Oral therapy for rosacea

Journal of Drugs in Dermatology, Jan, 2006 by Hilary E. Baldwin

More recently, Erdogan et al utilized low dose isotretinoin at 10 mg QD for 4 months and showed significant reduction in inflammatory lesions, erythema, and telangiectasia at 9 weeks. (42) Ertl et al compared the use of topical tretinoin to the combination of topical tretinoin and isotretinoin and showed superiority with the combination. (41) In a comparison study of oxytetracycline 250 BID to isotretinoin 30 mg QD for 2 months, oxytetracycline was found to have superior global assessment scores at 8 weeks. (43)

More studies are needed to determine appropriate dosing schedules as well as optimal treatment duration. Unlike acne vulgaris, it is not clear that there is a target dose for which to aim that will render a permanent cure. Schmidt et al documented remissions lasting up to 2 years after a course of isotretinoin. (37) In our continuing search for a therapy that does not result in antibacterial resistance, isotretinoin may be a viable alternative, especially in males and older women past child-bearing years. Most studies utilized low dose, long-term use of isotretinoin at which point nuisance side effects are practically nil. Birth defects, however, are possible at any dose. Low dose does not mean low vigilance.

Dapsone

Several case reports in the literature support using Dapsone in severe, refractory rosacea. (44) Most often their use was in patients in whom isotretinoin was contraindicated.

Flaxseed Oil

Flaxseed oil 1000 mg BID has been suggested for ocular rosacea.

Hormonal Therapy

There are several studies from the 1970s and 1980s describing the benefits of oral contraceptive therapy for rosacea. (45,46) Spironolactone was also evaluated in men at doses of 50 mg daily. (47) Of 13 patients, 2 discontinued use due to side effects, and 7 had reduction of erythema and inflammatory lesions.

Drugs that Antagonize Flushing

Many anecdotal reports exist in the literature regarding agents that antagonize the flushing reaction. This includes vasoconstricting agents, other blood pressure reducing agents, and agents that alter flushing reactions in response to emotional stimuli.

Beta blockers in low doses (nadolol, 20 to 40 mg QD), (23) naloxone, (48) ondansetron, (49) aspirin, (50) and numerous selective serotonin reuptake inhibitors (28) have been reported in isolated case reports to be effective. There is no evidence-based medicine to support their use.

More commonly reported is the use of clonidine 0.05 mg BID. (51) At this dose, it does not reduce blood pressure, but does lower baseline malar temperature by peripheral vasoconstriction. In this author's practice, some flush and blushers do remarkably well on clonidine. There appears to be no indication of the types of patients who will respond. However, since control of this feature of rosacea is so difficult, it is always worth a trial course.

Antibiotic Resistance

In the last decade, there has been increasing concern regarding the prevalence of antibiotic resistance. Dahl reported antibiotic-resistant P. acnes of up to 60%. (52) Globally antibioticresistant P. acnes increased from 20% to 62% from 1978 to 1996. (53) European studies saw increases of 20% and 50% for tetracycline and erythromycin resistance, respectively. (54,55) Increasing P. acnes resistance causes a decrease in treatment success over time and treatment failures.