Jennifer H. Allen, MD, of Allen Dermatology, Macon, GA, has 30 years of clinical experience. In a conversation with American Health & Drug Benefits (AHDB), Dr Allen shared her observations about and management approaches to rosacea.
AHDB: As a dermatologist, what has been your experience with rosacea and its effect on patients?
Dr Allen: Every day I see patients with rosacea, which means that over my 30 years in practice I have seen hundreds of patients with this condition. I have been impressed over the years at how rosacea devastates the people who have it. I have seen women who hardly leave the house because they are embarrassed over their appearance. Almost anything can cause a flare—hot drinks, spicy foods, wine, weather, stress—you simply cannot avoid all the triggers. Men tend to have worse rosacea, and they can even develop rhinophyma, which I see about twice a year. I show my male patients pictures of rhinophyma, and this convinces them to be adherent to treatment, which can prevent disease progression to rhinophyma.
The treatment of patients with rosacea has to be individualized, and patients require good education about caring for their skin. Although they often self-diagnose their rosacea before they see me, they are also often doing things that are irritating their skin, such as scrubbing their face, using buff puffs, and so on. They have already tried everything to improve their condition, and they have to learn to treat their faces kindly and gently. Treatment is very individual. There is no cookbook approach.
Of all the conditions in dermatology that have treatment limitations, rosacea is definitely one of the diseases with the greatest unmet needs for new medications. When I am able to help patients with rosacea, they are very thankful.
AHDB: How has the management of rosacea changed over the years?
Dr Allen: For years we controlled rosacea with topical medications, and for patients with papules and pustules (ie, “bumps”), we used tetracycline, but that is no longer an option. Now we have better options, both for topical use and for systemic treatment, including low-dose 40 mg doxycycline (Oracea), which is anti-inflammatory, and minocycline (Minocin) 50 mg.
AHDB: What are some of the obstacles to successful treatment of rosacea?
Dr Allen: We can usually control papulopustular rosacea with low-dose antibiotics; however, the erythema that is characteristic to rosacea remains a problem for patients. We need better medications to control the erythema.1 Another problem pertains to the cost of rosacea treatment, which is often borne by the patient because of problems with reimbursement.
AHDB: Can you be more specific about reimbursement issues?
Dr Allen: Medicare only pays for generic medications for first-line therapy of dermatologic conditions, and these are not always the best treatment options. For example, I like to prescribe low-dose (40 mg) doxycycline, but Medicare will not pay for this, because there is no generic version of this agent. In this situation, I will use 50-mg doxycycline or minocycline. For topical medications, access can also be a problem.
The 0.75% metronidazole gel (0.75% MetroGel) has been available for years in a generic form, so it can be readily approved by payers, including Medicare, but it does not help with the redness of rosacea. The 1% metronidazole gel, however, contains niacinamide, which helps with the redness, as well as papulopustules; however, to get reimbursed patients must first fail treatment with the 0.75% metronidazole, or pay out of pocket, and in some cases the 1% metronidazole gel will still not be approved by payers.
I would like to prescribe the 1% metronidazole gel to many patients right from the beginning, because practically all rosacea has a redness component, and the use of the 1% gel can often avoid the use of oral antibiotics. So, this situation is very frustrating for dermatologists.Azeleic acid is the other effective topical medication, and it comes in the 15% gel (Finacea) or 20% cream (Azelex). However, it is often difficult to get approval for coverage for these treatments.
AHDB: What is your general approach to treatment?
Dr Allen: If my patient with rosacea has more bumps than erythema, I prescribe metronidazole gel, and if the patient has more erythema than bumps, I prescribe the 15% azeleic acid gel, because it is not as effective for bumps. Studies have shown that the 15% azeleic acid gel is more effective than the 20% azeleic acid cream, because it penetrates more deeply into the skin, and I have observed this in clinical practice. Some patients will need both metronidazole and azeleic acid, and others with more severe papules and pustules will require a systemic antibiotic. For these patients I prescribe doxycycline or minocycline.
Other approaches can also help. I sometimes use intense pulsed light for the redness, but insurance plans do not reimburse for this. It costs about $330 per treatment, and many patients require this about 4 times annually to control redness. We also use sodium sulfacetamide, a topical antibiotic, and we sometimes add acne medications.
AHDB: Are there new or emerging treatment options for rosacea?
Dr Allen: For patients who have some seborrheic dermatitis associated with their rosacea (which is fairly common), I am starting to use hyaluronate acid sodium salt 0.2% (Bionect) cream, which attracts and binds water and plays a role in inflammation and tissue repair, as well as Promiseb cream, an antiseborrheic cream that helps to repair the skin barrier. These are alternatives to topical steroids, which can be good for rosacea flares but should not be used for more than a few weeks.
I have heard “rumors” that new topical medications are expected to become available for rosacea in the near future. I truly hope they will be effective and help satisfy that great unmet need in dermatology.
- This interview took place before the recent US Food and Drug Administration approval of the topical gel brimonidine (Mirvaso) for the treatment of facial erythema of rosacea.