Optimizing the Use of Topical Brimonidine in Rosacea Management: Panel Recommendations

As reported in the cases published in the literature, typically there is a rapid recovery.^{13, 18, 19} Rarely, an event may last weeks. In a majority of cases, the event improved or resolved after stopping brimonidine therapy.¹³

Less Formal Reports of “Rebound”
Dermatologic meetings and other informal communications have yielded comments about “rebound” that encompass changes in redness that happen at a variety of time points after initiation of brimonidine therapy. Given further analysis of existing data, it seems that these comments likely refer to different pathophysiologic phenomena. As discussed above, some patients experience a worsening of redness, either occurring shortly after application (within first 6 hours) that we propose to qualify as paradoxical erythema (see below proposed new terminology) or an exaggerated recurrence of erythema after the effects of the first application have subsided (approximately 10-12 hours after application). Our clinical experience has been that the paradoxical erythema phenomenon is most bothersome for patients, particularly since it often strikes during the time period when the patient most wanted to be free of their redness; in contrast, late exaggerated recurrence of erythema is most likely to occur while the patient is at home or even sleeping.

We have heard colleagues use the term “rebound” in reference to patients who were not satisfied with the drug effect for individual reasons and voiced this complaint to their physician. For instance, some patients may not appreciate a beneficial effect with brimonidine gel on overall facial erythema when redness due to perilesional erythema and/or telangiectasia is unmasked and lesions become more visible. Others may feel the product results in “overwhitening.” In addition, irritation may occur at any time during the course of drug exposure.

As shown in Figure 4, there are several overall steps that should be considered with the initiation of brimonidine therapy for redness of rosacea and these steps can readily be remembered.

Assess rosacea. First, assess (“A”) the clinical features of rosacea to confirm the diagnosis and rule out alternatives such as acne, seborrheic dermatitis, perioral dermatitis, lupus erythematosus, photoaging, facial keratosis pilaris, or chronic actinic dermatitis. Then, create the overall treatment plan, targeting the different clinical symptoms of rosacea that are present in the individual patient.²¹

Provide patient education. Educate (“E”) the patient about rosacea, taking care to explain triggers (for example: UV light exposure, heat, spicy foods, red wine or other factors the patient associates with symptoms),²¹ and discuss the potential benefits and limitations of brimonidine therapy. Use of brimonidine will not completely negate the erythema-inducing effects of triggers, and patients should be aware that brimonidine therapy does not afford carte blanche to ignore potential triggers. Further, brimonidine will not eliminate papules, pustules, or telangiectasias and is not a curative therapy.^{16, 17} In our experience, setting appropriate expectations for patients can significantly minimize the likelihood of dissatisfaction with therapy and the clinician.