Rosacea

Rosacea treatments

According to a thorough and informative 2009 Review on Rosacea published by Thomas Jefferson University (Jefferson Medical College), “…the cure for rosacea remains elusive, and all currently used medications are for symptomatic control only. No precise treatment algorithm has become the standard of care; treatment remains empirical.”1 This may sound ominous, but in reality, we have several methods of tackling rosacea which are proven effective.

Common treatments (doctors sometimes prescribe a combination of two or more together):

  • Metronidazole (MetroGel, MetroCream): An often prescribed treatment, studies show this topical antibiotic providing superior results to placebo1-2 (72% reduction in rosacea lesions, 45% redness reduction, statistically significant improvement in dilated blood vessels).
  • Azelaic acid (Azelex): Studies have shown effectiveness (73.4% reduction in rosacea lesions, significant redness reduction, no improvement in dilated blood vessels) with concentrations up to 20%. 15% is standard.3-5
  • Sodium sulfacetamide 10% and sulfur 5% (Sulfacet): Studies hint toward good results6 (80% reduction in rosacea lesions, 69% redness reduction. I could not find data on dilated blood vessels).
  • Benzoyl peroxide or benzoyl peroxide + clindamycin (Benzaclin): Trial results from benzoyl peroxide administration show significant improvement in rosacea lesions,7 but no improvement in dilated blood vessels. Benzoyl peroxide + clindamycin shows a 71.3% reduction in rosacea lesions, and significant redness reduction.8-9 I could not find data regarding dilated blood vessels for benzoyl peroxide + clindamycin.
  • Isotretinoin (Accutane): This is particularly effective for younger patients and also those with phymatous rosacea.10
  • Oral antibiotics (most notably doxycycline):11 Patient and doctor should be in close contact and limit exposure to short term therapy (no longer than one year). Results from trials show a 48%-59% improvement in rosacea lesions. No evidence of reduction in dilated blood vessels.
  • IPL (Intense pulsed light) and long-pulsed dye lasers: These machines provide treatments that can help with redness and dilated blood vessels, but are impermanent solutions.
  • Regular opthamologist care for eye symptoms. Be sure to see your opthamologist if you suspect ocular rosacea.

Less common treatments:

  • Oral nicotinamide + zinc (Nicomide, Nic/Zn): 79% of patients showed moderately better or much better improvement in appearance (based on patient global evaluation) after 4 weeks of treatment.12
  • Hormonal treatment—Spironolactone, Prednisone, Oral Contraceptives13
  • Mite, parasite, fungal treatment--Permethrin cream (Nix), Ivermectin (Stromectol), Crotamiton (Eurax), Ketoconazole (Nizoral)
  • Alpha blockers

Experimental treatments:

  • Rifaximin (SIBO treatment):14 An interesting study in the journal Clinical Gastroenterology and Hepatology showed a much higher prevalence of intestinal bacteria (SIBO) in people with rosacea than those without. Patients were given Rifaximin, an antibiotic which does not penetrate the intestinal wall, effectively reducing or eradicating SIBO. After SIBO was controlled, 20 of 28 patients cleared completely, and 6 more greatly improved. Results lasted for at least 9 months at follow-up.

Other things you can do to help your symptoms:

Wear sunscreen: Sunscreen is an important adjunct to rosacea care.15 Pharmaceutical manufacturers incorporate sunscreen into prescription preparations at times. Zinc oxide and titanium dioxide are effective broad spectrum sunscreen ingredients that seem to be well tolerated by people with rosacea.

Avoid products that strip or irritate the skin such as soap (use soap-free cleanser instead), sodium lauryl sulfate (avoid cleansers with this ingredient), astringents, toners, menthol, and camphor.

References

1. Culp B and Scheinfeld N. "Rosacea: a review." Pharmacy & Therapeutics. 2009; 34(1): 38-45.

2. Tan JK, et al. "Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea." Journal of Cutaneous Medicine and Surgery. 2002; 6(6): 529-34.

3. Bjerke R, Fyrand O and Graupe K. "Double-blind comparison of azelaic acid 20% cream and its vehicle in treatment of papulo-pustular rosacea." Acta Dermato-Venereologica. 1999; 79(6): 456-9.

4. Gupta AK and Gover MD. "Azelaic acid (15% gel) in the treatment of acne rosacea." International Journal of Dermatology. 2007; 46(5): 533-8.

5. Liu RH, et al. "Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials." Archives of Dermatology. 2006; 142(8): 1047-52.

6. Torok HM, et al. "Combination sodium sulfacetamide 10% and sulfur 5% cream with sunscreens versus metronidazole 0.75% cream for rosacea." Cutis. 2005; 75(6): 357-63.

7. Montes LF, et al. "Topical treatment of acne rosacea with benzoyl peroxide acetone gel." Cutis. 1983; 32(2): 185-90.

8. Breneman D, et al. "Double-blind, randomized, vehicle-controlled clinical trial of once-daily benzoyl peroxide/clindamycin gel in the treatment of patients with moderate to severe rosacea." International Journal of Dermatology. 2004; 43(5): 381-7.

9. Kapes B. "P. acnes possible factor in rosacea: BenzaClin a significant Tx in lesion reduction." Dermatology Times. 1 Apr. 2003.

10. Hoting E, Paul E and Plewig G. "Treatment of rosacea with isotretinoin." International Journal of Dermatology. 2007; 46(5): 533-8.

11. Del Rosso JQ, et al. "Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea." Journal of the American Academy of Dermatology. 2007; 56(5): 791-802.

12. Fivenson DP. "The mechanisms of action of nicotinamide and zinc in inflammatory skin disease." Cutis. 2006; 77(1 Suppl): 5-10.

13. Jansen T, Plewig G and Kligman AM. "Diagnosis and treatment of rosacea fulminans." Dermatology. 1994; 188(4): 251-4.

14. Parodi A, et al. "Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication." Clinical Gastroenterology and Hepatology. 2008; 6(7): 759-64.

15. Goldgar C, Keahey DJ and Houchins J. "Treatment options for acne rosacea." American Family Physician. 2009; 80(5): 461-468.

Further Reading

Helm TN and Schechter J. "Biopsy may help identify early pyoderma faciale (rosacea fulminans)." Cutis. 2006; 77(4): 225-7.

Kendall SN. "Remission of rosacea induced by reduction of gut transit time." Clinical and Experimental Dermatology. 2004; 29(3): 297-9.

Niren NM, et al. "The Nicomide Improvement in Clinical Outcomes Study (NICOS): results of an 8-week trial." Cutis. 2006; 77(1 Suppl): 17-28.