Grappling with rosacea treatment, causes

National report - While the question of what specifically causes rosacea remains unanswered, dermatologists can still address the condition with a number of existing treatment options and look forward to new ones being researched now.

According to Guy F. Webster, M.D., Ph.D., clinical professor in the department of dermatology at Jefferson Medical College in Philadelphia, a new class of medicine is in the very early testing phases and could some day be added to the armamentarium for the treatment of rosacea.

"The causes of rosacea are still unknown," Dr. Webster says. "None of the theories are very impressive at explaining why rosacea patients get pimples. We are waiting to find that explanation."

New, old treatments

The new class of drugs to treat rosacea is called incyclinide (CollaGenex). Dr. Webster reports that drugs in this class are, "derived from doxycycline but have no antibiotic activity. Just a lot of anti-inflammatory activity."

While it is still too early to draw any conclusions, he says preliminary information is, "very promising." However he advises dermatologists to patiently wait and see where the research leads.

"This is early. We'll see how they do in big trials."

Current options

In the meantime, Dr. Webster reminds dermatologists to make the most of currently available treatment options, both topical and oral.

Among topical agents, he considers erythromycin and clindamycin to be "worthless" in the treatment of rosacea.

Topical agents that can be effective include: metronidazole, tacrolimus/pimecrolimus, clindabenzoylperoxide/clinda, azeleic acid, sodium sulfacetamide/sulfur and tretinoin.

Among the choices of oral agents for rosacea, Dr. Webster considers tetracycline, doxycyline and minocycline to be effective. What makes them so effective is their direct anti-inflammatory effect on the condition. They are often effective in subantibiotic dosages.

He also considers Cipro (Bayer) and Bactrim (Roche) to be effective, but should be used only when tetracyclines fail. He also recommends isotretinoin "when all else fails for nodular dz."

Beta blockers and SSRIs are considered to be "occasionally effective," according to Dr. Webster.

Among antibiotic choices, the most effective include tetracyclines, ciprofloxacin, trimethoprim/sulfamethoxazole and metronidazole.

He notes that no antibiotics are active against Demodex, but all except metronidazole are active against P. acnes.

Rosacea types

Papular rosacea appears to be the most responsive to treatment, according to Dr. Webster. He recommends topical metronidazole, benzoyl peroxide/clindamycin, sulfacetamide/sulfur or azeleic acid. Oral therapy might include tetracyclines (both traditional and sub MIC) and isotretinoin.

For steroid rosacea, Dr. Webster points out that a patient's use of homeopathic products could have vasoconstrictor activity, so patient history should include questioning about the use of such products. A useful diagnostic clue to steroid rosacea is its location under the nares.

He says gentle steroid withdrawal typically does not work.

He notes that it is quite common for patients to experience both rosacea and seborrehic dermatitis in an overlap of conditions. When treating such an overlap, he finds that it can be very resistant to traditional rosacea treatments. Good treatment choices can include topical tacrolimus/pimecrolimus or Loprox (Hoechst-Roussel). Also effective are oral tetracyclines or, in extreme cases, cyclosporine followed by a topical agent. He also advises his patients to avoid irritants that can exacerbate the condition.

Pyoderma faciale can be related to pregnancy or brought on by withdrawal from steroid therapy. It is characterized by an "explosive onset," Dr. Webster says.

He recommends a combined therapy of 40 mg prednisone tapered over three weeks, followed by 20 mg to 40 mg isotretinoin or minocycline for two to three months.