INTRODUCTION
Rosacea is a chronic, cutaneous inflammatory syndrome that most commonly affects the convexities of the central face, including the cheeks, chin, nose, eyes, and central forehead. Often characterized by remissions and exacerbations, it manifests as various combinations of cutaneous flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions and rhinophyma.1 Individuals are typically affected by some, but not all, of these characteristics, based on the form of rosacea they encounter.
The different forms of rosacea include erythematotelangiectatic (ETT), papulopustular (PP), phymatous, and ocular.2 The causes of rosacea are poorly understood, but appear to involve chronic inflammation, environmental triggers, ingested foods, and microorganisms, either alone or in combination.2 Although it occurs primarily among elderly, fair-skinned individuals, the prevalence of rosacea is poorly characterized. Estimates range from 5% in the US and Russia3,4 to 10-13% in Sweden and Germany.1,4 The primary clinical feature of ETT rosacea is transient or persistent facial erythema which, if left untreated, may progress to disfiguring papules or pustules.5,6 Consequently, patients with rosacea have a higher incidence of social embarrassment, social anxiety, depression, stigmatization and decreased self-esteem5, 7-9 leading to diminished quality of life.5,10-12
The only FDA-approved systemic agent for treating rosacea is a modified-release doxycycline product.13 This agent is only indicated for the treatment of inflammatory papules and pustules associated with rosacea in adult patients. It is not effective for treating generalized erythema.13 Carvedilol, a nonselective β-blocker with α-1 blocking activity, has been used off-label to treat erythema and flushing.14 Other systemic agents, which are used off-label, for treating rosacea-related papules and pustules include tetracyclines, macrolides, metronidazole, and isotretinoin.14
Azelaic acid gel is FDA-approved for the topical treatment of inflammatory papules and pustules of mild-to-moderate rosacea; however, the efficacy of this product for treating erythema in the absence of papules and pustules has not been evaluated.15 The only FDA-approved topical product for persistent facial flushing is brimonidine tartrate gel, an α-2 agonist,16 while topical
The different forms of rosacea include erythematotelangiectatic (ETT), papulopustular (PP), phymatous, and ocular.2 The causes of rosacea are poorly understood, but appear to involve chronic inflammation, environmental triggers, ingested foods, and microorganisms, either alone or in combination.2 Although it occurs primarily among elderly, fair-skinned individuals, the prevalence of rosacea is poorly characterized. Estimates range from 5% in the US and Russia3,4 to 10-13% in Sweden and Germany.1,4 The primary clinical feature of ETT rosacea is transient or persistent facial erythema which, if left untreated, may progress to disfiguring papules or pustules.5,6 Consequently, patients with rosacea have a higher incidence of social embarrassment, social anxiety, depression, stigmatization and decreased self-esteem5, 7-9 leading to diminished quality of life.5,10-12
The only FDA-approved systemic agent for treating rosacea is a modified-release doxycycline product.13 This agent is only indicated for the treatment of inflammatory papules and pustules associated with rosacea in adult patients. It is not effective for treating generalized erythema.13 Carvedilol, a nonselective β-blocker with α-1 blocking activity, has been used off-label to treat erythema and flushing.14 Other systemic agents, which are used off-label, for treating rosacea-related papules and pustules include tetracyclines, macrolides, metronidazole, and isotretinoin.14
Azelaic acid gel is FDA-approved for the topical treatment of inflammatory papules and pustules of mild-to-moderate rosacea; however, the efficacy of this product for treating erythema in the absence of papules and pustules has not been evaluated.15 The only FDA-approved topical product for persistent facial flushing is brimonidine tartrate gel, an α-2 agonist,16 while topical
