Medical Dermatology

WAIKOLOA, Hawaii - Glaucoma eye drops and a nasal decongestant spray are two seemingly unlikely yet quite effective off-label therapies for the redness and flushing of rosacea.

"For patients who are having a big problem with flushing [or] blushing, brimonidine [Alphagan] is a great drug. I use it routinely in my office," Dr. Guy F. Webster said at the annual Hawaii Dermatology Seminar sponsored by the Skin Disease Education Foundation.

Dr. Guy F. Webster

"I prescribe the 0.15% concentration and tell patients to put a couple of drops on their fingers, rub it onto their cheeks, see how long the effects last, and then use it accordingly. Typically, you can get through a workday with one application," according to Dr. Webster of Jefferson Medical College, Philadelphia.

Brimonidine, whose approved indication is glaucoma, is an alpha-2-adrenergic receptor agonist and thus a vasoconstrictor. So is oxymetazoline, an over-the-counter nasal decongestant sometimes sold as Afrin and other brand names. Dr. Webster has his rosacea patients spray it on their cheeks.

"The redness will go away for a few hours. It's a pretty darn good drug and seemingly safe," he commented.

About 15 years ago, there were reports of a big rebound effect following chronic use of nasal decongestants for their indicated purpose. That doesn't seem to be a problem when oxymetazoline is applied to the skin, in Dr. Webster's experience, and as also borne out in a published detailed case report by another dermatologist (Arch. Dermatol. 2007;143:1369-71).

Dr. Webster said he likes brimonidine because it's his clinical impression that the drug not only relieves the flushing and redness of rosacea, but it also improves the fixed telangiectasias that are often present. Oxymetazoline does not have that effect.

Both drugs are now in formal clinical trials aimed at winning an indication for treatment of flushing/blushing in rosacea patients. There are no drugs approved for that purpose at present.

Oral flush blockers that are used off-label include clonidine, which curbs menopause- and carcinoid-related flushing but "is a waste of time in the average rosacea patient," according to Dr. Webster, because it can't touch flushing induced by heat, red wine, chocolate, or other triggers. Aspirin inhibits the flushing associated with nicotinic acid therapy for dyslipidemia but is "otherwise useless" for the flushing/blushing of rosacea, he continued.

Rosacea has four major diverse manifestations: the papulopustular, phymatous, vascular, and ocular forms. Dr. Webster commented that he is often asked if there will ever be one drug that effectively treats all these seemingly distinct subtypes. Perhaps, he said. But if it's going to happen, then it will likely be a drug that interrupts the neurologic trigger for flushing and blushing, which may be the common underlying trigger.

"The one thing we can say with absolute certainty is that there is something neurologically weird about rosacea patients," he observed.

Dr. Webster disclosed that he serves as a consultant to or has other financial relationships with a number of pharmaceutical companies, including Allergan Inc., which markets brimonidine.

04/07/10