Raising Awareness for Rosacea Treatment Adherence

April was National Rosacea Awareness month, designated by the National Rosacea Society. This year’s theme was to raise awareness for rosacea treatment adherence. There are numerous treatment options currently available and more in the pipeline. But how can dermatologists encourage adherence? Hilary Baldwin, MD, sheds light.

Dr Baldwin is an associate professor of dermatology at Rutgers Robert Wood Johnson Medical School in New Brunswick, NJ.

The Dermatologist: What treatments are currently
available for rosacea?

Dr Baldwin: We have a wealth of treatment options in 2022.¹ Choices of pharmacologic treatment are based on the patient’s particular aspects of disease. For the background erythema of rosacea, brimonidine and oxymetazoline do a good job of decreasing redness on a daily basis. For the inflammatory lesions, we have numerous topical creams and a single oral medication. Depending on severity of disease, we may use more than one topical cream or a topical along with an oral medication. Topical medications include ivermectin, minocycline 1.5% foam, azelaic acid, and metronidazole. Not only are these medications effective, but adverse effects are uncommon and mild. An anti-inflammatory dose of doxycycline is the only oral medication for rosacea that is approved by the US Food and Drug Administration (FDA). It is effective, is unlikely to cause adverse effects, and does not cause antibiotic resistance that is associated with full-dose doxycycline. Although it is not FDA approved for this indication, isotretinoin is useful for refractory disease.

Additionally, laser and light treatments work well for treating telangiectasias and reducing the background redness of rosacea. Phymatous tissue can be removed by numerous physical modalities.

Most patients will have multiple aspects of rosacea: background erythema, telangiectasias, inflammatory lesions, and ocular involvement, so combination therapy is the norm.

The Dermatologist: Why is it important for patients to adhere to these medications?

Dr Baldwin: Rosacea is a chronic disease that will necessitate long-term therapy. Adhering to medication use will result in more significant resolution of rosacea findings. Additionally, it has been shown that patients who use their medications consistently and achieve clear skin (as opposed to merely “better”) may be able to stop using their medications for several months. Some will remain clear indefinitely.²

The Dermatologist: How can dermatologists ensure patient buy-in for adhering to medications?

Dr Baldwin: Adherence to medications is a challenge with any disease, particularly when it is chronic. More so than with short-term fixes, medications intended to be used for the long haul need to be user-friendly. Using the simplest regimen possible, avoiding tolerability issues, utilizing affordable products, and paying attention to cosmetic elegance will improve the likelihood of regular usage.³

These requirements highlight the importance of obtaining patient buy-in with the regimen from the get-go. As clinicians, our job is to endeavor to fix all aspects of a patient’s rosacea.⁴ However, many patients are bothered by a particular finding (inflammatory lesions or erythema) and not others. Because inflammatory lesions and erythema do not respond to the same medications, combination disease will require combination therapy, by definition complicating the regimen. Before embarking on a therapeutic regimen, it is important to ascertain what characteristics of disease are most bothersome to the patient. Inflammatory lesions can be treated with topical or oral medications, and many patients have a preference; erythema can be treated pharmacologically or with laser or light therapy. Giving the patient a say in therapeutic options can improve adherence.⁵

The Dermatologist: What treatment options are in the pipeline?

Dr Baldwin: We will soon be able to prescribe benzoyl peroxide (BP) for our patients with inflammatory rosacea. Historically, BP has been shown to be effective, but tolerability issues prevented its use in those with sensitive skin. The new product—microencapsulated BP 5%—encapsulates the BP in a porous silica shell. Rather than placing a large bolus of BP onto the skin, small amounts are released over time, resulting in efficacy without irritation.

The Dermatologist: Some rosacea phenotypes cause negative social, emotional, and psychological effects.⁶ What are your tips for managing patients’ mental health over the course of the treatment plan?

Dr Baldwin: It is important as clinicians to treat all aspects of a patient’s disease. Patients should be encouraged to express the negative psychosocial impact of their disease. Referral, if appropriate, to a mental health colleague is often helpful. Reminding patients that consistent use of their therapeutic regimen will result in rapid efficacy can also be helpful. Because the disease is chronic, periodic inquiries regarding ongoing emotional distress are warranted.

The Dermatologist: What else should dermatologists know about rosacea treatment adherence?

Dr Baldwin: Studies with both topical and oral rosacea medications have indicated a difference between clear and near clear outcomes (or better vs well). In clinical trials, the FDA considers “treatment success” to be attaining the state of clear or near clear. But in real life, clinicians and patients know the difference between the two. There is a sizeable difference in residual lesions and in patient quality of life. Furthermore, attaining clear skin has been shown to be associated with a longer remission of disease than those who stop therapy at the near clear stage. Some patients who reach clear skin never relapse. Overall, it behooves us to push ourselves and our patients to reach clear skin.

References
1. Rosacea treatment algorithms. National Rosacea Society. Accessed February 25, 2022. https://www.rosacea.org/physicians/rosacea-treatment-algorithms

2. Rosacea awareness month to highlight the importance of adherence to therapy. News release. National Rosacea Society. February 8, 2022. Accessed February 25, 2022. https://www.rosacea.org/press/2022/february/rosacea-awareness-month-to-highlight-importance-of-adherance-to-therapy

3. Getting your patients' buy-in on medication adherence. National Institute of Diabetes and Digestive and Kidney Diseases. Published March 14, 2018. Accessed February 25, 2022. https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/getting-parents-buyin-medication-adherence

4. Patient education materials. National Rosacea Society. Accessed February 25, 2022. https://www.rosacea.org/physicians/patient-education-materials

5. Internet surveys and their impact on adherence for rosacea. ClinicalTrials.gov. Accessed February 25, 2022. ClinicalTrials.gov identifier NCT03048058. https://clinicaltrials.gov/ct2/show/NCT03048058

6. Huynh TT. Burden of disease: the psychosocial impact of rosacea on a patient's quality of life. Am Health Drug Benefits. 2013;6(6):348-354. https://www.ahdbonline.com/payer-perspectives-in-dermatology/1571-feature-1484-0