Treatment with Newer Topical Creams
Rosacea is a common skin disease. It often begins with a tendency to blush or flush more easily than other people. Overtime, the condition progresses and patients may have the following signs and symptoms, often in combination, and the condition is then not just simply about redness:
- Erythematotelangiectatic rosacea: Redness, flushing, visible blood vessels, and skin tends to be sensitive, dry and rough;
- Papulopustular rosacea: Redness, swelling and acne-like breakouts;
- Phymatous rosacea: skin thickens and has a bumpy texture, particularly affecting the nose and the medial cheeks, and pores are visibly bigger;
- Ocular rosacea: eyes get red and irritated, eyelids can be swollen.
With time, there may be permanent redness in the central face.
There is as yet no cure for rosacea. However, treatment can help to control the disease and control the signs and symptoms. Different treatment may help different aspects of the condition.
Two relatively newer topical medication have been approved by the FDA of USA in the past few years and have been added to the armamentarium in the treatment of rosacea, namely 1% ivermectin cream (Soolantra) and 0.33% brimonidine gel (Mirvaso).
The active ingredient in Soolantra cream is ivermectin, which has anti-parasitic and anti-inflammatory properties. However the exact mechanism by which it helps in controlling rosacea is not known. It can help in reducing the inflammatory acne-like lesions, but not so much of the redness or flushing aspect of the condition.
It needs to be applied once per day, to the area of concern, usually the central part of the face but avoiding the eyes and mucosal surface.
Be patient, as it takes at least a couple of weeks before one can start to see the effect of the medication. Long term studies have shown that the efficacy of the medication may continue to increase beyond 16 weeks of continual treatment. Therefore, do not give up too quickly and discard it as being useless.
Soolantra is a relatively safe medicine. The main adverse effect of the cream is local burning or stinging sensation, the reported incidence of which is about 1%. As with most newer medicine, safety data of use during pregnancy or lactation is lacking and it should be used under such circumstances only if the potential benefits outweigh the potential risks.
Safety and effectiveness of Soolantra cream in paediatric patients have not been established either. It is not very important as rosacea is not a common condition in the paediatric population anyway.
Mirvaso (Brimonidine 0.33% gel) is approved by the FDA for treatment of persistent redness in rosacea. Brimonidine will cause blood vessels to constrict and so helps in reducing the redness of rosacea. It is to be applied once daily. It’s onset of action can be as quick as 30 minutes. For patients who respond to treatment, the duration of activity can vary from a couple of hours to up to 12 hours in some patient. Not uncommonly patients may find that the effect of the drug starts wearing off after 3-4 hours. However, it is not advisable to reapply it because of that. That may increase the incidence of side effects.
There are some precautious that need to be considered before trying this medication. As the drug affects vascular reactivity, patients with co-existing blood supply insufficiency problem e.g. inadequate blood supply to heart or brain or to other organs may not be a good candidate for this cream. Patients with low blood pressure are more likely to experience dizziness with the cream. Patients taking other medications need to inform their doctors beforehand to make sure there is no significant drug interaction before using this cream, e.g. medications for blood pressure or depression.
Adverse reaction to the gel can also be troublesome. Redness, burning sensation, flushing and skin irritation occur in 5-10% of patients after using this gel. It may take some days or weeks before these side effects start to develop. Nasal congestion or blurred vision have been reported in about 1-2% of patients. Some patients even feel there is rebound redness, meaning the redness is even worse than before when stopping the medication. And as with all medication, one can be allergic to it. If there is any significant discomfort after using the medication, stop it and ask your doctor.
Use of mirvaso gel is not recommended during pregnancy or lactation.
Despite all these potential hiccoughs and problems, brimonidine gel can be useful and valuable in some patients, particularly those who find redness and flushing to be significantly disturbing. Imagine you are talking to clients or giving a talk or presentation to a group of audience. You do not want to look flushed and blushed, or have a red face as if you have had a drink before the presentation. Test it to learn it’s characteristics on you, so you will know whether you can depend on it if the situation arises.
As with all medication, no single drug is going to be effective for everyone, and there are always potential adverse reactions with any treatment. And always consult your dermatologist before considering any medications, even it’s only a topical cream.