Study breaks down best treatment for subtypes of rosacea

19 Jan 2024 --- Rosacea is a common chronic inflammatory skin disorder, mainly affecting the center of the face. Its pathogenesis is complex and still not completely understood. A study from Italy reviews the current literature on rosacea and provides an overview of therapeutic approaches that specifically address each clinical subtype. 

Four subtypes of rosacea have been identified based on the predominant clinical features: Erythemato-teleangiectatic (face flushing), papulopustular (pus-filled blemishes), phymatous (thickened swollen skin) and ocular rosacea (inflammation, redness, burning and itching of the eyes). 

Recurring episodes of flushing, persistent erythema, inflammatory papules, telangiectasias, phymatous changes and ocular symptoms primarily characterize rosacea. It encompasses innate and adaptive immune system dysregulation, neurovascular dysfunction and genetic and environmental factors. 

Best treatments
Insights into this condition have led to several pharmacological treatments, such as topical medications, from conventional azelaic acid, metronidazole, benzoyl peroxide, clindamycin and erythromycin. 

New treatments include brimonidine, oxymetazoline, ivermectine and minocycline, but also systemic drugs such as oral antibiotics, isotretinoin, non-selective β-blockers or α2-adrenergic agonists and laser- or light-based therapies, with new therapeutic approaches. 

The study asserts that vascular lasers and light-based therapies should be the preferred treatment in people experiencing transient or persistent centrofacial erythema and telangiectasia.

Generally, papulopustular rosacea patients rapidly respond to topical medications, including azelaic acid, metronidazole, ivermectin, benzoyl peroxide, clindamycin and erythromycin. 

Papulopustular rosacea causes red and inflamed dots on the face.Even though for many years systemic therapies were preferred only for refractory patients, with the introduction of tetracyclines, oral therapy has become more commonly prescribed as a first-line treatment, alone or more often in combination with topical therapies. Additionally,  papulopustular rosacea treated with the oral Janus kinase (JAK) inhibitor tofacitinib showed significant regression of rosacea signs and symptoms.

Rhinophyma is a hypertrophy of the nasal soft tissues, presenting with a bulbous appearance. Among the pharmaceutical agents, isotretinoin is associated with a better prognosis of rhinophyma and the shrinkage of the overall volume of phymata by reducing the size of the sebaceous glands. The researchers assert that although it does not appear to be a curative option, it could represent a promising strategy after laser treatment to prevent relapse.

Ocular symptoms are mainly represented by chronic blepharoconjunctivitis, episcleritis, chalazion, meibomian gland dysfunction and corneal complications. According to the study, the long-term use of topical corticosteroids should be avoided due to side effects such as ocular hypertension, glaucoma, posterior subcapsular cataracts and tear-film instability.

Instead, novel therapeutic perspectives include intense pulsed light therapy for the treatment of evaporative dry eye disease with chronic meibomian gland dysfunction.

Future treatments
The study explains that a more precise understanding of the molecular basis of rosacea is still needed and could lead to the identification of new therapeutic targets addressing the root cause of the disease in the near future.

In addition to commonly used topical and systemic therapies and physical approaches, new evidence is slowly emerging on the therapeutic potential of novel agents, such as monoclonal antibodies or oral small molecules (JAK inhibitors) in rosacea.

“Indeed, given the complex pathogenesis and the role of JAK in this disease, there is a rationale as to why JAK inhibitors could theoretically prove effective for the treatment of rosacea, as has already happened in psoriasis, atopic dermatitis and vitiligo,” say the study’s authors.

However, the researchers highlight that currently available data on the efficacy and safety of these novel therapeutic approaches is still scarce.

Edited by Sabine Waldeck