Advances in the topical treatment of acne and rosacea

Journal of Drugs in Dermatology, Sept-Oct, 2004 by Roger I. Ceilley

Surgery and Light-Based Therapies

Telangiectasia and phymatous changes, most notably rhinophyma, are not manageable with topical or systemic therapy. Their treatment has traditionally been surgical. Telangiectasia have been treated by electrodestructive methods or with lasers targeted to vascular lesions such as the KTP, 1064 nm Nd:YAG, visible light lasers and intense pulsed light (IPL).

Phymatous changes can be treated using a variety of ablative lasers. A new approach has been the use of photodynamic therapy with ALA-PDT as is being used to treat actinic keratoses (47).

Skincare in Rosacea

As in the case of acne, appropriate daily skincare is an essential aspect of management. In addition to avoiding known triggers, patients should receive a regimen and a list of recommended products for cleansing, moisturizing and sun protection in addition to their medications. They, like acne patients, should be instructed to treat their skin very gently. Rather than rubbing, they should blot the skin dry, since rubbing can create a rosacea flare. They should use tepid rather than hot water which can strip oils from the skin and cause vasodilation of the blood vessels near the surface. The importance of sun protection and avoidance should be stressed.

Summary

Acne and rosacea are two very common skin disorders with several characteristics in common which make it useful to discuss them together and for which similar treatment paradigms can be applied. Both are essentially inflammatory in nature. Both present with papules and pustules, and both can cause severe psychosocial disability. For both diseases, combination therapy employing combinations of topical and systemic therapies are the treatment of choice.

For acne, current best practice mandates the early use of a topical retinoid for all patients so as to normalize the follicle, treat existing comedones and prevent the formation of new ones, as well as to modulate inflammation and enhance the penetration into the follicle of other topically applied agents. In cases where inflammatory lesions are present, a topical or systemic antibiotic is also required for the shortest interval possible so as to minimize the risk of acquiring resistant bacterial variants.

Topical therapy with metronidazole is the standard and most widely used topical agent for rosacea, but an oral antibiotic may be required to more rapidly clear papules and pustules in all but the most mild cases. As in acne treatment, the use of systemic antibiotics should be discontinued as early as possible after the presenting lesions have resolved. Azelaic acid 15% gel and sodium sulfacetamide 10%/sulfur 5% either as a topical lotion or a cleanser have also been shown to confer benefits similar to those obtained with topical metronidazole in rosacea.

The new paradigm that is emerging, however, is the use of laser or light-based modalities in combination with the topical/systemic regimens to improve and hasten the cosmetic results obtained with conventional therapy. As this combination of prescription and procedural therapy becomes more common-place, there will be continued evolution in the ways in which light-based therapies can be optimally combined with topical and systemic regimens. The use of conventional topical therapies is essential to maintain the remission obtained with the combined conventional and procedural treatment regimens.