Understand worsening redness may occur. Last, understand
(“Uâ€) that there is the potential for a worsening of erythema.
Figure 5 presents an algorithm for managing worsening
redness, which in our clinical experience may occur in approximately
10-20% of cases. First, determine the timing of
worsening redness relative to application, then decide together
with the patient whether to continue therapy or discontinue
with or without re-challenge. Treat symptoms as needed. In
the appropriate patient, we recommend using acetyl salicylic
acid (80-500 mg/day) or another nonsteroidal anti-inflammatory
drug (NSAID) such as ibuprofen or naproxen if burning/
stinging sensations are present, an antihistamine if swelling
or pruritus is occurring, and a topical corticosteroid if needed.
13 Topical calcineurin inhibitors may also be considered.
Cooling compresses may also help patients who feel facial
warmth. If redness is prolonged, device therapy might be a
consideration. For the rare cases of redness that first appear
late after initiation of therapy (>3-4 months), manage as a suspected
allergic contact dermatitis and consider patch testing
to rule out contact allergies. An augmented index of suspicion
is warranted because allergic or irritant contact dermatitis could occur during therapy at the 3-4 month time point or earlier,
especially if the patient has a history of sensitivity to the
excipients in brimonidine gel, extremely sensitive skin, or previous
exposure to brimonidine eye drops.
