Myths and Updates in Rosacea Treatment

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At this year’s American Academy of Dermatology Innovation Academy, I talked about some myths and misconceptions regarding rosacea, and there are a lot of them. The first one is that patients come in and they think their pink cheeks are just the way they are made because they look at their parents, siblings, and grandparents who have pink cheeks. But it turns out that erythema, especially persistent background erythema, is one of the diagnostic criteria for rosacea. For many of our patients with rosacea, it is the factor that bothers them the most, and we know that erythema can progress over time. We believe that if we intervene early, we may change the trajectory of the disease.

Another common myth that patients have is that they do not need to spend a lot of money on branded benzoyl peroxide. Over-the-counter benzoyl peroxide is more economical, and patients have access to it easily. But the problem is that our patients with rosacea are so sensitive, if they put a regular benzoyl peroxide on their skin, they will have significant stinging and burning. The way we can get around this is using a silica microencapsulated benzoyl peroxide, which allows a slow and deliberate release of benzoyl peroxide to the skin. Not only have we found that this is not irritating, but most patients see an improvement in their background irritation when they start using it. About half of patients with moderate to severe disease get to clear or almost clear.

Patients often think that rosacea is just another form of acne, but we know this is not true. Rosacea is an inflammatory disease that involves an abnormality of the innate immune system. Psoriasis was the first of the inflammatory skin diseases to teach us that the inflammation might not be just skin deep. So, we asked, do we see systemic inflammation in rosacea as well? There was a recent study looking at cardiac comorbidities in patients with different severities of rosacea, and it does appear that there is a positive association between rosacea and several cardiac comorbidities. But then there was another analysis that looked at inflammatory bowel disease in which patients who had inflammatory bowel disease were more likely to have rosacea, but the converse was not true. If you have rosacea, you do not have an increased risk of developing inflammatory bowel disease. However, there is a wrinkle. Patients with rosacea are sometimes treated with oral tetracycline drugs, and there is some evidence showing an association between oral tetracycline antibiotics and the development of inflammatory bowel disease.

Although we know there are several factors that can rev up or exacerbate rosacea, in general, there are no bacteria at the core of the disease pathogenesis. So, why do antibiotics work in rosacea if we are not treating bacteria? The reason they work is because they have nonantibiotic properties, and those include the fact that they are anti-inflammatory, decrease oxidative stress, and can improve abnormal vasculature and prevent fibrosis. When we look at the antibiotics that we have available, topical minocycline foam once a day has been highly effective for patients with moderate to severe rosacea. About half of the patients get to clear or almost clear. And when we look at the side effects profile, one of the things we worry about is minocycline-induced pigmentation, but that does not seem to happen. When we think about what is new in the oral treatment of rosacea, we have an extended-release, low-dose minocycline that has been studied in 40-mg and 20-mg concentrations. In the phase 2 studies, we found that the 40-mg dose was statistically superior, not only to the placebo, but also to the subantimicrobial dose doxycycline currently US Food and Drug Association (FDA) approved for rosacea. In the phase 3 trials, we saw more than 60% of patients getting to clear or almost clear. Hopefully, we will see FDA approval for extended-release, low-dose minocycline soon.

Overall, I think it is an exciting time for the treatment of rosacea. We must remember that these patients are suffering. They are generally adults and should be at an age where they should not have bumps or redness on their face. And now we have the tools to get our patients to clear or almost clear.