Dr. Leslie Baumann, Dermatologist

Leading dermatologist Leslie Baumann, M.D. reviews new rosacea treatment options, including low-dose doxycline (Oracea®) and intense-pulse light (IPL) therapy in a Miami Herald story published today.

Dr. Baumann pointed out that there are a variety of rosacea treatment options, including prescription medications. “Several years ago, a low dose form of doxycycline called Oracea® was developed. This drug is not a true antibiotic. Instead, it works through its anti-inflammatory properties. Oracea® can be used for long periods to prevent and treat rosacea without the complications associated with long-term antibiotic use.”

According to Dr. Baumann, a form of light treatment called Intense Pulsed Light (IPL) treatments has also been developed that has “revolutionized the treatment of rosacea“. IPL is a non-laser light source that can be used to treat several signs of rosacea. It was first approved for the treatment of fine dilated blood vessels (telangiectasias), but it may now be used to reduce persistent redness (erythema), flushing, and the bumps/pimples of rosacea subtype 2.

Dr. Baumann added that dermatologists may also prescribe a topical medication to be used in combination with oral medications or IPL treatments. Commonly prescribed rosacea medications include metronidazole (MetroGel®), azelaic acid (Finacea®) and sulfacetamide. Elidel®, a calcieurin inhibitior normally prescribed to control the inflammation associated with atopic dermatitis (eczema) may also be prescribed in some cases for rosacea.

Dr. Baumann added additional rosacea skin care tips to help rosacea sufferers manage their condition.

• Avoid spicy foods and hot drinks
• Drink coffee or tea cooled down or iced
• Take omega-3 fatty acids that can fight redness and irritation. Sources include flaxseed and fatty fishes like salmon
• Avoid are spa treatments like facials, some forms of chemical peels, microdermabrasion, hot wax, saunas and steam rooms, as they can irritate sensitive skin.

Rosacea affects up to 14 million Americans but it often goes undiagnosed. It is most common in the fair-skinned, but its cause is unknown. Rosacea usually appears on the skin of the face with redness of the nose, cheeks and forehead, bumps or pimples, broken blood vessels. It is frequently mistaken as acne.

Dr. Leslie Baumann is a board-certified dermatologist, author of Skin Type Solution, and the CEO of the Baumann Cosmetic & Research Institute in Miami Beach. Dr. Baumann also authors the twice-weekly Yahoo! Health blog “The Skin Guru”, with over 3 million readers, and writes a twice-monthly column in The Miami Herald. She authored Cosmetic Dermatology: Principles and Practice (McGraw-Hill, 2002), the world’s best-selling cosmetic dermatology textbook, as well as the New York Times best-selling book, The Skin Type Solution (Bantam Dell, 2006), which focuses on her revolutionary and proprietary skin typing system.

The National Rosacea Society has designated April as National Rosacea Awareness Month to alert the public of the signs and symptoms of rosacea and the importance of early diagnosis and treatment.

As part of Rosacea Awareness Month, dermatologists have enhanced their practice Websites with patient education content regarding rosacea. Rosacea handouts cover a wide range of issues, including the four different subtypes of rosacea and rosacea treatment options, including topical medications (Finacea®, MetroGel®), oral medications (Oracea®), surgical procedures, and IPL for rosacea.

The rosacea content includes information about rosacea triggers and a rosacea diary to help those afflicted with rosacea to track their symptoms. Most rosacea handouts include links to the National Rosacea Society so that patients can learn more about this education and advocacy organization dedicated to improving the lives of people with rosacea.

Rosacea, also called “acne rosacea,” is a non-contagious, chronic skin condition found most commonly in people 30 to 60 years of age.

“It has been called ‘The Great Impostor’ because people often confuse rosacea with other conditions, such as a sunburn or acne, or even eye irritation, and fail to seek medical help,” said Dr. Jonathan Wilkin, chairman of the NRS medical advisory board. “People need to be more aware of this highly prevalent disorder, and the need for treatment and lifestyle changes before it becomes progressively severe.”

The incidence of rosacea is now rapidly growing as the populous baby boom generation passes through the most frequent ages of onset. Yet surveys have found that the public has little knowledge of this chronic but treatable disorder, including how to recognize it and what to do about it.

The importance of seeking appropriate treatment for ocular rosacea was outlined in the Winter Newsletter from the National Rosacea Society, “Eye Irritation Needs Special Attention“.

Ocular Rosacea, Courtesy of the National Rosacea Society

Ocular rosacea can develop BEFORE the onset of any skin and more than 60% of people with rosacea reported having eye symptoms.

Ocular rosacea can result in a variety of eye symptoms, including a watery eyes, bloodshot appearing eyes, a gritty sensation, burning or stinging, dryness, itching, light sensitivity and blurred vision. Blepharitis (inflammation of the eyelid) and the formation of collarettes (narrow circles of loosened keratin, the protein that makes up the outer layer of skin) around the base of the eyelashes are common.

Initial treatment of mild to moderate ocular rosacea may include artificial tears, application of warm compress to the eyes, and cleansing the eyelashes twice each day with water, or with baby shampoo on a wet washcloth. A topical antibiotic ointment may be prescribed for application to the eyelids. A low dose of antibiotic, such as Oracea® or doxycycline (generic) may also be prescribed to reduce inflammation.

Symptoms of rosacea on the skin may also require ongoing treatment with topical medications, such as azelaic acid (Finacea®), or metronidazole (MetroGel®, Noritate®) and laser or light procedures (IPL).

Use of a rosacea diary can be helpful for tracking and managing rosacea symptoms, including eye symptoms. Some people feel that restricting the use of caffeine, spicy foods and alcohol and reduce symptoms of ocular rosacea.

Talk to your doctor if you have rosacea and are experiencing eye symptoms, or if you have chronic eye dryness and irritation that has not responded to previous treatments.

“Thanks to the many thousands of rosacea sufferers who have donated to this program, remarkable progress has been made in understanding this condition despite the challenges presented by its many signs and symptoms,” said Phoenix area dermatologist Mark Dahl, M.D., Professor of Dermatology at the Mayo Clinic Arizona and a member of the National Rosacea Society Medical Advisory Board.

The role of cathelicidins has been explored by Dr. Richard Gallo and colleagues at the University of California-San Diego. They have discovered that cathelicidins may cause inflammatory bumps and pimples as well as vascular effects such as flushing and visible blood vessels called telangiectasia.

Investigators believe that the production of cathelicidins and related biochemicals may be prompted by known rosacea triggers, such as heat, corticosteroids, sun exposure and microorganisms such as Demodex folliculorum.

Other research has investigated the role that kallikreins, interferon and neuropeptides around blood vessels contributes to the development of the flushing and inflammation of rosacea.

Demodex folliculorum, a microscopic mite that normally inhabits human skin, has been found in greater numbers in those with rosacea. However, it  has been debated whether it may be a cause or simply a result of rosacea. It now appears that its true connection with rosacea’s signs and symptoms may be linked to a distinct bacterium associated with the mites, called Bacillus oleronius. One study found that B. oleronius stimulated an inflammatory response in 79% of of those with subtype 2 rosacea (papulopustular rosacea).

Meanwhile, others are investigating possible genetic components of rosacea, the effect of topical antibiotics on skin lipid production, and the molecular pathway that results in flushing caused by niacin (vitamin B3 or nicotinic acid).

Rosacea Symptoms

Hilary Baldwin, M.D., Rosacea Expert

According to rosacea expert and study investigator Hilary Baldwin, M.D., “These results could change the way physicians treat rosacea.” Dr. Hilary Baldwin added that “ORCA confirms the safety of Oracea® and its effectiveness as a papulopustular rosacea treatment, even as monotherapy, with 3 out of 4 patients showing significant improvements over 12 weeks of treatment.”

The rosacea study evaluated 1421 patients with mild to severe papulopustular rosacea (rosacea subtype 2).

Oracea® is an oral medication that was developed to isolate doxycycline’s anti-inflammatory properties. This sub-antimicrobial dose, also called anti-inflammatory dose doxycycline, does not kill bacteria and does not lead to bacterial resistance. (Oracea® is a unique formulation of 30-mg immediate-release doxycyline and 10-mg delayed-release beads.)

ORCA stands for “Oracea® for Rosacea: A Community-Based Assessment”.

In the ORCA study, results found that the side effect profile of Oracea®, even in large populations, was consistent with that seen in controlled, clinical trials, with the most frequently reported side effects being mild to moderate nausea and diarrhea.

Rosacea is a chronic inflammatory skin disorder that primarily affects the face. It is prevalent amongst fair-skinned individuals who are 30 to 65 years old.  It often appears as skin lesions redness, visible blood vessels, papules and pustules in the middle of the face (forehead, nose, cheeks). Increased redness or flushing may result from certain rosacea triggers, such as alcohol, spicy food, sun exposure and hot showers. Stinging, burning and sensitivity of the skin and an intolerance to cosmetics are also very common and in some cases the eyes can become red, dry and itchy. There is presently no cure for rosacea, but topical and oral medications, as well as laser and light treatments, may reduce its signs and symptoms. Early diagnosis and treatment of rosacea can prevent its progression.

Oracea® is the only FDA approved oral medication for the treatment of rosacea. The ORCA trial was sponsored by Galderma Laboratories L.P., the manufacturer of  Oracea®. More information about the ORCA Trial is available from Galderma.

Important Safety Information About Oracea®

Oracea® is indicated for the treatment of only inflammatory lesions (papules and pustules) of rosacea in adult patients. You may experience intestinal upsets, sore throat or sinus infections/sinusitis when taking Oracea®. Do not take Oracea® if you are allergic to tetracyclines, and it may cause harm to a developing fetus; so do not take Oracea® if you are pregnant or breastfeeding.
When taking Oracea®, stay out of direct or artificial sunlight, and make sure you tell your doctor if you have stomach or GI problems, kidney disease, have a yeast or fungal infection, take blood thinners, take oral contraceptives, or take medicine to treat acne, psoriasis or seizures. Oracea® does not treat bacterial infections. Use Oracea® only as prescribed by your doctor.

For more information about Oracea®, see Full Prescribing Information.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Julie Harper, M.D., Dermatologist

Azelaic acid has been the focus of recent studies for the treatment of rosacea and the results have been encouraging, according to dermatologist Julie C. Harper, M.D.

In a story published in Internal Medicine News, “Studies Highlight Effectiveness of Azelaic Acid for Rosacea“, Dr. Harper described how 15% azelaic acid was shown to control the inflammatory response in normal human skin cells.

Dr. Julie Harper is Clinical Associate Professor in the Department of Dermatology at the University of Alabama at Birmingham (UAB) and in private practice at the Dermatology and Skin Care Center of Birmingham. Her comments reported comments were made at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Harper explained that how azelaic acid might exert its anti-inflammatory effects.

In one study of 72 patients, a 15% gel formulation of azelaic acid used once daily was shown to be as effective as the same formulation used twice daily. No significant difference was found between the once- and twice-daily groups. In another study of patients with mild to moderate rosacea, topical azelaic acid 15% gel plus 40 mg oral doxycycline (anti-inflammatory dose doxycycline) was shown at treatment week 6 to be associated with significantly greater improvement in mean inflammatory lesion count, compared with metronidazole 1% gel combined with oral doxycycline.

According to Dr. Julie Harper, “Azelaic acid is a commonly prescribed topical medication for the treatment of rosacea. These new developments give us insight into why this product works so well,” Dr. Harper noted. “We are also learning a great deal about the pathogenesis of rosacea and other skin diseases. The more we learn, the more efficiently and effectively we can treat these diseases.”

A story in the summer issue of the Rosacea Review from the National Rosacea Society described rosacea subtype 1 as being characterized by flushing and persistent redness of the central face, that often occurs before or at the same time as the bumps and pimples of rosacea subtype 2 (papulopustular rosacea). Visible blood vessels may also be present, and in many cases the skin may be irritated and unusually sensitive.

According to dermatologist Dr. Jonathan Wilkin, Chairman of the NRS medical advisory board, identifying and avoiding lifestyle and environmental factors that trigger rosacea symptoms in individual cases can be especially effective in controlling the flushing and redness of (rosacea) subtype 1.

Standard management of rosacea subtype 1 involves the tracking of rosacea triggers with the assistance of a rosacea diary, and the ongoing avoidance of those triggers.  Those with rosacea often have extremely sensitive skin, making it essential to select skin care products that do not irritate the skin. This may include using non-soap cleansers, washing with lukewarm water, and gently dabbing the skin dry with a soft towel rather than rubbing the skin to minimize irritation. The use of green or yellow cosmetics can also be used to counteract visible redness, and cover makeup may be used to conceal visible blood vessels and other signs of rosacea.

The visible blood vessels and persistent redness may be effectively treated with laser or intense pulsed light (IPL) therapy.

Dr. Wilkin added that, unlike with the red bumps and pimples of subtype 2 that may be treated with topical medications (Clenia, MetroGel, Finacea) and/or oral medications (Oracea), no drugs have been approved by the U.S. FDA to treat the persistent redness of rosacea subtype 1.

However, the use of certain medications can reduce some symptoms. For instance, aspirin, NSAIDs, antihistamines, and other medications may be prescribed to help reduce flushing caused by other triggers, such as alcohol or niacin.

In addition, beta-blockers (propranolol), normally used to control high blood pressure, may be prescribed to reduce flushing associated with emotional stress.

There has also been interest in the use of nasal decongestants, such as Afrin, on the skin to reduce redness.

Sunscreens for Rosacea

Since sun exposure may lead to the development of rosacea, or a worsening of rosacea symptoms, it is important to implement effective sun avoidance measures and to regularly use a sunscreen.

According to a story in the summer issue of the Rosacea Review by the National Rosacea Society, those with rosacea should consider a ”sunblock” or “physical sunscreen” that contains titanium dioxide or zinc oxide when selecting a sunscreen.

These reflect the sun’s rays rather than absorbing them and tend to be better tolerated by sensitive skin.

According to Dr. Lisa Maier, dermatologist and Associate Professor in the Department of Dermatology at the University of Michigan, “sunscreens whose vehicles include silicone may be especially well tolerated”.

See Rosacea Survey Summary.

In the survey of 1,289 people with rosacea,  71% of respondents said they had experienced persistent redness, and 63%  said they had suffered from frequent flushing. These are classic symptoms of rosacea subtype 1 (erythematotelangiectatic rosacea).  In addition, 63% said they had suffered outbreaks of pimples (pustules) and 61% reported experiencing bumps (papules). These are classic symptoms of rosacea subtype 2 (papulopustular rosacea).

In addition to these common effects of rosacea, the survey found that more than one-half of the respondents had been affected by a number of less well-known potential effects of the condition. 61% of respondents said they had also experienced eye symptoms, a condition known as subtype 4 rosacea (ocular rosacea). Among those who experienced eye symptoms, complaints ranged widely, including dry eye, a gritty feeling, eye itching, bloodshot appearance,  burning sensation in the eyes, watery eyes, reduced vision, and styes.

Other widely reported signs and symptoms included facial itching (41%) dry appearance (40%), raised red patches (30%), skin thickening on the nose also called “rhinophyma” (22%), signs beyond the face (21%).

Of those who stated that rosacea had affected areas other than the face, 48% said they had signs and symptoms on the neck, 46% noted the condition had affected the scalp, 42% said it was evident on the chest, 36% said it affected the ears,  16% said it affected the arms and 8% said it affect their legs.

“Many (of those with rosacea) experience a variety of manifestations in succession or at the same time,” said Dr. Boni Elewski, dermatologist and professor of dermatology at the University of Alabama-Birmingham. “That’s why it’s important for patients to be aware of the many possible effects of the disorder, so they know when to seek an evaluation and appropriate help from a dermatologist.”

IMPORTANT NOTE: 86% of the respondents reported that rosacea treatments and lifestyle modifications reduced effects of their rosacea.

Jeffrey C. Poole, M.D., Dermatologist

Dermatologist Jeffrey C. Poole, M.D. provides an overview of rosacea treatment options and describes how they are shaped by the type of rosacea.

“Erythrotelangiectatic rosacea (rosacea subtype 1) may be the initial phase of rosacea for many people.  Patients are red, flush easily from various stimuli such as alcohol, caffeine or temperature changes.  Sun protection is key to prevent long term progression of this stage, which may progress.  Coverup makeups can be used, and the newer mineral makeups seem to work well and are non-irritating”, says Dr. Poole.

Dr. Poole adds that for rosacea subtype 1, “the best treatment is the Pulsed Dye Laser  (PDL) or intense pulsed light (IPL).  These lasers and light sources target the blood vessels that are the cause of this condition.  Generally 3-4 treatments are sufficient for excellent results.”

Dr. Poole points out that most of the prescription medications for rosacea target papulopustular rosacea (rosacea subtype 2). Topical medications (metronidazole and azelaic acid) and oral medicines, such as doxcycycline (Oracea) and minocycline, are very effective in decreasing the red pimples and bumps. Long-term use of rosacea medications is the rule, and flares tend to recur as rosacea medications are weaned. Dr. Poole added that “pulsed dye laser treatment may improve rosacea subtype 2 symptoms and decrease the frequency of flares.”

Rhinophyma, seen with rosacea subtype 3, generally only occurs with men and less commonly than a few generations ago.  Treatment of rhinophyma can be with ablative lasers such as the CO2 laser, or with an electrocautery unit.  Dr. Poole stated that “Many patients find improvement in their sleep and less snoring, as well as a improved cosmetic appearance, with treatment.”

Dr. Poole is a board certified dermatologist in Metairie, Louisiana. In addition to his private dermatology practice, Poole Dermatology, Dr. Poole is also an Assistant Clinical Professor of Dermatology at both the LSU and Tulane Schools of Medicine, acting as their Pediatric and Adolescent specialist, and remains a board-certified pediatrician. He is a Fellow of the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American Society of Laser Medicine and Surgery and the Society for Pediatric Dermatology.