Pharmacy & Therapeutics - January 2009 - (Page 43) CONTINUING EDUCATION CREDIT Non–FDA-Approved Oral Agents Azithromycin (Zithromax, Pfizer), perhaps acting as an antioxidant, appears to be useful for treating rosacea in doses of 250 mg three times per week.29,30 If azithromycin, which is now available as a generic brand, is competitively priced with minocycline and doxycycline, its minimal side effects, lack of drug interactions, and three-times-weekly dosing could make it a good alternative for rosacea patients. The systemic treatment of Helicobacter pylori infection has been advocated as a possible therapy for rosacea. In some studies, the two conditions have been found to be associated. Eradication of H. pylori can be achieved using a triple-therapy regimen lasting one to two weeks consisting of omeprazole (Prilosec, AstraZeneca) and a combination of two of the following: clarithromycin (Biaxin, Abbott), metronidazole, or amoxicillin (Amoxil, GlaxoSmithKline).31 Although not commonly used clinically, other oral antibiotics with reported efficacy include penicillin 2.4 million units daily, erythromycin 250–500 mg two to four times daily, amoxicillin or ampicillin (Principen, Apothecon) 100–500 mg daily or twice daily, metronidazole at doses of 250 mg two to three times daily, and dapsone 50 to 200 mg once daily. Non-antibacterial regimens can also be used. Isotretinoin has proved effective for rosacea.16 Although effects may be delayed with isotretinoin, when compared with standard therapies, a reduction in the number of papules is evident within two weeks. The most significant results have been noted in younger patients with less severe manifestations of disease; however, isotretinoin has also been useful for treating and reducing phymatous changes.16 Acitretin (Soriatane, Roche), ketoconazole (Nizoral, Janssen), spironolactone (Aldactone, Pfizer), and prednisone are also reported to be effective. Oral agents reported to treat flushing include oral contraceptives, some psychoactive drugs, aspirin, beta-blockers, ondansetron, and cyclooxygenase-2 (COX-2) inhibitors. The oral contraceptives chlormadinon acetate/mestranol (Ovosiston) and the antiandrogen agent cyproterone have been suggested as being effective hormonal treatments for rosacea. Nonmedical Therapies Patients should be instructed about the regular use of sunscreens, the appropriate use of concealing makeup, and the need for careful follow-up of any ocular symptoms.35 Basic skin-care regimens, including the daily use of a sunscreen, offer significant benefits (Table 8). Clinical assessments, confirmed by biophysical measurements (electrical capacitance, transepidermal water loss, and lactic acid stinging test), indicated that moisturizers contributed to the restoration of the skin barrier. Skin dryness, roughness, and desquamation were much improved, and skin sensitivity was significantly reduced. Skin properties were enhanced, and skin discomfort was relieved.36 Kinetin (N6-furfur yladenine) is a plant cytokinin that reportedly helps restore skin barrier function and may be beneficial for improving the signs and symptoms of rosacea. A twice-daily application of kinetin 0.1% lotion was found to be a well-tolerated moisturizing lotion choice for patients with mild-to-moderate inflammatory rosacea.37,38 In one trial, treatment with oral minocycline, spironolactone, and Chibixiao, a Chinese herb, was superior to minocycline and spironolactone alone.39 Beyond treating the symptoms of rosacea, physicians should address psychological problems and should provide patient education. Patients’ concerns about their appearance and a lack of hope for effective therapy can cause psychological distress, which can be immediately alleviated when patients learn that rosacea is a recognized and controllable disorder. Patients are often concerned that others might believe that their symptoms are caused by overindulgence in alcohol or by poor personal hygiene. Although alcohol consumption can exacerbate rosacea, symptoms also occur in people who abstain from alcohol. Patients should also be reassured that rosacea is often unrelated to poor hygiene. Education about triggers can help patients gain control over rosacea symptoms.40 Combination Therapies Effective treatments, including topical metronidazole and systemic antibiotics, have anti-inflammatory activity, which may actually be more important than their antimicrobial activity. For mild-to-moderate rosacea, an anti-inflammatory dose of doxycycline in combination with topical metronidazole gel 1% appears to be effective in reducing inflammatory lesion counts, and it is well tolerated.32 Table 8 Guidelines for Sunscreen and Cosmetics in Rosacea Patients with Sensitive Skin and Skin Barrier Dysfunction • Cleansers should be soap-free. • Choose sunscreens that protect against ultraviolet A (UV-A) and UV-B light; titanium dioxide and zinc oxide are tolerated best. • Cosmetics and sunscreens should contain protective silicones. • Choose a light foundation that is easy to spread and can be set with powder; foundations that contain UV-A and UV-B sunscreen are encouraged. • Avoid astringents, toners, menthols, camphor, and products that contain sodium lauryl sulfate. • Avoid waterproof cosmetics and heavy foundations that are more difficult to apply and to remove without irritating solvents. Data from Baxi S. US Pharmacist 2007;32(7):13–17;42 and Pray JJ, Pray WS. US Pharmacist 2003;28(6).43 Phototherapy Several reports have found light-based treatments to be effective for the er ythema of rosacea. Multiplexed laser appears to help in reducing erythema and telangiectasia.33 Intense pulsed light (IPL) at a wavelength of 550 to 670 nm may be effective for rosacea and solar lentigines, and it is particularly useful for ETR.34 Both the flash lamp-pumped, long-pulse dye laser and the potassium-titanyl-phosphate laser may be used to treat facial telangiectasias.25 Vol. 34 No. 1 • January 2009 • P&T® 43
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