Diagnosis and Treatment of Rosacea

In her session, “Rosacea: Diagnosis and Treatment,” presented at Fall Dermatology Week 2022, Julie Harper, MD, reviewed the new diagnostic classification of rosacea, pathogenesis of rosacea, and treatment strategies that target the pathogenesis and clinical phenotypes of rosacea.

“For a long time, we've been talking about subtyping people with rosacea. We say you either have papulopustular rosacea, erythematotelangiectatic rosacea, or ocular rosacea.” Dr Harper started. “If we try too hard to push somebody into 1 of those subtypes, we may be leaving some of their rosacea largely untreated.”

She talked about the two diagnostic features of phenotypes of rosacea: fixed centrofacial erythema and phymatous changes. “Treat everything you see. Different signs of rosacea will require multiple modes of treatment,” Dr Harper stated.

Next, she discussed modified-release doxcycline 40 mg. “This is the only oral tetracycline [US Food and Drug Administration] FDA-approved to treat the inflammatory lesions of rosacea. It is not specifically indicated for background erythema.”

• 30 mg immediate-release doxycycline and 10 mg delayed-release doxycycline
• Maintains a subantimicrobial dose
• Does not select for resistance organisms
• Low dose doxycycline or minocycline does not equal a subantimicrobial dose

Another option Dr Harper suggested was sarecycline, a narrow-spectrum tetracycline, which is FDA approved for acne and not rosacea.

• Narrow-spectrum tetracycline with minimal activity against Gram negatives
• FDA-approved for acne (2018)
• Well-tolerated, with rates of vertigo, dizziness, and sunburn similar to placebo
• Low rates of gastrointestinal disturbances (3% with sarecycline; 2% with placebo)
• 1.5 mg/kg, once a day, with or without food

According to a pilot study of sarecycline in rosacea, “Sarecycline treatment achieved a significantly greater percentage of participants achieving IGA [Investigator’s Global Assessment scale] endpoint at week 12 vs multivitamin.”

Dr Harper moved on to minocycline foam 1.5%, “The only minocycline FDA-approved to treat rosacea and of course it's the only topical tetracycline.”

She also elaborated on benzoyl peroxide. “It's not yet FDA approved, but that is anticipated. And by the time you even see this, it may be FDA approved, but this is not just benzoyl peroxide. It's 5% microencapsulated benzoyl peroxide.”

Furthermore, there is erythema in rosacea:

• Flushing (transient erythema)
• Persistent facial erythema (nontransient erythema)
• Telangiectasia
• Perilesional erythema

Dr Harper touched upon combination treatments, which include:

• Metronidazole 1% gel (38.42% success/50.7% reduction)
• Azelaic acid 15% foam (43.4% success/62.74% reduction)
• Ivermectin 1% cream (40.1% success/65.7% reduction)
• Modified-release doxycycline 40 mg (30.7% success/60% reduction)
• Minocycline 1.5% foam (50.6% success/60.8% reduction)

Dr Harper moved on to combination studies, which have the goal to help achieve clear skin, maximize remission periods, and minimize burden of disease. She included the following in combination studies:

• Doxycycline 20 mg twice daily and metronidazole 0.75% lotion
• Modified-release doxycycline and metronidazole 1% gel
• Doxycycline and azelaic acid gel
• Modified-release doxycycline and ivermectin 1% cream
• Ivermectin 1% cream and brimonidine 0.33% gel

“Look at the patient, identify every feature that you see, document the full menu of features that they have.” Dr Harper concluded. “Don't try to do too much with one tool. We have lots of good, different tools and opportunities to treat the different features of rosacea. So don't tie your hands, give your patients the results that they want, which is to get them as close to clear as we can possibly get them.”

Reference
Harper J. Rosacea: diagnosis and treatment. Presented at: Dermatology Week 2022; September 14-17, 2022; Virtual.