When treating rosacea and acne, pay close attention to the potential for adverse effects ranging from skin irritation to drug resistance, according to Dr. Joseph F. Fowler Jr.
Irritation is especially common in rosacea patients, and there can be significant adverse effects from systemic treatments of both rosacea and acne. Fortunately, newer formulations of both topical and systemic drugs have been created to reduce the adverse effects and increase the efficacy of these treatments, said Dr. Fowler of the University of Louisville (Ky.).
At the Caribeean Dermatology Symposium, he outlined a treatment plan for acne and rosacea patients with sensitive skin and reviewed the adverse effects of current treatments. Dr. Fowler disclosed being a consultant and conducting clinical studies for a number of pharmaceutical companies that produce rosacea and acne treatments.
Rosacea patients tend to have more sensitive skin, Dr. Fowler said in an interview, so topical medications need to be carefully chosen. Data suggest that metronidazole 1% (MetroGel, Galderma) is the least irritating. Another topical option is azelaic acid gel 15% (Finacea), which has been shown to be somewhat more irritating, but slightly more efficacious. Both of these options cause less irritation than do many of the generic products on the market.
“From a topical standpoint, it is fairly difficult to find products that are both highly effective and nonirritating,” Dr. Fowler said. “We probably don't have a topical agent that is tremendously efficacious, especially in more severe rosacea.”
When a topical therapy is efficacious but is causing irritation, Dr. Fowler recommends using an adjunctive therapy such as calcineurin inhibitors, antifungal treatments, and moisturizers. The treatments may not do much alone, but they can be added to the regimen to allow tolerance of the first topical agent.
For patients with moderate to severe rosacea or even mild cases where an oral agent is preferred, systemic treatment may be appropriate. However, Dr. Fowler tries to use the lowest doses possible because of concerns about oral antibiotics' adverse effects, such as gastrointestinal symptoms, vertigo, photosensitivity, autoimmune disease, and antibiotic resistance.
For example, he tries to avoid using higher doses (the levels used in acne treatment) when treating chronic rosacea. Dr. Fowler recommends using sub-antimicrobial-dose doxycycline generic 20 mg/twice a day or Oracea delayed release. He said that he prefers to use Oracea delayed release because the once-a-day formulation is better for patient compliance. In addition, the delayed release probably gives more of an anti-inflammatory effect, he noted.
In acne, watch out for irritation from topical retinoids, he said. Generally, the irritation tends to increase as the efficacy increases. When using a topical retinoid, Dr. Fowler recommends slowly stepping up treatment from a mild retinoid such as low-dose adapalene to one with a higher strength.