Rosacea – The Chronicle of Skin & Allergy - March 2011
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Rosacea – The Chronicle of Skin & Allergy - March 2011

Treating patients with rosacea in 2011 

By Louise Gagnon, Correspondent, The Chronicle

Canadian dermatologists have had one more therapeutic option available for use in their Rosacea patients, following approval last summer of azelaic acid 15%.

“It seems to be working well,” says Dr. Lyn Guenther, a professor in the depart ment of medicine at the University of Western Ontario and a dermatologist in private practice in London, Ont. “There is not one therapy that works in 100 per cent of patients 100 per cent of the time. For some people, a treatment like metronidazole may not be sufficient. It is nice to have another option.” Dr. Guenther notes some patients are very loath to taking oral antibiotics and want to try all possible topical agents before resorting to oral antibiotics.

Azelaic acid gel (15%), is a topical therapy designed to address the inflammatory papules, pustules and flushing or redness that characterizes papulopustular rosacea. Two randomized, placebo-controlled trails of the azelaic acid gel conducted in the U.S. demonstrated a reduction in redness and swelling in rosacea patients and demonstrated that the topical therapy was well-tolerated.

Finacea can be used as monotherapy to treat the papulaes, pustules, and redness associated with rosacea or it can be used in combination with therapies such as metronidazole, which is available as a gel or cream, according to Dr. Guenther. Patients with rosacea typically have sensitive skin, and it is recommended that they use mild skin cleansers that do not sting, adds Dr. Guenther. There are about two million Canadians living with rosacea, with the disorder being more prevalent among Caucasian woman aged 30- 50 years. It typically affects those affected with fair skin.

Rosacea triggers cant always be avoided 

One of the keys to preventing rosacea flares or exacerbating rosacea symptoms is to avoid the numerous recognized triggers such as spicy foods, alcohol, wind, sun, and strenuous activity, but patients can’t insulate themselves from all the triggers all the time, notes Dr. Lisa Kellett, a Toronto dermatologist and medical director at DLK on Avenue.

“People have to be reasonable,” says Dr. Kellett. “You have to live. You just have to use your judgement. Don’t have a glass of wine before you are having your picture taken, but rather have a glass of wine after your picture is taken.” While rosacea is a chronic condition and represents a spectrum of disease, Dr. Kellett notes it can be treated.

“It cannot be cured but it can be controlled,” says Dr. Kellett, who advises that topical treatments represent first-line therapy and that physicians then seek oral antibiotics like minocycline, tetracycline, and doxycycline if patients do not see satisfying results with topical treatments. “You really do need maintenance treatment whether you are using topical antibiotics, or a laser.” Light therapies, such as intense pulsed light, and lasers, such as the pulse-dye laser are used to treat the telangiectasia, erythema, and visible blood vessels that are present in patients with rosacea, says Dr. Kellett.

Pulse-dye laser treatments can be more aggressive or less aggressive depending on the practitioner, notes Dr. Chris Keeling, a dermatologist in Edmonton and clinical associate at the University of Alberta.

“You usually get the most improvement after the first the treatment, but can continue to see decreased vessel numbers with successful visits,” says Dr. Keeling. The use of the pulse-dye laser or IPL permits patients to return to there regular activities immediately, according to Dr. Keeling. “You can get rid of the patients [blood] vessels without downtime,” he says. “You can have laser treatments and go back to work in the afternoon.” The downside of pulse-dye laser treatment is that there is some discomfort with the treatment that turns off some patients after one treatment, and for many patients seeking broadband light therapy or laser treatment is a cost that they will have to pay for themselves. “The sensation is like a rubber band snapping against the skin,” says Dr. Keeling. “It is uncomfortable, but most patients tolerate it.”

Low self esteem common

Patients may return for as many as 10 treatments if they want to rid themselves of almost every visible vessel, but some may be satisfied with the results after a couple of treatments. A series of pulsed-dye laser treatments will keep the blood vessels away for about four years, says Dr. Keeling. It is recommended that patients under go one or two pulsed-dye laser treatments per year as maintenance therapy.

Treating the papules and pustules or the telangiectasia and flushing that can accompany rosacea can improve quality of life for patients, some of whom experience low self esteem and frustration. The unique aspect of the azelaic acid 15% is that it is natural product, says Dr. Keeling. “It is derived from wheat, barley, and rye,” explains Dr. Keeling. “It reduces skin cell proliferation, and it can be used in acne as well. Some dermatologists use it to treat melasma.”

One of the potential limitations of azelaic acid 15% is that it can increase facial hairs, warns Dr. Mark Lupin, a dermatologist in Victoria, director and founder of Cosmedica Laser Center, a clinical instructor in the department of dermatology in the faculty of medicine at the University of British Columbia, and a fellow of the American Society of Laser Medicine and Surgery. “That [possible side effect] may be a concern for woman,” say Dr. Lupin.

Ocular rosacea occurs in up to 50 per cent of rosacea patients, and some patients may not be aware that their eyes are affected, stresses Dr. Lupin. “Patients may not know it,” says Dr. Lupin. “You may wake up with dry eyes and not think of it as a skin condition. If they present with minor symptoms, a topical ophthalmic lubricant should treat it.” If an ophthalmic lubricant is appropriate, Dr. Lupin refers patients with ocular rosacea to an ophthalmologist for treatment, but more severe ocular rosacea may be better treated with oral therapies.

“If they present with red eyelids, something more than just topical therapy may be required,” explains Dr. Lupin. “The advantage of a systemic therapy is that if we see someone with inflammation and ocular rosacea, the inflammation and their eyes will both improve [with systemic therapy].”

Some oral agents such as doxycycline are more photo-sensitive than other agents, and are not a judicious treatment choice in the summer months for rosacea patients, says Dr. Lupin. In addition, IPL should not be applied to treat rosacea symptoms when patients are tanned, noted Dr. Lupin. Sulfa drugs are also part of the pool of therapies that can used to treat rosacea, but clinicians need to be aware that patients may have a sulfa allergy, which excludes them as candidates for sulfa drugs.

Amiodorone may cause rosacea symptoms

Flushing and redness can also be alleviated with newer anti-oxidant products, notes Dr. Lupin. “They are designed to strengthen the collagen, and they do seem to help with diminishing the blood vessels,” says Dr. Lupin.

Physicians should be aware that some pharmacotherapies contribute to the symptoms of rosacea, says Dr. Guenther. A drug like amiodarone, an antiarrhythmic agent, is commonly prescribed, but can act as a rosacea trigger. “You can prescribe alternatives [to amiodarone], and the rosacea will disappear,” says Dr. Guenther. “Often, we will speak to the cardiologist, and they then will switch the patient to another drug. There are usually a few different choices.”

Other therapies such as epidermal growth factor inhibitors, designed to treat particular cancers, can also worsen rosacea symptoms, adds Dr. Guenther.

Rosacea may be induced by steroid use, and therapies such as tacrolimus and pimecrolimus can be effective in those instances, Dr. Guenther added in conclusion.

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