Pharmacy & Therapeutics - January 2009 - (Page 41) CONTINUING EDUCATION CREDIT Table 5 FDA-Approved Topical and Oral Therapies for Rosacea Topical Antibiotics Metronidazole 0.25%, 0.75%, 1% cream, gel, lotion (e.g., MetroCream, MetroGel) Non-antibiotics Azelaic acid 15% gel (Azelex) Oral Antibiotics Doxycycline, USP (Oracea Capsules) 40 mg once daily (30-mg immediaterelease and 10-mg delayed-release beads) Sodium sulfacetamide 10% and sulfur 5% combination, lotion, cream, pledgets, shortcontact preparation, cleanser (Sulfacet) Sodium sulfacetamide 10% lotion Sodium sulfacetamide 10%, sulfur 5%, sunblock lotion combination antibiotics, such as clindamycin (Cleocin, Pfizer), erythromycin (Akne-Mycin, DTP Laboratories/Healthpoint Ltd.) and metronidazole, sulfacetamide–sulfur (Sulfacet, Sanofi-Aventis), and azelaic acid (Azelex).12 Some studies have indicated efficacy for a number of treatments. Topical metronidazole is more effective than placebo in clinical studies. Between-patient and within-patient trials showed clear improvement in those using azelaic acid when compared with placebo.15 In a randomized trial comparing 15% azelaic acid and 0.75% metronidazole gel (MetroGel), azelaic acid was clinically superior in improving the inflammatory lesions and erythema associated with rosacea.18 However, studies show a greater potential for irritation from azelaic acid 15% than from metronidazole gel 0.75%, which had significantly greater potential risk of irritation when compared with metronidazole 1% gel.19 However, three cases of allergic contact dermatitis resulting from topical metronidazole have been reported.20 Other topical treatments include sulfur products, such as sodium sulfacetamide 10%/sulfur 5% combinations with or without a sun-blocking agent. These are available in lotions, creams, pledgets, short-contact preparations, and cleansers. Table 6 Non–FDA-Approved Oral Treatment of Rosacea Standard but Non-approved Oral Antibiotics Tetracycline 500 mg b.i.d. Doxycycline 50–100 mg b.i.d. Useful but Less Commonly Used Oral Antibiotics Azithromycin 250 mg t.i.w. (Zithromax) Clarithromycin 250–500 mg b.i.d.–q.d. (Biaxin) Oral Antibiotics Reported but Not in Common Clinical Use Penicillin 2.4 million units q.d. Oral Treatment of Flushing Oral contraceptives (Ovosiston) Non-antibiotic Oral Treatment Ivermectin 250 µ/kg q.w. (Stromectol) Erythromycin 250–500 mg Psychiatric medications Isotretinoin 0.15–2 mg/kg b.i.d.–q.i.d. (Akne-Mycin) • Amitriptyline 25 mg q.d. (Accutane) q.d. (Elavil) • Clonidine 0.1 mg q.d. (Catapres) • Pimozide (Orap) Amoxicillin or ampicillin 100–500 mg q.d.–b.i.d. Metronidazole 250 mg b.i.d.–t.i.d. (MetroCream, MetroGel) Dapsone 50–200 mg q.d. Aspirin Acitretin 25–50 mg q.d. (Soriatane) Ketoconazole 400 mg q.d. x 1–4 weeks (Nizoral) Spirolactone 50 mg q.d. x 4 weeks (Aldactone) Prednisone 1 mg/kg (for rosacea fulminans only) Minocycline 50–100 mg b.i.d. Minocycline time-released 45, 90, 135 mg (Solodyn) Doxycycline, subantimicrobial dose, 20 mg b.i.d. (Periostat) Beta blockers Ondansetron (Zofran) COX-2 inhibitors b.i.d. = twice daily; COX-2 = cyclooxygenase-2; mg = milligram; q.d. = once daily; q.i.d. = four times daily; q.w. = weekly; t.i.w. = three times weekly. Vol. 34 No. 1 • January 2009 • P&T® 41
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