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The flushing and telangiectasias associated with rosacea are notoriously difficult to treat with standard medications. Newer technologies, namely medical lasers and light sources, have made it possible to control and improve erythematotelangietatic signs of rosacea. The potassium-titanyl-phosphate laser in particular is an efficacious and safe tool for treatment of this disease.
This article will examine oral therapies utilized in the treatment of rosacea. Important topics include recognizing which types of rosacea can benefit from oral therapy and concerns regarding the emergence of bacterial resistance.
Since rosacea is a chronic disease and many patients find prescription therapies unsatisfactory, they frequently turn to herbal ingredients for relief of their persistent facial redness. The most useful and frequently used herbal compounds include licorice, feverfew, green tea, oatmeal, lavender, chamomile, tea tree oil, and camphor oil. The utility of most of these herbs is based on their purported anti-inflammatory properties. Some of these herbs have proven effects, many have potential benefits, and some may aggravate rosacea. Due to the fact that many patients fail to inform their physicians about their use of herbal ingredients, dermatologists should be aware of what patients may be using and be able to advise them about the efficacy of these ingredients or the potential for adverse effects.
Topical metronidazole (Noritate 1% Cream, Dermik; MetroCream 0.75% Cream, MetroLotion 0.75% Lotion, Metrogel 0.75% and 1% Topical Gel, Galderma) has been used for the treatment of rosacea for over 30 years. Several placebo-controlled trials have demonstrated its effectiveness in the treatment of moderate-to-severe rosacea. It is also effective in preventing relapses of disease and is well tolerated by most patients. A growing number of formulations are available.
The pathogenesis of rosacea is poorly understood, though clinical features of the disease are well-recognized. This article updates current views on mechanisms potentially associated with rosacea. Although data is limited, correlation with therapies is reviewed.
Acne rosacea is a common skin disorder which affects adults, usually women. Erythema, papules, pustules and telangiectases, the main clinical manifestations of the disease are located on the face. Currently opinions dealing with pathogenesis and clinical forms of rosacea are presented. As the clinical picture might be confusing, similar to other illnesses, differential diagnosis with other dermatoses like acne vulgaris, erysipelas, seborrhoeic and contact eczema as well as systemic diseases like lupus erythematosus, dermatomyositis, scleroderma, sarcoidosis and leukemia were discussed.
The persistence of facial telangiectasis and erythema in patients with rosacea frequently presents a major cosmetic problem. It may also contribute to relapses of papular and pustular lesions. This study of 27 patients treated for their telangiectasia and erythema with a flash lamp pumped dye laser tuned at 585 nm is described. The laser gave good or excellent reduction of telangiectasia and erythema and overall appearance in 24 of the patients with between one and three treatments. In addition, papule and pustule activity was decreased in 59.2% of the patients, with those with the most severe pre-treatment activity having the most significant improvement. It is suggested that this is a useful additional form of treatment that may improve the telangiectasia and erythematous component of rosacea.
Metronidazole cream 1% was applied externally for the treatment of rosacea during 2 months in 14 women and 6 men. Two patients failed to come for control examination. Out of 18 patients who completed the treatment in 5 the lesions disappeared completely and were not returning during 3 months of follow-up, in 11 cases an improvement was achieved, in 1 case no improvement occurred, and in 1 case worsening was noted. These results suggest that the cream with metronidazole is an effective treatment for rosacea.
Twenty patients with severe rosacea were treated with isotretinoin for 3-6 months. Six patients initially received 1.0 mg/kg and 14 patients 0.5 mg/kg of isotretinoin. The response was good or excellent in all patients and the papulopustular lesions in particular cleared promptly. Patients receiving 1.0 mg/kg of isotretinoin experienced more side-effects and the dose had to be lowered in five of the six patients. Seventeen of the 20 patients had no relapses during a follow-up of one year showing that isotretinoin has a long-lasting favourable effect in rosacea.
Nineteen patients with severe or recalcitrant rosacea were treated twice daily with 0.75 percent metronidazole topical gel in an open label study. Sixteen of the patients (84 percent) showed 50 percent or greater reduction in inflammatory lesions, while fifteen (79 percent) demonstrated a reduction in erythema severity and an improvement when evaluated by the investigator global assessment. No positive response was recorded for any patient prior to topical medication, whereas six of nine patients previously treated with tetracycline/minocycline demonstrated improvement. Seven of these nine patients responded to topical metronidazole treatment. One additional patient who did not respond to minocycline or desonide treatment showed a good response to topical metronidazole. Only one patient reported local irritation after using metronidazole. These results demonstrate that topical metronidazole gel is safe and effective for the treatment of severe or recalcitrant rosacea.
A 38-year-old male homosexual patient, who had suffered from hepatopathy for many years and from rosacea since 15 years, showed pronounced exacerbation of the rosacea following HIV infection.
Regarding treatment of acne vulgaris and rosacea, there is not much difference between hospital and practice nor among practicing dermatologists. Most of the assistants performing the important physical-manual treatment have had the same training. After analytical conversation and etiologic as well as diagnostic classification, the patients undergo the following manual treatment: cleansing, astringing, removing of comedones, massage, face pack, and covering with tinted emulsion. At home, acne: cleansing, massage, skin lotion, vitamin A acid, benzoylperoxide, antibacterial therapy; in serious male cases of acne conglobata, Roaccutan. Rosacea: antiseptic (antibiotic) treatment (topically and systemically), metronidazole (Arilin); in serious male cases, Roaccutan.
Isotretinoin (Accutane) is a lately developed synthetic oral retinoid for treatment of severe forms of cystic acne resistant to therapy. Its pharmacological effect principally consists in decreased size of the sebaceous glands, reduced sebum production, as well as alteration of the bacterial micropopulation. At a dosage of 0.5 mg up to 1.0 mg/kg body weight daily, isotretinoin led to significant reduction of the inflammatory skin eruptions and long-lasting remission after discontinuation of the drug. With regard to 18 patients suffering from rosacea, the application of Accutane brought about satisfactory results, as well. Mucocutaneous side-effects were almost compulsory, but did never lead to discontinuation of the treatment. Because of its teratogenity, isotretinoin must not be applied in case of gravidity. Accutane offers new modes of therapy with respect to patients suffering from nodulocystic acne or severe rosacea which did not respond to common forms of treatment.
Sporotrichosis is rarely included in the differential diagnosis of rosacea. A patient who clinically appeared to have rosacea, but proved by culture and clinical response to have sporotrichosis of the fixed cutaneous variety, is reported.
13-cis-retinoic acid was given with good results to 7 patients with exceptionally severe rosacea. Side effects were transitory and of minor consequence and subsided quickly on reduction of the dosage and topical application of mild cosmetics. The long-lasting remissions recorded to date indicate that 13-cis-retinoic acid may prove a new and successful approach to the treatment of rosacea.
The effects of clonidine hydrochloride, an agent effective in suppressing other types of flushing reactions, were investigated in patients with erythematotelangiectatic rosacea. Clonidine hydrochloride, 0.05 mg, was given orally twice daily for two weeks. Mean arterial BP was not altered during clonidine treatment. Flushing reactions provoked with water at 60 degrees C, red wine, and chocolate were not suppressed during clonidine treatment. Clonidine did lead to malar hypothermia. It may be that any treatment benefit obtained from the reduction in vascular reactivity by clonidine in rosacea is offset by the malar hypothermia.
Reports about a good effectiveness of systemic therapy of papular rosacea with metronidazole stimulated us to investigate the value of a local treatment 1) with metronidazole mixed in Ungt. emulsific. aquosum, 2) some other available imidazole-derivative-cremes, 3) a new agent bifonazole. The last substance had a better effectiveness than the others, but the results with all these preparations were well enough to recommend them even in lower concentrations for local treatment of papular rosacea.
Introduced on the basis of a primary incidental observation metronidazole has gained more and more interest in the treatment of rosacea. Even before its list of indications had widened steadily. First being used for trichomoniasis, metronidazole is now administered in diseased states as different as anaerobic infection and dependence on alcohol. Although even prolonged administration so far has caused on the whole only minor side-effects in man the experience gained in experimental animals fuels doubts with respect to its long-term safety. Although metronidazole therapy for rosacea proved effective we propose to confine its use to cases that do not respond to tetracycline or local treatment. Pregnancy should be considered a contraindication.