Pharmacy & Therapeutics - January 2009 - (Page 44) CONTINUING EDUCATION CREDIT Duration of Therapy Like acne, rosacea naturally waxes and wanes. However, because the damage from rosacea can be progressive (unlike acne), the continuous use of therapy has advantages. Many acne and rosacea patients can continue with an antibiotic for more than a year without adverse effects.41 However, physicians should keep in mind the increased bacterial resistance caused by prolonged use of antibiotics. Long-term therapy with minocycline beyond six months also carries an increased risk of pigmentary deposition.41 Role of the Pharmacist Patients with any form of facial eruption are often acutely embarrassed or highly apprehensive about consulting a pharmacist. Rosacea is a disfiguring condition, constantly visible to anyone with whom the individual has face-to-face interaction, and it can produce a great deal of stress, embarrassment, frustration, anger, and depression. Patients cannot often predict the duration of the condition, the degree of severity, or the likelihood of a favorable treatment outcome. Pharmacists play a vital role in evaluating the patient. This includes obtaining a medication history, observing the number and types of lesions, referring patients to a physician if needed, helping to choose the appropriate therapeutic regimen, and counseling patients. Pharmacists should discuss the goals of treatment, realistic expectations, length of therapy, appropriate use of products, and the importance of adhering to the regimen.42 Pharmacists can help physicians in educating patients about the causes of acne and rosacea by dispelling myths that these conditions are related to poor hygiene or eating poorly and by helping patients to identify triggers for worsening rosacea. The range of treatments for rosacea can be overwhelming to patients and physicians. Pharmacists can help patients choose appropriate products and advise them on when to consult a dermatologist.43 To decrease the risks of drug interactions, pharmacists maintain updated patient medication profiles, including use of herbal products, OTC medications, and natural supplements, and they monitor for “red-flag” drugs or drugs with a narrow therapeutic index. Pharmacists have a responsibility to warn patients and prescribers about drug interactions.44 also take into account each patient’s sensitivity to irritation from topical agents. Oral antibiotics, such as doxycycline 50 mg daily or twice daily, can be used for rosacea that is refractory to topical therapies. Oral therapy should be considered for patients who have mostly inflammatory papules and pustules without significant erythema. Younger patients with less severe manifestations of disease and patients with phymatous changes may have excellent responses to isotretinoin. Combinations of topical and oral therapy may provide satisfactory results for individuals with mild-to-moderate rosacea or for those with both inflammatory and erythematous components. The best combination therapy appears to be doxycycline and metronidazole gel 1%. Physicians and pharmacists should use FDA-approved therapies unless the patient’s condition is refractory to typical treatment. Pharmacists should be reminded to obtain medication histories, to assess the severity of symptoms, and to consider referring patients for appropriate treatment. Pharmacists can be helpful in educating patients about realistic treatment outcomes and in counseling them about compliance and the appropriate use of prescribed therapies. References 1. Rohrich RJ, Griffin JR, Adams WP Jr. Rhinophyma: Review and update. Plast Reconstr Surg 2002;110(3):860–869; quiz, 870. 2. Scheinfeld NS. Rosacea. Skinmed 2006;5:191–194. 3. Halder RM, Brooks HL, Callendar VD. Acne in ethnic skin. Dermatol Clin 2003;21(4). 4. Berg M, Liden S. An epidemiological study of rosacea. Acta Dermatol Venereol 1989;69:419–423. 5. Pray WS, Pray JJ. Differentiating between rosacea and acne. US Pharmacist 2004;29(4). 6. Kroshinsky D, Glick SA. Pediatric rosacea. Dermatol Ther 2006; 19(4):196–201. 7. Shelley WB, Shelley ED. Advanced Dermatologic Therapy II, 2nd ed. Philadelphia: WB Saunders; 2001. 8. Berth-Jones J, Clark SM, Henderson CA. Rosacea and perioral dermatitis. In: Lebwohl M, Heymann WR, Berth-Jones J, et al., eds. Treatment of Skin Disease. London: Mosby; 2002. 9. Rosacea. In: Marks JG, Miller JJ (eds.). Principles of Dermatology, 4th ed. Philadelphia: Elsevier/Saunders; 2006. 10. Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol 2004; 51(3);327–341. 11. Helm KF, Menz J, Gibson LE, Dicken CH. A clinical and histopathologic study of granulomatous rosacea. J Am Acad Dermatol 1991;25:1038–1043. 12. Del Rosso JQ. Medical treatment of rosacea with emphasis on topical therapies. Exp Opin Pharmacother 2004;1:5–13. 13. Norwood R, Norwood D. Treating rosacea. US Pharmacist 2007; 32(9):45–53. 14. Dressler-Carre M. Acne vulgaris and rosacea. In: Arcangelo VP, ed. Pharmacotherapeutics for Advanced Practice: A Practical Approach. Philadelphia: Lippincott Williams & Wilkins, 2005. 15. Van Zurren EJ, Graber MA, Hollis S, et al. Interventions for rosacea. Cochrane Database Syst Rev 2005(3). 16. Pelle MT, Crawford GH, James WD. Rosacea II: Therapy. J Am Acad Dermatol 2004;51(4):499–512. 17. Nally JB, Berson DS. Topical therapies for rosacea. J Drugs Dermatol 2006;5:23–26. 18. Elewski BE, Flesicher AB, Pariser DM. A comparison of 15% azelaic acid gel and 0.75% metronidzole gel in the topical treatment Conclusion When patients present with rosacea, appropriate therapeutic strategies should address the clinical features, the subtype of rosacea, and the staging or severity of lesions.45–48 Patients with typical features of pre-rosacea and only transient symptoms may respond to OTC agents. However, the increasing abundance of primary rosacea features (e.g., flushing, nontransient erythema, papules, pustules, telangiectasias) and secondary features (e.g., burning, stinging, edema, ocular manifestations, extrafacial lesions, phymatous changes) should lead physicians and pharmacists to consider prescription therapy instead of OTC treatments. For patients with inflammatory papules or pustules and a significant erythematous component, topical therapy may be considered. The most effective topical therapies seem to be azelaic acid and metronidazole. Health care providers should 44 P&T® • January 2009 • Vol. 34 No. 1
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