The Canadian Dermatology Association has released clinical practice guidelines to provide health care providers with evidence-based recommendations to assist in the diagnosis and management of rosacea.
The guidelines, published in The Journal of Cutaneous Medicine and Surgery (Sept. 2016; 20(5):432-435), were divided into four parts representing the subtypes of rosacea: erythema, papules and pustules, phymatous, and ocular. The Canadian panel of experts took into consideration the balance of desirable and undesirable outcomes ,the quality of supporting evidence, the values and preferences of patients, and the costs of treatment.
“I think the most important take away message is that we have multiple options for the treatment of all different facets of rosacea,” Dr. Catherine Zip, a clinical associate professor at the University of Calgary and an author of the guidelines, told DERM.city. “For clinicians who are not dealing with rosacea on a regular basis, it is great to look at a chart and ask ‘where should I start, what are my initial treatment options, and where do I go from there?’”
Each recommendation was given a strength of either weak or strong. “Recommendations likely to apply to all or virtually all patients would be given a strong recommendation. Recommendations appropriate for some but not all patients . . . would be determined to be weak,” stated the authors. The recommendations were also given a quality level of very low, low, moderate, or high based on the authors’ confidence of effect.
“If you look at these guidelines, all the recommendations are weak,” said Dr. Zip. “That reflects the fact that for many treatments we do not have good randomized, contolled data. We have a lot of clinical experience using [the treatment options] and efficacy in some patients, but we do not have strong randomized controlled data. We have much experience using [the treatment options] and see efficacy in many patients, but we do not have large randomized controlled data to support the efficacy. Looking at all of these recommendations it was either because of lack of such data or higher cost that would typically bring the level of recommendation down to weak.”
Erythema of rosacea
A newer treatment, topical brimonidine, was given a weak recommendation with a “high
confidence in effect estimate but perceived variability in patient values in preferences” for the treatment of erythema based on two high-quality randomized controlled trials (RCT).
“The trials [found that] approximately 30 per cent of patients do really well on the medication, [and] I think this is consistent with what we are seeing in practice. Some people respond very well, but it does not help everybody,” said Dr. Zip. “And some patients do get rebound, I have
seen that.” She added, however, that in her experience most patients who think they have rebound are actually noticing the return of erythema as the effect of the medication wanes at
around 12 hours. She suggested discussing this effect when prescribing brimonidine.
“There are other options for erythema besides brimonidine. There has been some reports of improvement in erythema using topical metronidazole and azelaic acid,” noted Dr. Zip. “But the best data is in support of the use of topical brimonidine.”
Topical metronidazole was given a weak recommendation with moderate confidence in effect estimate and topical azelaic acid a weak recommendation with high confidence in effect estimate.
Other treatment options for erythema of rosacea included vascular laser treatment (Nd:YAG or pulsed dye laser [PDL]) or intense pulsed light (IPL), low dose oral doxycycline, and
skin care and camouflage.
Rosacea papules and pustules
“Topical ivermectin was recommended for the treatment of papules and pustules of rosacea and it was a weak recommendation for very similar reasons to brimonidine. There is very good data to support its use, two large RCTs, but it is a more expensive treatment option and there may be other medications that would be more affordable yet effective for patients,” said Dr. Zip.
“Other options [for] that group [of patients] would be either topical metronidazole or topical azelaicacid, which were also given weak recommendations, mainly because there is less data to support their use in clinical trial settings.”
Oral doxycycline, oral tetracycline,and oral isotretinoin were also recommended. “There have been no placebo-controlled trials [for oral isotretinoin]; however, panelists reported good results in their own practices, and isotretinoin may be a good choice for those in whom tetracycline group antibiotics were not effective or are contraindicated,” noted the authors.
Recommendations for treating phyma include topical retinoids, oral tetracycline or doxycycline, ablative laser surgery (using C02 or Er:YAG modalities), or surgery (including electrosurgery and cryosurgery), and oral isotretinoin.
“When you treat rhinophyma with electrosurgical treatment or with a resurfacing laser it is possible to create scarring, so definitely there is a skill set to doing that kind of procedure [and
achieving] a good outcome,” she said.
“For rhinophyma we really have very little data to guide us in our treatment choices, and so we based our recommendations for rhinophyma mainly on collective clinical experience,” she noted.
Options for treating ocular rosacea, according to the guidelines, include lid care and artificial tears, oral doxycycline, oral tetracycline, cyclosporine drops, and referral to an
Dr. Zip said another important finding in developing the guidelines was that there is not
much research on the impact of rosacea on quality of life (QoL).
“We know from clinical experience that rosacea has a huge impact on QoL, and certainly
a stigma too, like the red nose associated with excessive alcohol consumption. But most of the studies have not addressed QoL impact or how it is modified by treatment because QoL is
a relatively recent focus of studies.”
Non-proprietary and brand names of therapies: topical brimonidine (Onreltea, Galderma); topical metronidazole (MetroGel, Metro-Cream, MetroLotion, Galderma); topical azelaic