Improving treatments HELP rosacea sufferers

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Improving treatments HELP rosacea sufferers
Aug 1, 2006
Nancy A. Melville
Dermatology Times

National report Û While rosacea remains incurable for the estimated 14 million people who suffer from the condition, treatment options are evolving to provide dermatologists with a more effective armamentarium in helping to control the condition.

One of the most exciting developments for rosacea treatment is a major shift in the approach to antibiotics, which stands to overcome the hurdle of potential resistances in treating severe cases.

"People are now looking at antibiotics in a new way," says Karyn Grossman, M.D., a dermatologist in private practice in Santa Monica, Calif. "Instead of using them for bacterial reduction, the anti-inflammatory effect of antibiotics in the treatment is becoming more prominent."

The Food and Drug Administration's (FDA) recent approval of Oracea, (CollaGenex), represents a big step in that new direction. The treatment, which has completed phase 3 clinical trials, is a once-a-day, sustained-release, 40 mg dose of doxycycline that works by reducing the inflammation in rosacea.

Importantly, the dose of the antibiotic is low enough to not actually kill the bacteria, allowing for a more sustained treatment without the risk of developing a resistance. (See related story.)

"This opens up a very attractive regimen that greatly reduces concerns about resistance," says Jonathan Wilkin, M.D., chairman of the National Rosacea Society's medical board and the former chief of the division of dermatology and dermatological drug products for the FDA.

"It takes the dosage down to a level that preserves the anti-inflammatory activities of the product, and at that low dose, you can take care of the papules and pustules, which are the major problems for rosacea sufferers.

"I don't think it eliminates absolutely all possibility for a resistance," he adds. "But it must so greatly reduce the frequency of resistances that I think this will be a very popular alternative."

The treatment will be particularly beneficial for patients with severe rosacea who don't respond to topicals alone, even after an initial phase of antibiotics, he explains.

Topicals

In terms of newer topical treatments that may also help non-responders, a gel form of dapsone, made by Canadian company QLT Inc., and sold as Aczone Gel, 5%, offers promise of providing the same significant improvement seen with oral dapsone, but without the side effects that represented a risk to users.

Aczone has FDA approval for the topical treatment of acne vulgaris; however, there is a caveat Û dermatologists are required to screen patients to determine if they are predisposed to hemolytic anemia due to a deficiency of the enzyme G6PD, (glucose 6-phosphate dehydrogenase). Patients found to have the deficiency need to be monitored with regular blood counts.

Since oral dapsone can be highly effective in treating the papules and pustules of rosacea, its topical use is something that could be highly valuable for dermatologists, Dr. Wilkin says.

"I think this will be a worthy alternative to explore, particularly for those patients who do not respond to the other topical medications that are currently available."

Laser and lights

Heavily promoted lasers and light-based therapies continue to gain popularity for rosacea and acne treatment alike.

Studies, mostly smaller in nature, show that techniques including IPL, pulsed-dye lasers, KTP and radiofrequency can offer the chance to treat visible blood vessels without much bruising or discomfort.

"Laser and light therapies often provide some relief for rosacea patients," Dr. Grossman says. "I personally like combining Levulan Kerastick with IPL treatments."

Until a greater body of research comes out, however, laser use for rosacea will likely remain a matter of doctor preference.

"What we're really looking forward to is larger trials done in a blinded fashion or with more numbers of patients so we can get a better idea of the laser and light-based efficacy on rosacea," adds Diane Thiboutot, M.D., professor of dermatology at the Penn State University College of Medicine, Hershey, Pa.

In addition to improved laser research, another item on experts' rosacea wish list is a topical treatment to address the patulous follicles that represent the earliest changes of rhinophyma Û the thickening of the nose that can occur in the most severe cases of rosacea, Dr. Wilkin says. Laser or other types of surgery are typically required to treat the problem.

"If we had a topical that could inhibit the connective tissue and glandular elements that overgrow, that would really be exciting," he tells Dermatology Times.

In addition, while lasers can often treat redness in the face and telangiectasias, a medical therapy to also address them could be highly beneficial, Dr. Wilkin adds.

Ocular rosacea

And a product is also badly needed for ocular rosacea, which causes the eyes to become watery or bloodshot and includes eye irritation, burning, stinging and dryness.

"A lot of people with ocular rosacea go undiagnosed and simply spend their lives trying to treat it with Visine," he says. "But if we had drops that were specific to that condition, that would be an enormous benefit to this population."

Meanwhile, offering patients advice such as using soapless soap or water that isn't too hot, and avoiding anything that is alcohol-based or causes stinging in a daily regimen of face-washing, can go a long way toward reducing rosacea flare-ups.

Acne to rosacea

And since acne is often a precursor to rosacea, dermatologists should make sure patients don't make the mistake of using acne medications that may only exacerbate their rosacea.

"Many patients, especially younger ones who might be transitioning from acne into rosacea, still think they have acne when they're really developing rosacea," Dr. Thiboutot explains. "They'll still be using the products they used for their acne and come to find that their skin is only getting worse."

Untreated impact

The impact from untreated rosacea can be much more than skin-deep, according to surveys conducted by the National Rosacea Society (NRS). Nearly 70 percent of rosacea patients polled said the condition had reduced their self-confidence and self-esteem, and as many as 41 percent said it even caused them to avoid public contact or cancel social engagements.

Nearly 70 percent said their rosacea had adversely affected their professional interactions, and 30 percent said the condition had caused them to miss work.

Even worse is the fact that many don't realize anything can be done about it.

"Rosacea will often run in the family, and sufferers will just write it off as an inherited 'complexion,' " Dr. Wilkin says. "They don't recognize that it's a condition that can be controlled with some really good modalities."

The good news is that the majority of patients who do seek treatment see significant improvement Û another NRS survey of 1,077 patients with rosacea found that 87 percent reported getting their condition under control with treatment.

"I tell patients that in rosacea, 'cure' is a four-letter word, and while it may not be feasible, we can at least seek control and achieve long-term remissions," Dr. Wilkin says.

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