Patient-focused Solutions in Rosacea Management: Treatment Challenges in Special Patient Groups

July 2019 | Volume 18 | Issue 7 | Original Article | 608 | Copyright © July 2019

Ahuva Cices MD, Andrew F. Alexis MD MPH

Skin of Color Center, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY

Figure 4that most rosacea clinical trials rely on the 2012 NRS subtypes for inclusion criteria and assess efficacy based on outcome measures specific to the disease subtype rather than the phenotype, which more accurately reflects the constellation of features that would ideally be treated simultaneously.11 Recognizing the lack of concordance between the archetypal NRS subtypes and real world patients, the ROSCO panel established consensus treatment guidelines (Figure 4) that encourages targeting individual features of rosacea and use of multiple therapies to achieve desired results.11

Randomized control trials (RCT) are an integral part of evidence based medicine, and their data support the use of topical azelaic acid, metronidazole, and ivermectin, as well as oral doxycycline for the treatment of mild to moderate PPR and the use of topical ivermectin and oral doxycycline for severe PPR.19,20 Inflammatory lesions of PPR, active phyma, and ocular features can be managed with doxycycline 40 mg as an anti-inflammatory at subantimicrobial doses.11 Effective treatments targeting the erythema of ETR include topical alpha-adrenergics (eg, oxymetazoline, briminodine), as well as intense pulsed light (IPL), and pulsed-dye laser (PDL) at 585-595 nm.11 Telangiectasia require physical modalities for eradication such as electrodessication, IPL, or laser therapies.11 Importantly, the 2015 Cochrane review found no difference in efficacy of IPL and PDL for erythema and telangiectasia (moderate quality evidence).11

High quality RCTs in rosacea are increasing and improving our therapeutic arsenal, however there remains a large gap in knowledge in less common subtypes, namely phymatous and ocular rosacea, as well as the spectrum of rosacea in skin of color.11 The lack of large controlled trials for the treatment of less common phymatous and ocular subtypes is exemplified by the 2015 Cochrane review of rosacea interventions, which found no RCTs for phymatous rosacea and concluded that more studies are warranted to evaluate treatments for ocular rosacea.19 ROSCO recommends treatment of inflamed phymatous rosacea with lasers, oral doxycycline, or isotretinoin; therapies for non-inflamed phymas can include CO2 lasers, microdermabrasion, and surgical excision based on patient preferences.4,11 Initial treatments for ocular rosacea include education on eye care and lid hygiene, use of lubricating drops, and increased dietary intake or supplementation with omega-3 fatty acids. Collaboration with ophthalmology is recommended for more advanced cases.4,11

Treatment approach for rosacea in non-white populations is the same as that used in white populations, with the exception that special consideration must be given to avoid post inflammatory hyperpigmentation.3,12 Few rosacea studies have significant numbers of subjects with skin of color as the general dearth of non-white subjects in clinical trials is amplified in rosacea, which is less prevalent in these populations. Individual studies for oral doxycycline and topical oxymetazoline showed equivalent efficacy in subjects with Fitzpatrick skin phototypes I-III and phototypes IV-VI.3,21 Vascular lasers are effective in the treatment of vascular components of rosacea in skin of color, however IPL is generally not advised in types IV-VI due to higher risks of dyspigmentation.3,12 Use of longer wavelengths and lower fluence in skin of color is advised to minimize the risk of pigmentary alterations or scarring.3

Given the heterogeneity of rosacea, there is no single best therapy, and often multiple treatment modalities including gentle skin care, trigger avoidance, topical agents, oral medications, and laser- or light-based therapies targeting specific disease manifestations are employed in order to achieve desired results.4,5 Use of multiple therapies should be based on the patient’s desire for treatment of multiple disease features, and should target specific complaints rather than disease severity given the large role of patient perception on disease impact.11 Maintenance therapy is dependent on treatment modality and patient preference.11 A comprehensive approach is appropriate (Figure 5). This model highlights the importance of communication with patients to shape personalized treatment plans. Patients should be reassessed regularly to maintain an optimal treatment plan as the disease presentation may change over time.