• Editor: Dr. Stuart Maddin • Volume 14, Number 2 • February 2009 1 Indexed by the US National Library of Medicine and PubMed Volume 14 • Number 2 • February 2009 Rosacea and Its Topical Management M. Gooderham, MSc, MD, FRCPC Peterborough, ON, Canada ABSTRACT Many options exist for the treatment of rosacea, including topical and systemic therapies, laser and light-based therapies, and surgical procedures. A classification system for rosacea identifies 4 subtypes (i.e., erythematotelangiectatic, papulopustular, phyma- tous, and ocular), which may help guide therapeutic decision-making. The goals of therapy include reduction of papules, pustules, erythema, physical discomfort, and an improvement in quality of life. Standard topical treatment agents include metronidazole, azelaic acid, and sodium sulfacetamide-sulfur. Second line therapies include benzoyl peroxide, clindamycin, calcineurin inhibitors, and permethrin. Keywords: rosacea; topical therapy; systemic therapy; laser ALSO IN THIS ISSUE: Drug Treatments for Skin Disease Introduced in 2008 (on Page 4) Rosacea is a chronic relapsing skin disorder characterized by facial flushing, persistent erythema, telangiectasia, and inflammatory papules and pustules affecting the central face. The National Rosacea Society has described a classification system based on 4 main subtypes: erythematotelangiectatic, papulopustular, phymatous, ocular, and one variant, i.e., granulomatous. 1 Rosacea can contribute to lower self-esteem and have significant psychosocial implications, e.g., stress at work and social isolation. 2 This can have a significant impact on quality of life and should be taken into consideration when treating these patients. Treatment starts with making a proper diagnosis, including identification of subtype. Following this, conservative measures, such as trigger avoidance, proper skin care, camouflaging cosmetics, and photoprotection should be discussed in detail. Topical pharmacotherapeutic options include: azelaic acid (Finacea ® Gel, Intendis/Bayer), clindamycin, clindamycin 1%-benzoyl peroxide 5% gel (BenzaClin ® , sanofi-aventis; Duac ® , Stiefel), erythromycin, metronidazole (MetroCream ® , MetroLotion ® , MetroGel ® , Rozex ® Gel, Galderma; Noritate ® , Dermik), or sodium sulfacetamide 10% + sulfur 5% (Plexion ® , Medicis; Rosac ® Cream, Stiefel; Rosula ® Lotion, Doak Dermatologics; Sulfacet-R ® , Novacet ® Lotion, Perrigo). For patients with moderate-to-severe papulopustular rosacea or those with ocular involvement, systemic therapy is often prescribed and options include doxycycline, erythromycin, metronidazole, minocycline, tetracycline, or in severe cases, low dose isotretinoin. The telangiectatic component does not respond to either oral or topical therapy, and is best treated with laser and light-based therapies. Surgical intervention may be required for the phymatous subtype. Therapeutic choices will depend on patient expectations, tolerance, previous therapies used, rosacea subtype, and severity. This article will focus on topical therapies for rosacea. Azelaic Acid (AZA) AZA is a newer therapeutic option for the treatment of rosacea. It was approved by the US FDA in 2002, the European Union in 2003, and in Canada in 2004, although it has only recently become commercially available in Canada. AZA is a naturally occurring dicarboxylic acid that can be found in dietary sources, such as whole grains. 3 It lacks toxicity, is nonteratogenic and nonmutagenic. 4 It has multiple biologic effects including anti-inflammatory, antikeratinizing and antibacterial activities. The likely mechanism of action is via inhibition of reactive oxygen species produced by neutrophils. 4 A novel 15% gel formulation (Finacea ® , Intendis/Bayer) is available for the treatment of rosacea, in addition to a 20% cream formulation approved for use in acne vulgaris. The 15% gel, although formulated to a lower concentration than the cream, is significantly more bioavailable than the cream because of an optimized aqueous gel vehicle. Multiple reviews have been published examining the use of AZA in rosacea. 3,5,6 Two pivotal phase III trials have shown that AZA 15% gel, applied twice daily for 12 weeks, was superior when compared with the vehicle for patients with papulopustular rosacea. 7 A mean reduction in inflammatory lesion counts ranged from 51%–58% in the AZA group, compared with 39%–40% in the vehicle group. Improvement in erythema scores ranged from 44%–46% in patients treated with AZA, compared with 28%–29% in the vehicle group. 7 In a 15-week study, AZA 15% gel applied twice daily also showed significant benefit over metronidazole 0.75% gel. 8 In these studies, the use of AZA 15% gel led to a mean