Treating Rosacea: FDA Approved Medications and Their Side Effects
- Rosacea is a common progressive condition that affects facial skin.
- Many medications — from topical antibiotics and anti-inflammatory creams, to low-dose oral antibiotics — are available to control major symptoms.
- Some medications have an associated safety and side effect profile.
- Lifestyle changes, a sensitive skin care regimen, and the avoidance of known triggers are very helpful in controlling this condition.
Often misdiagnosed as adult acne, rosacea is a distinct condition featuring flushing and inflammation, as well as pus-filled swellings (pustules), and red bumps or pimples (papules).
Treatments include a number of medications to counteract inflammation, pimples, and redness.
We asked Tsippora Shainhouse, MD, FAAD, an LA-based board-certified dermatologist and a Clinical Instructor at the University of Southern California, to provide some insight on this condition.
“Rosacea is an inflammatory skin condition that generally presents with facial redness, warmth, and increased vessels on the skin [erythrotelangiectatic rosacea, or spider veins]. It can also be associated with acne, ocular symptoms, and an enlarged nose/chin,” Dr. Shainhouse explains.
(The nose and chin symptoms are due to thickening of the skin — called rhinophyma — a condition that is more common among men than women.)
More than 60% of those with rosacea have eye symptoms, known as ocular rosacea. Signs and symptoms usually involve irritation, dryness, conjunctivitis, and inflammation of the eyelids or eyes.
Rosacea is more common among people with fairer skin — for example, among those of Northern European or Celtic ancestry — and in those middle-aged or older.
This condition is also associated with an excess of a type of skin enzyme associated with inflammation, known as metalloproteinases. “Blocking these pro-inflammatory enzymes can help reduce signs and symptoms,” Dr. Shainhouse points out.
Psychological effects of rosacea
The causes of rosacea are unknown. It is a chronic, often episodic, condition that can lead to emotional and psychological distress, affecting an individual’s quality of life. Symptoms come and go — often without warning — causing embarrassment and affecting self-esteem.
In fact, surveys have shown almost half of those with rosacea avoid social situations and 76% live with lowered self-esteem. Those with rosacea may also experience stigmatization — facial redness may be mistakenly interpreted as a sign of alcoholism, or their papules and pustules being misinterpreted as signs of poor personal hygiene.
Rosacea tends to be under- or misdiagnosed, with only about 10% of individuals with the condition seeking out professional care. This is unfortunate as rosacea can affect a person’s professional and social life, and because it’s highly treatable.
In order to avoid flare-ups, individuals with this condition are routinely counseled by their dermatologists to identify their triggers and steer clear of them. Some common triggers include:
- Sun exposure (ultraviolet light generally)
- Extremes of temperature (e.g., hot baths, saunas)
- Spicy foods
- Hot beverages
- Creams that irritate the skin (e.g., alcohol, witch hazel, fragrance, menthol, peppermint, eucalyptus oil, clove oil, salicylic acid, and exfoliating agents)
Exposure to certain bacteria, particularly the bacterium Bacillus oleronius found in the normal skin mite species Demodex folliculorum, may also be related to flare-ups. Other known triggers include physical or psychological stress.
Medications for rosacea
There is no cure for rosacea, but a wide array of treatments has been developed to care for this condition, including light-based therapies and medications.
Pharmacological agents involved in rosacea treatment include those applied directly to the skin (topical) and those that are taken systemically (i.e. orally).
Rosacea treatments are aimed at decreasing red skin patches and healing the bumps and pustules. In general, the more severe the symptoms, the longer the treatment.
Improvement should be apparent in four to six weeks, but may need to continue long term because the condition often returns once medication is stopped. Oral antibiotics may be required if progress with the topical agents isn’t enough.
The following medications have received approval by the US Food and Drug Administration (FDA) for the treatment and management of rosacea.
Topical metronidazole cream or gel is an antibiotic that helps resolve the inflamed papules, pustules, red skin patches, and spider veins of rosacea. Side effects are rare; those reported include mild itching, skin irritation, and dry skin.
- Azelaic acid
Topical azelaic acid cream, gel or foam works as an anti-inflammatory to treat the bumps, lesions, and swellings of rosacea. It can cause mild burning, stinging, itching, tenderness, dryness or irritation.
Using moisturizer before or after azelaic acid treatment may lessen these side effects.
- Doxycycline (or tetracycline or minocycline)
In rosacea treatment, oral antibiotics such as doxycycline are administered at doses lower than required to be effective as antibiotics. “They are used to block pro-inflammatory metalloproteinase enzymes that trigger inflammation, redness, and pimples,” Dr. Shainhouse says.
This medication is usually taken for four to six weeks, but longer treatment may be required. Common side effects are gastrointestinal and include nausea and vomiting, diarrhea, bloating and indigestion, abdominal pain, and loss of appetite.
Tetracycline may also affect birth control effectiveness, and should not be taken during pregnancy.
- Brimonidine tartrate
Topical brimonidine tartrate gel is a safe, effective general treatment for moderate to severe facial redness associated with rosacea. It is presumed to act by constricting dilated blood vessels in the face.
Research has shown it can start working as soon as 30 minutes after it has been applied, and the effects may last up to 12 hours. Unfortunately, brimonidine is not effective on spider veins, papules, or pustules.
Side effects include flushing, worsening of redness, burning or irritation of the skin, and itching. Rarer side effects can include dry mouth, headaches, pins and needles, and dry skin.
Worsening of the flushing associated with rosacea — also known as a rebound effect — has also been reported.
- Sodium sulfacetamide/sulfur
Sodium sulfacetamide/sulfur is a topical antibacterial agent that is also effective against Demodex skin mites which have been implicated in rosacea.
There is some evidence it is more effective in improving the redness, papules and pustules, and overall severity of rosacea than metronidazole.
A common drawback, as with any medication containing sulfur, is its “rotten eggs” smell. Also, if combined with benzoyl peroxide — a common acne treatment — orange-brown discolorations may end up on clothing (although it isn’t a problem on the skin itself). It is commonly applied in either a “leave on” or wash formulation.
Side effects from this medication are rare and generally mild, limited mostly to skin reactions such as dryness, red patches, itching, and discomfort. Using it near the eyes can cause irritation. Use in the eyes has been noted to cause rare but serious skin reactions.
Sodium sulfacetamide should not be used in patients known to be hypersensitive to sulfonamides, sulfur, or any other component of the preparation. Sodium sulfacetamide should be avoided by pregnant or nursing women due to known adverse side effects.
Topical ivermectin is an anti-inflammatory and anti-parasitic agent targeting Demodex mites, and is effective for treating inflamed lesions.
There isn’t a detailed understanding of how it works, but oral ivermectin is a known treatment for ticks and mites. As such, it’s thought that topical ivermectin may be effective by decreasing the number of hair follicle mites present. Research using ivermectin has shown it significantly delays relapse after successful metronidazole treatment.
The most commonly reported side effect of ivermectin treatment is worsening of red patches and/or flushing.
Oxymetazoline hydrochloride 1% cream (RHOFADE) is a new FDA-approved topical medication to treat persistent redness and flushing of adult rosacea patients. It has long been used as a nasal decongestant. Oxymetazoline is thought to decrease the redness and flushing of rosacea by constricting blood vessels beneath the skin.
This medication appears to have minimal side effects, but longer term evaluation is necessary to confirm this.
Oxymetazoline’s most common side effects when used for rosacea include skin reactions (dermatitis), worsening of rosacea pimples, itching, redness, and pain.
Important safety warnings accompany this medication because it may affect blood pressure. It should therefore be used with caution in those with heart disease, blood pressure issues, vascular insufficiency, and glaucoma.
No data exists on its safety for pregnant or nursing women.
Oral isotretinoin is a medication used frequently to treat severe acne. At low doses it is also sometimes used in rosacea treatment, especially in cases that are difficult to resolve, although it has not been FDA-approved for this specific purpose.
Isotretinoin is a strong medication that can lead to a number of side effects, and is usually prescribed by dermatologists.
Common side effects include dryness and cracking of the skin, lips and nostrils; inflammation of the eyes or eyelids; pain in the muscles or joints; back pain; blood in the urine, and mood changes. Isotretinoin can also cause birth defects if taken during pregnancy.
Lifestyle changes such as regularly applying sunscreen, moisturizer, and adopting sensitive skin care habits can be very helpful. This means trying soap-free cleansers, using fragrance-free moisturizers, avoiding astringents, and being gentle when washing, all in an effort to avoid triggering inflammation.
Rosacea can be a lifelong condition but as you can see, there are many medications available to help you cope with it. Your dermatologist can help design a treatment regimen that puts your best face forward.
If you are concerned you may have rosacea, or are having trouble controlling it, see your doctor to find out about treatment options that are available for you.
» If you don’t have a dermatologist, use Zwivel’s online directory to search for skin specialists in your area.
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