Rosacea is a common skin condition that patients will often present with in the pharmacy. Here are some common questions that pharmacists may be asked, writes Christine Clark
Key learning points
Rosacea is an inflammatory skin disease that affects up to 10% of the population. Although poorly understood and often dismissed as a minor condition, it can have a profound impact on quality of life. A number of new treatments have been developed in recent years and these should help many sufferers.
1 My face tends to flush in a warm room. Have I got rosacea?
Not necessarily. Many people find that their faces flush in a warm room. People with rosacea have persistent redness in the middle of the face (on the cheeks, chin, forehead and nose) and experience intense flushing in response to triggers, such as temperature changes, sunlight, alcohol, hot or spicy food, embarrassment, exercise or stress.
They may also have spider veins (broken thread veins and telangiectasia) and sensitive skin (stinging, burning and easily irritated), inflammatory papules or pustules. Less common manifestations are redness and soreness around the eyes (ocular rosacea) and men with rosacea sometimes develop an enlarged, red nose (rhinophyma).
2 Someone told me it used to be called acne rosacea — does that mean it is a sort of acne?
No, rosacea is different from acne. Although papules and pustules can be found in both conditions, only acne is associated with comedones. Comedones, arising from colonisation of sebaceous glands by Propionibacterium acnes, can develop into papules and pustules. Acne is mainly seen in people under the age of 30 whereas rosacea mainly affects people in the 30 to 60 year group. Acne often affects the upper chest and back, whereas rosacea is confined to the face.
3 Can rosacea be cured?
At present there is no cure but there are treatments to reduce the symptoms. Part of the problem is that the cause of rosacea is unknown. It is recognised to be a chronic inflammatory skin disease associated with abnormally sensitive skin. Neurogenic inflammation seems to play a big role and once this is better understood it may open the way for new treatments.
4 I don’t want to bother the doctor with this. What is available as an OTC treatment?
Good skincare is a vital part of treatment for rosacea and all of the products required for this are available without prescriptions. Good skincare for rosacea involves regular use of UV protection (sun protection factor 30-plus), moisturisers, gentle cleansers and avoidance of triggers. Moisturisers should be unperfumed products. Similarly, cleansers should be mild, unperfumed products designed for sensitive skin.
A number of available ‘anti-redness’ products usually contain sunscreens to protect the skin from UV light and green pigments to neutralise the redness. Some also contain ingredients that are said to be soothing. For example, Eucerin Anti-Redness contains Symsitive, an agent that appears to reduce neurogenic flushing.
5 What prescription treatments are there?
Current treatment guidelines recommend ‘phenotype-led’ treatment1. Clinicians also recognise that patients may need a combination of treatments with several products to manage their symptoms.
Topical brimonidine (Mirvaso gel) is recommended for first-line treatment of persistent erythema. Brimonidine is an alpha-adrenergic agonist that causes local vasoconstriction, thereby reducing redness, when applied topically. It has a rapid onset of action and the effects wear off after about 12 hours.2
Occasionally, the use of brimonidine can make pustules look more prominent because removing background redness can cause them to stand out more. Brimonidine was originally developed for the treatment of glaucoma and has been used in eyedrops for this purpose for many years.
Topical ivermectin 10mg/g (Soolantra cream) was superior to metronidazole cream in reducing inflammatory lesions of rosacea.3 It has the advantage of once-daily application, whereas most other topical treatments must be applied twice daily. Topical ivermectin is generally well-tolerated with mild skin burning and irritation, pruritus and dry skin being the most common problems.
The main action of tetracyclines (and metronidazole) in rosacea is believed to be anti-inflammatory rather than antibacterial, and this is why the low-dose, modified-release formulation of doxycycline (Efracea) was launched. Efracea contains 40mg of doxycycline — a dose too low to have any antibiotic activity. It does not cause the development of antibiotic resistance at this dose and is, therefore, more desirable than a 50mg dose of conventional doxycycline.
6 What about Demodex mites?
Demodex folliculorum is a tiny mite that lives on the skin (in the hair follicles of the face) of most people. It is present in people with papulopustular rosacea. However, the exact role of Demodex has yet to be clarified. Topical ivermectin eradicates Demodex mites.4
7 Lisa is 31 years old and flushes easily, especially if stressed. She wants to look good for a job interview and asks if there is anything to help minimise or disguise the effects.
There are several products designed especially for people with rosacea. These include mild wash products and green-tinted moisturisers. Also, several cosmetic companies produce green-tinted foundations. These look strange in the tube but once
on the skin the effect is simply to neutralise the redness.
8 Brian is a 52-year-old man who has always had sensitive skin. He says that shaving can make his face sore and wants a moisturiser that will not make his skin worse.
Brian should be offered an unperfumed moisturiser, containing a sunscreen, at sun protection factor 30 or more. He should also be advised to use a mild, emollient wash product for his face.
9 Steve is 35 years old and suffers from rosacea. He is afraid that people will think his red face is due excessive alcohol intake and this could harm his career prospects.
Steve could benefit from topical brimonidine and will need to be referred to a prescriber. He would need to use the brimonidine gel daily because when its vasoconstrictor effects wear off the redness returns. He should also be reminded to avoid trigger factors such as hot or spicy food.
10 Rachel is a 42-year-old woman who has used metronidazole gel in the past for her moderate-severe papulopustular rosacea with modest success. She is very health-conscious and does not want to disturb her gut microbiome by taking long-term tetracyclines; she asks if there are any effective alternatives.
According to current recommendations ivermectin 1% cream would be the most appropriate first-line treatment for Rachel.
It is applied once daily, is well-tolerated and not associated with the development of antibiotic resistance. She will need to be referred to a prescriber as ivermectin 1% cream is prescription only medication.
Christine Clark is a trained pharmacist and freelance medical writer
1 Schaller M et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol 2017;176:465-71
2 Facial erythema of rosacea: brimonidine tartrate gel. NICE Evidence Summary (ESNM43) July 2014
3 Inflammatory lesions of papulopustular rosacea: ivermectin 10 mg/g cream. NICE Evidence Summary (ESNM68), January 2016
4 Cardwell et al. New developments in the treatment of rosacea – role of once-daily ivermectin cream. Clin, Cosmet Investig Dermatol 2016;9:71-77