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OtherPractice

Topical treatments for rosacea

Paul Fritsch, Michael R. Kolber and Christina Korownyk
Canadian Family Physician November 2019, 65 (11) 803;
Paul Fritsch
Family medicine resident at the University of Calgary in Alberta.
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Michael R. Kolber
Professor the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Christina Korownyk
Associate Professor, the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

Which topical agents provide the best patient-reported improvements in rosacea?

Bottom line

For moderate to severe papulopustular rosacea, topical metronidazole, azelaic acid, and ivermectin have similar benefit, with about 65% to 75% of patients reporting improvement compared with about 40% of patients using placebo over 2 to 3 months. Head-to-head trials show that azelaic acid and ivermectin might be slightly better than metronidazole. Cost might assist choice.

Evidence

  • A systematic review of RCTs of treatments versus placebo with patient-oriented outcomes1 showed the following:

    • - In a meta-analysis by the PEER (Patients, Experience, Evidence, Research) Group of 2 similar RCTs of 178 patients using daily 1% metronidazole,2,3 patient-perceived symptom improvement after 2 months was 75% versus 37% with placebo (number needed to treat [NNT] = 3).

    • - In a meta-analysis by the PEER Group of 2 RCTs of 1371 patients,4 patients using daily 1% ivermectin showed good to excellent improvement after 3 months (68% vs 37% with placebo; NNT = 4).

    • - In 4 RCTs of 1226 patients,5–7 twice-daily 15% to 20% azelaic acid showed good to excellent improvement after 3 months1 (63% vs 42% with placebo; NNT = 5).

  • Daily 1% ivermectin versus twice-daily 0.75% metronidazole in 1 RCT of 962 patients8 showed good to excellent improvement after 4 months (86% with ivermectin and 75% with metronidazole; NNT = 10).

  • In the highest-quality, largest RCT9 of 251 patients, twice-daily 15% azelaic acid versus twice-daily 0.75% metronidazole showed good to excellent improvement after 15 weeks (78% with azelaic acid and 64% with metronidazole; NNT = 8).

  • Adverse events (primarily burning and stinging) for metronidazole, ivermectin, and azelaic acid were similar to placebo.1 In 1 trial,9 more patients using azelaic acid had adverse events than those using metronidazole (26% vs 7%).

  • Limitations: Most trials were industry sponsored.

Context

  • Canadian guidelines’ first-line recommendations are for topical metronidazole, azelaic acid, or ivermectin.10

  • The estimated 90-day costs in Alberta are as follows11:

    • -$92 for twice-daily 15% azelaic acid,

    • -$54 for daily 1% metronidazole,

    • -$220 for daily 1% ivermectin, and

    • -$440 for twice-daily 0.75% metronidazole.

  • There is no clinical difference between 0.75% and 1% metronidazole.1

  • Other topical treatments have less evidence for their use1 or are not currently recommended.10

  • Oral medications are reserved for severe symptoms or topical treatment failure.10

Implementation

Recently recommended diagnostic criteria for rosacea consider persistent centrofacial erythema or facial skin thickening (most commonly on the nose) independently diagnostic for rosacea. Additional major (eg, papules, pustules, and telangiectasias) and minor (eg, stinging sensation) features might assist with the diagnosis.12 Observational studies find that triggers (most commonly reported: sun exposure, stress, hot weather, wind, and alcohol use) might exacerbate rosacea.13 Until evidence to the contrary is found, avoidance of these potential triggers seems reasonable.

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Van Zuuren EJ,
    2. Fedorowicz Z,
    3. Carter B,
    4. van der Linden MMD,
    5. Charland L
    . Interventions for rosacea. Cochrane Database Syst Rev 2015;(4):CD003262.
  2. 2.↵
    1. Bjerke JR,
    2. Nyfors A,
    3. Austad J,
    4. Rajka G,
    5. Gjersten BT,
    6. Haavelsrud O,
    7. et al
    . Metronidazole (Elyzol) 1% cream v. placebo cream in the treatment of rosacea. Clin Trials J 1989;26(3):187-94.
    OpenUrl
  3. 3.↵
    1. Nielsen PG
    . Treatment of rosacea with 1% metronidazole cream. A double blind study. Br J Dermatol 1983;108(3):327-32.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Stein L,
    2. Kircik L,
    3. Fowler J,
    4. Tan J,
    5. Draelos Z,
    6. Fleischer A,
    7. et al
    . Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol 2014;13(3):316-23.
    OpenUrlPubMed
  5. 5.↵
    1. Bjerke R,
    2. Fyrand O,
    3. Graupe K
    . Double-blind comparison of azelaic acid 20% cream and its vehicle in treatment of papulopustular rosacea. Acta Derm Venereol 1999;79(6):456-9.
    OpenUrlCrossRefPubMed
  6. 6.
    1. Draelos ZD,
    2. Elewski B,
    3. Staedtler G,
    4. Havlickova B
    . Azelaic acid foam 15% in the treatment of papulopustular rosacea: a randomized, double-blind, vehicle-controlled study. Cutis 2013;92(6):306-17.
    OpenUrlPubMed
  7. 7.↵
    1. Thiboutot D,
    2. Thieroff-Ekerdt R,
    3. Graupe K
    . Efficacy and safety of azelaic acid (15%) gel as a new treatment for papulopustular rosacea: results from two vehicle-controlled, randomized phase III studies. J Am Acad Dermatol 2003;48(6):836-45.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Taieb A,
    2. Ortonne JP,
    3. Ruzicka T,
    4. Roszkiewicz J,
    5. Berth-Jones J,
    6. Peirone MH,
    7. et al
    . Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol 2015;172(4):1103-10. Epub 2015 Feb 11.
    OpenUrlPubMed
  9. 9.↵
    1. Elewski BE,
    2. Fleischer AB Jr,
    3. Pariser DM
    . A comparison of 15% azelaic acid gel and 0.75% metronidazole gel in the topical treatment of papulopustular rosacea. Arch Dermatol 2003;139(11):1444-50.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Asai Y,
    2. Tan J,
    3. Baibergenova A,
    4. Barankin B,
    5. Cochrane CL,
    6. Humphrey S,
    7. et al
    . Canadian clinical practice guidelines for rosacea. J Cutan Med Surg 2016;20(5):432-45. Epub 2016 May 17.
    OpenUrlCrossRefPubMed
  11. 11.↵
    Interactive Drug Benefit List [website]. Edmonton, AB: Government of Alberta; 2019. Available from: https://idbl.ab.bluecross.ca/idbl/load.do. Accessed 2019 Jun 7.
  12. 12.↵
    1. Schaller M,
    2. Almeida LMC,
    3. Bewley A,
    4. Cribier B,
    5. Del Rosso J,
    6. Dlova NC,
    7. et al
    . Recommendations for rosacea diagnosis, classification and management: update from the global Rosacea Consensus (ROSCO) 2019 panel. Br J Dermatol 2019 Aug 7. Epub ahead of print.
  13. 13.↵
    1. Oge’ LK,
    2. Muncie HL,
    3. Phillips-Savoy AR
    . Rosacea: diagnosis and treatment. Am Fam Physician 2015;92(3):187-96.
    OpenUrl
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Canadian Family Physician: 65 (11)
Canadian Family Physician
Vol. 65, Issue 11
1 Nov 2019
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Paul Fritsch, Michael R. Kolber, Christina Korownyk
Canadian Family Physician Nov 2019, 65 (11) 803;

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