Pharmacy & Therapeutics - January 2009 - (Page 40) CONTINUING EDUCATION CREDIT considered in the clinical differential diagnosis. The most common conditions seen in clinical practice are listed in Table 4. pustular, phymatous, and glandular types respond to different therapies. From a practical standpoint, subtyping can guide therapeutic decisions. Certain modalities are useful in all patients, stemming from overlap among the subtypes; however, the timing of their use may vary.16 The current gold standard of oral medical treatment is tetracycline-type antibiotics. Newer light treatments, with intense pulsed light and long-pulsed dye lasers, seem to be effective at decreasing erythema and eliminating telangiectasias, but these modalities are expensive and usually do not permanently eliminate erythema or telangiectasias.17 Flushing can be treated with medications that have provided some success in other studies, including beta-blockers, clonidine (Catapres, Boehringer Ingelheim), naloxone (Narcan, Endo), ondansetron (Zofran, GlaxoSmithKline), and selective serotonin reuptake inhibitors (SSRIs). However, evidence supporting many of these therapies is limited.16 FDA-approved topical and oral therapies are presented in Table 5; non–FDA-approved oral treatments are listed in Table 6, and non–FDA-approved topical treatments are outlined in Table 7. Treatment As a result of the development and release of newer topical formulations, the diagnosis and treatment of rosacea have received renewed attention over the past several years.12 However, the cure for rosacea remains elusive, and all currently used medications are for symptomatic control only. No precise treatment algorithm has become the standard of care; treatment remains empirical.13,14 According to a Cochrane Database Review, the quality of studies evaluating rosacea treatments has generally been poor. It is possible that topical metronidazole (e.g., MetroGel, MetroCream, Galderma) and azelaic acid (Azelex, Allergan) as well as oral metronidazole (Flagyl, Pfizer) and tetracycline (Sumycin, Par) might be effective, but there is insufficient evidence for the effectiveness of other treatments. Well-designed, double-blind, randomized clinical trials are needed to evaluate current treatments.15 The existing evidence for the treatment of rosacea in patients of color is also meager.16 To treat darker skin successfully, clinicians must pay special attention to the presence or potential development of pigmentary alteration or keloids. Clinicians can provide effective care to these patients with the judicious use of widely available over-the-counter (OTC) and prescription products. In view of the clinical and histological variation found in rosacea patients, it is no surprise that ETR and the papulo- Topical Therapy FDA-Approved Topical Agents The efficacy of topical therapy for rosacea relates primarily to the reduction in inflammatory lesions (papules, pustules), a decreased intensity of erythema, a decrease in the number and intensity of flares, and amelioration of symptoms, which may include stinging, pruritus, and burning. The list of standard topical agents used to treat rosacea includes topical Table 4 Differential Diagnosis of Rosacea Disease Acne vulgaris9,12 Similarities • Papules, pustules, erythema • • • • Differences Comedones Earlier onset Not limited to central third of face No telangiectasias or flushing Steroid rosacea41,47 • Erythema, papules, pustules, telangiectasias • Central third of face • Blepharitis • Erythema • Erythema, papules • Related to topical application of corticosteroids, tacrolimus (Protopic, Astellas/Fujisawa), and pimecrolimus (Elidel, Novartis) • Scaling, eczematous changes • Paranasal, nasolabial, extrafacial distribution • Perioral distribution • Smaller lesions • No telangiectasia, flushing, or blushing • Follows size and shape of causal agent • Scaling • Spongiosis and parakeratosis on histology • Seasonal • Usually extrafacial • Malar distribution • Photosensitivity Seborrheic dermatitis Perioral dermatitis7,48 Contact dermatitis • Erythema, papules, pustules • Burning, stinging • Erythema, papules, plaques • Erythema Photodermatitis Lupus Data from references 7, 9, 12, 41, 47, and 48. 40 P&T® • January 2009 • Vol. 34 No. 1
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