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

Inhibit/minimize inflammation. Take appropriate steps to inhibit/decrease the inflammation (“I”) that is often present due to poor skin care and the disease itself.^{1, 21} These steps can include evaluating/changing skin care practices and using medical therapy.¹ We find that patients commonly have poor skin care habits which, when combined with rosacea, result in sensitive skin and often compromised barrier function. Because irritation and problems with topical therapies are more likely to occur in this setting,¹ evaluate the patient’s skin barrier function and improve if needed. Improving barrier function can be achieved by 2-4 weeks of using gentle, well-formulated cleanser and moisturizer/barrier repair products prior to starting topical brimonidine therapy.¹ The American Acne and Rosacea Society recommends choosing products that repair/maintain barrier function, enhance skin hydration, and minimize irritation.¹ Rosacea management should also include regular photoprotection using both sun avoidance and a broad-spectrum sunscreen/sunblock with a sun protection factor of 30 or higher.¹ Patients should also be reminded that brimonidine has no sun protective effect and therefore appropriate daily sun protection is advised.

It is our experience that the paradoxical erythema phenomenon (redness occurring 3-6 hours after application) may be minimized by skin barrier repair and a “start low, go slow” approach to dosage (see below).

Minimize rosacea-associated inflammation using traditional rosacea therapies.²¹ Treat inflammatory lesions when present. ²¹ They will be more visible after the use of brimonidine and patients may be distressed by this. Educate patients about perilesional erythema and telangiectasias, and inform them that these skin characteristics may become more visible once brimonidine gel reduces the overall facial erythema. It can also be useful to screen for frequent flushing, since it has been theorized that patients who flush have particularly labile skin that is prone to undesired redness with brimonidine.

Optimize application of brimonidine. Teach patients to properly apply the medication in a very thin layer, optimizing (“O”) their application techniques and starting with a very small pea size amount (once daily). Start with this smaller amount of medication and increase the amount as the patient gains experience. It is important to ensure that patients are continuing their moisturizer/barrier repair product along with the topical brimonidine. Have a staff member show the patient how to apply brimonidine in a uniform distribution. We have also found that it is useful to instruct patients to try the first application of brimonidine on a day when they can stay home most of the day to observe effects; this could be on a weekend or vacation day. Judicious use of samples may be beneficial in this regard. Although it is common sense, patients should be made aware that they should not apply brimonidine at bedtime and may adjust the timing of their dose based on their daily routine and/or special events. Intermittent use of this drug has not been studied and it is difficult to predict the side effect profile when used in this manner.