able to do multiple things,” she said. “The importance is for someone with rosacea, who might have some redness and flushing, but might also have some telangiectasia or deeper blood vessels, you can treat both of those issues [redness/flushing and telangiectasia] at the same time with this technology.” 

Flushing and blushing can also be treated for temporary relief with emerging topical agents such as oxymetazoline hydrochloride cream 1%. “I love the concept of a ‘quick fix’ which involves using topical vasoconstrictors to treat flushing,” said Dr. Rao. “We know that brimonidine tartrate has been found to create rebound erythema in many patients. There is another agent, oxymetazoline hydrochloride cream 1%, which I would certainly try if it becomes available in Canada.”

If patients with rosacea do not respond to standard treatments, Dr. Rao will prescribe oral isotretinoin for patients who are “very refractory” to existing treatments. When treating rosacea in individuals who have darker skin tones, clinicians need to be cautious about using medical devices, according to dermatologists. “Laser parameters are often gentler [in patients with rosacea],” explained Dr. Rao. “They involve reduced fluence, longer pulse durations, longer wavelengths, and more cooling.”

Treating ocular rosacea and skin care for rosacea patients

To address ocular rosacea, Dr. Rao employs over-the-counter soothing eye drops or lubricants or hydrating agents to reduce the eye symptomatology of ocular rosacea. Topical ivermectin can be employed to manage ocular rosacea, but it needs to be used judiciously, according to Dr. Rao. “I would not use it on the eyelids but around the eyelids on the periorbital skin,” said Dr. Rao.

A small study has highlighted the efficacy of topical ivermectin for the treatment of cutaneous and ocular rosacea, where the therapy decreased conjunctival redness as well as blepharitis (Ocul Immunol Inflamm 2021; 29:1137-1141).

In addition, topical ivermectin has been shown to be effective in the treatment of Demodex blepharitis in a study of more than 100 patients (Cornea 2022 Apr 1; 41(4):427-434). If ocular rosacea presents with severity, a referral to an ophthalmologist may be warranted, noted Dr. Martinka. “When patients have moderate-to-severe symptoms, at that point we consider sending them to an ophthalmologist.”

Because many patients with rosacea have sensitive skin, their skin regimen requires the elimination of abrasive components, said Dr. Martinka. “With someone who has rosacea, skin care would include the use of gentle cleansers and gentle moisturizers, avoiding the use of any harsh ingredients, and avoiding direct sunlight,” said Dr. Martinka. “It’s important that patients wear lots of sunscreen, remember to reapply sunscreen, and avoid direct sunlight.”

Non-proprietary and brand names of therapies:

microencapsulated benzoyl peroxide (not approved in Canada); topical ivermectin (Rosiver, Galderma); oral doxycycline 40 mg modified release (Apprilon, Galderma); minocycline (no branded products); oxymetazoline hydrochloride cream 1% (not  approved in Canada); brimonidine tartrate gel (Onreltea 0.33%, Galderma); oral isotretinoin (Accutane, Roche; Epuris,
Cipher), Absorica LD, (Sun Pharma)