Distressed with the expense of exotic rosacea treatments ? The stress of rosacea is enough without also having to worry about how to afford treatments. Finding affordable rosacea treatments is a real challenge. Here are my top 5 suggestions for building your rosacea-beating regime while on a budget.

1. Make your own cleanser

Colloidal Oatmeal has promise as natural product because of it’s cleansing, moisturizing, buffering, soothing, protecting and anti-inflammatory properties.

While products like Linda Sy’s Mild Oatmeal Facial Cleanser and Aveeno Oatmeal Anti-Itch are not cheap recommendations, you should be able to source colloidal oatmeal easily from a health food store. Colloidal Oatmeal is defined as a product made from grinding and processing whole oat grain with strict requirements on the particle size and fat content. The small particle size and the way that it disperses in water means that when it deposits on the skin it forms an occlusive barrier.

Try mixing a small amount of Colloidal Oatmeal with warm water and lathering it on your face. Gently remove it with cool water.

See also the Homemade Mixes Forum and the Custom Topical Formulations resources page for more suggestions on making your own super cheap topicals.

2. Use generic prescriptions

Newer releases of antibiotics like Oracea and Solodyn can be extremely expensive, especially without medical insurance. One alternative is to discuss with your doctor the possibility of trying generic doxycycline instead.

Doses of 50mg a day of doxycycline will closely match the amount of active antibiotic in Oracea and Solodyn. Higher doses many also be of benefit until the inflammation of rosacea subsides. Generic doxycycline is far more affordable that these 2 newly released re-packaged antibiotics.

Another possibility is to ask your doctor about generic metronidazole. The patent for metrogel (the 0.75% version specifically) has expired so generic equivalents are now available in several countries around the world. For more information see generic metrogel.

3. Hunt for Bargain Suggestions

Many of the `regular’ treatments for rosacea such as systemic and topical antibiotics are quite expensive. Be on the hunt for things you can try that are more reasonably priced. Here are some suggestions

• Prosacea: this can be sourced over the counter at places like Walgreens and Rite Aid for around $10. It seems to be an ok treatment for rosacea. Prosacea is based on a sulphur preparation.
• Cetaphil Gentle Skin Cleanser and Cetaphil Moisturizing Cream or Lotion are two under-rated skincare products. They are cheap, mild and easily available. If you can incorporate these in to your daily skincare regime then you are off to a good start to cheaply caring for your rosacea skin.
• Try to source a cheap zinc oxide based sunscreen. Some countries have cancer foundations that are good at providing affordable, simple sunscreens. You might be fortunate enough to find a low irritant formulation free of chemical sunscreens.

4. Manufacturer Rebates

Drug manufacturers recognise that their products can still be quite expensive by the time they get to the consumer. To try to mitigate this, rebates or coupons are sometimes offered.

A quick search revealed the following ; $10 Mail-In Rebate for Metrogel, and Save $10 on Finacea Instantly.

The very expensive Oracea also offers a Savings Card where you could save $25 per prescription for those without prescription insurance and help some insured patients pay no more than $25 per month. The similarly expensive Solodyn is also offering a $35 rebate.

While these manufacturer rebates come and go, keep an eye out for promotions offered by the manufacturers. Be aware of all the small print also as refunds can take many weeks to arrive, and promotions can be revoked at any time.

5. Ask for Physician Samples

When new drugs are being promoted, the sales team are desperate to find as many outlets as possible. This might mean that your doctor or specialist has drug samples just waiting to be handed out. Check with your local doctor’s surgery, and maybe even ring a few dermatologist to see if they ever get samples from the drug companys’ sales teams.

You might be lucky enough to find a good source for free samples. This is one asset that is worth trying to chase down and link up with.

Do you have any recommendations for your fellow rosacea sufferers that are on a budget ?

Related Articles

• cetaphil gentle skin cleanser well tolerated
• cetaphil moisturizing cream helps rosacea dry skin
• Prosacea User Reviews
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• Rosacea Support Community:  Homemade Mixes
• RSRP: Custom Topical Formulations

Metronidazole 0.75% gel vs. ketoconazole 2% cream in the treatment of facial seborrheic dermatitis: a randomized, double-blind study, D Seckin, O Gurbuz, O Akin, JEADV, Volume 21 Issue 3 Page 345-350, March 2007.

Background: Recently, two placebo-controlled studies have shown that topical metronidazole was effective in the treatment of seborrheic dermatitis.

Objective: To compare the efficacy and safety of metronidazole 0.75% gel with that of ketoconazole 2% cream in the treatment of facial seborrheic dermatitis.

Methods: A total of 60 consecutive patients with facial seborrheic dermatitis were included. Patients were randomized into two groups. One group used ketoconazole 2% cream with metronidazole gel as vehicle; the other group used metronidazole 0.75% gel with ketoconazole cream as vehicle for a 4-week treatment period. Main outcome measures were change in clinical severity scores, patients’ and investigator’s global evaluation of improvement and frequency of side-effects.

Results: All the assessments were made by an investigator who was unaware of which group the patients were allocated to. Mean percentage decrease in clinical severity scores from baseline to last available visit was 63.4% (95% CI 57.7–69) and 54.4% (95% CI 47.9–61) in the ketoconazole- and metronidazoletreated patients, respectively (P = 0.31). Eighty-two per cent of patients in the ketoconazole group vs. 79% of patients in the metronidazole group rated their global improvement as significant or moderate (P > 0.05). No statistically significant difference in the frequency of side-effects was detected between the two groups. The results of this study need to be confirmed in further studies involving large numbers of patients.

Conclusion: Our data demonstrated that metronidazole 0.75% gel had a comparable efficacy and safety profile with that of ketoconazole 2% cream in the treatment of facial seborrheic dermatitis.

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Galderma has long been associated with rosacea treatment, and is best known for the metronidazole based topicals metrogel, metrocream and metrolotion. CollaGenex has become known in recent years for their promotion of the oral rosacea treatment Oracea. Further, Collagenex is developing the Sansrosa technology as topical treatment for the redness and flushing of rosacea.

Galderma was formed in 1981 as a joint venture between Nestle and L’Oreal.

It seems like an excellent fit to me with both offering complimentary products. Additionally it is also good news for the creation of new rosacea treatments as the combined resources of the 2 companies can be targeted toward new products.

Read some further news coverage:

All rosacea sufferers should do themselves a favor and do some reading on the role of inflammation in rosacea. This is the most exciting direction for rosacea research, in my opinion. Though it can feel like you are reading a foreign language, I’d encourage everyone to stick at it.

More links at the bottom, but 2 places to start: Examining Inflammation as a Common Factor in Theories of Rosacea Pathophysiology (via Collagenex’s RosaceaToday info site) and Role of Inflammation (put together by Dan in the RSRP).

Even though there is a bit of a love hate relationship with the metronidazole based rosacea treatments, examining how it works is leading to some new and useful research.

Properties of metronidazole on free oxygen radicals in a skin lipid model system.

J Pharm Pharmacol. 2007 Aug; 59(8):1125-30, Authors: Narayanan S, Hunerbein A, Getie M, Jackel A, Neubert RH

Reactive oxygen species (ROS) play a vital role in the pathophysiology of the skin disease rosacea, a chronic, genetically-determined and UV-triggered disease, leading to facial redness and blemishes and exhibiting a deep impact on a patient’s self-esteem and quality of life. ROS can cause oxidative damage to nucleic acids, sugars, proteins and lipids, thereby contributing to adverse effects on the skin.

Metronidazole has been the first-line topical agent therapy for many years; nevertheless the mechanism of action is still not well understood. The therapeutic efficacy of metronidazole has been attributed to its antioxidant effects, which can involve two pathways: decreased generation of ROS within tissues or scavenging and inactivation of existing ROS. Previous investigations have shown that metronidazole reduces ROS by decreasing ROS production in cellular in-vitro systems. The aim of the following study was to demonstrate that metronidazole additionally exhibits antioxidative properties in a cell-free system, by acting as an antioxidant scavenger.

A simple skin lipid model (oxidative) system and a complex skin adapted lipid system in conjunction with thiobarbituric acid (TBA) test, a quantitative assay for the detection of malondialdehyde (MDA) and therefore lipid peroxidation, were used to determine the antioxidative properties of metronidazole after UV irradiation. Results clearly show that metronidazole has antioxidative properties in a cell-free environment, acting as a free radical scavenger. Simple skin lipid model: in the presence of 10, 100 and 500 mug mL(-1)metronidazole the MDA concentration was reduced by 25, 36 and 49%, respectively. Complex skin lipid system: in the presence of 100 and 500 mug mL(-1)metronidazole the MDA concentration was reduced by 19 and 34%, respectively.

The results obtained in this study and from previous publications strongly suggest that metronidazole exhibits antioxidative effects via two mechanisms: decrease in ROS production through modulation of neutrophil activity and decrease in ROS concentration by exhibiting ROS scavenging properties. The remarkable clinical efficacy of metronidazole in the treatment of rosacea is probably due to its ability to decrease ROS via different mechanisms, thereby protecting skin components from induced damage.

Related Articles:

• so just how does metrogel work ?
• metrogel: how it gets into your skin
• focus on metronidazole
• azithromycin (zithromax) is anti-oxidant, helps rosacea

We can see from a Collagenex annual report that COL-101 was the name for Periostat MR, which then became Oracea.

Safety and Efficacy Study to Compare Two Rosacea Treatment Regimens

Purpose: To compare the safety and efficacy of two treatment regimens: 1) COL-101 and metronidazole gel 1%; 2) Doxycycline hyclate 100 mg and metronidazole gel 1%

Official Title: A Clinical Trial to Determine the Effects of COL-101 Administered Once Daily With Metronidazole Topical Gel, 1% Versus Doxycycline Hyclate 100 mg Administered Once Daily With Metronidazole Topical Gel, 1% in Patients With Moderate to Severe Rosacea

This trial follows on from a 2005 paper that studied the combination of periostat and metrogel. That study concluded that combining sub antibiotic dose doxycycline with metrogel 0.75% was better than metrogel on its own.

Combining a systemic antibiotic with metronidazole has been the mainstay of rosacea treatment for several years. What we are seeing here is updates to studies since the introduction of oracea and metrogel 1%.

The second abstract suggests that a cream based metronidazole formulation (presumably metrocream, but could also include Noritate) had the greatest absorption when tested with human skin. They suggest that future research is needed to determine if indeed this makes any difference to rosacea symptoms.

Previously Rosacea News reported ;

metrogel, metrolotion, metrocream, noritate, once and twice per day – all the same same

“Despite quite a lot of activity in the marketing and development of the metronidazole treatments (lotion, cream, gel, generic equivalents, metrogel 1%, once per day, twice per day) this research suggests that the formulation and treatment frequency make little difference to the treatment outcome. So if you can tolerate one of the available formulations, there is likely marginal benefit from changing to another.”

Metronidazole based treatments do seem to attract a lot of research, maybe even too much research given the marginal improvement that many rosacea sufferers experience from the metro triplets. Imagine if the research poured in metronidazole was directed to new, leading edge treatments.

As background, from `measuring niacinamide (vitamin B3) moisturizer and skin barrier‘: 

“Confocal Raman microspectroscopy (CRS), in contrast, is a new technique that combines the well attested method of Raman spectroscopy (the study of inelastic scattering of light, rather than its absorption) with confocal microscopy, allowing noninvasive, realtime, in vivo measures of molecular concentration profiles.”

Follow-up of drug permeation through excised human skin with confocal Raman microspectroscopy. Eur Biophys J., 2007 Jun 13, Tfayli A, Piot O, Pitre F, Manfait M.

Skin is a multilayered organ which covers and protects the surface of human body by providing a barrier function against exogenous agents. Meanwhile, the efficacy of several topically applicated drugs is directly related to their penetration through the skin barrier. Several techniques are commonly used to evaluate the rate, the speed and the depth of penetration of these drugs, but few of them can provide real-time results. Therefore, the use of nondestructive and structurally informative techniques permits a real breakthrough in the investigations on skin penetration at a microscopic scale.

Confocal Raman microspectroscopy is a nondestructive and rapid technique which allows information to be obtained from deep layers under the skin surface, giving the possibility of a real-time tracking of the drug in the skin layers. The specific Raman signature of the drug enables its identification in the skin. In this study, we try to follow the penetration of Metronidazole, a drug produced by Galderma as a therapeutic agent for Rosacea treatment, through the skin. The first step was the spectral characterization of Metronidazole in the skin. Then micro-axial profiles were conducted to follow the penetration of the drug in the superficial layers, on excised human skin specimens. For more accurate information, transverse sections were cut from the skin and spectral images were conducted, giving information down to several millimeters deep. Moreover, the collected spectra permit us to follow the structural modifications, induced by the Metronidazole on the skin, by studying the changes in the spectral signature of the skin constituents.

Percutaneous absorption kinetics of topical metronidazole formulations in vitro in the human cadaver skin model, Adv Ther. 2007 Mar-Apr;24(2):239-46, Elewski BE

Topical formulations containing identical active agents are available in various vehicles and concentrations, which may affect percutaneous absorption. This study was undertaken to evaluate the in vitro percutaneous absorption pharmacokinetics of metronidazole in different vehicles and concentrations as the active agent in 6 topical formulations. Formulations were applied to sections from 3 cadaver skin donors, and percutaneous absorption of metronidazole was measured over a 48-h test period through the finite dose technique and the use of Franz diffusion cells. Metronidazole penetrates into and through human cadaver skin.

Data show the general ranking of delivery of similar concentrations of metronidazole according to vehicle as cream > lotion > gel. The 48-h penetration of metronidazole in the human cadaver skin model was greatest with cream formulations and lowest with gel formulations. These results reveal the importance of the vehicle selected for penetration of metronidazole into the skin. The relevant target zone in rosacea is the dermis because this is the area where inflammation takes place. Additional studies are warranted to examine absorption of metronidazole into the relevant target zone and the correlation of absorption with efficacy.

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Further Reading:

• focus on metronidazole
• metrogel less irritating than finacea
• metrogel, metrolotion, metrocream, noritate, once and twice per day – all the same same
• periostat and metrogel better than metrogel alone
• so just how does metrogel work ?

I have mentioned a few times in the past that the way that metrogel helps rosacea is unknown. This statement deserves some clarification. Actually the way that metronidazole works is well known. How the effect of metrogel leads to a benefit in rosacea, well, that is something worth exploring some more later on.

You may wonder why there is so much emphasis on the metronidazole based products ? As much as metrogel and its friends metrocream, metrolotion, rozex, noritate (and indeed generic metrogel, also from fougera) are not a panacea for rosacea, they do represent the single most proven treatment specifically for rosacea. Thus newly diagnosed rosacea sufferers are quite likely to leave their doctor’s surgery with a script for metro-something. All the studies show that in many cases metrogel does indeed work. Further, other studies clearly show that combining metrogel with antibiotics results in better clearance.

So back to `how does it work ?’  Well my one sentence summary is “metronidazole breaks down into a substance that kills the DNA of the cells of some particular bacteria and protozoa”.

Thanks to Dan for sending me the following links ;

From DrugBank: Metronidazole

Pharmacology: Metronidazole, a synthetic antibacterial and antiprotozoal agent of the nitroimidazole class, is used against protozoa such as Trichomonas vaginalis, amebiasis, and giardiasis. Metronidazole is extremely effective against anaerobic bacterial infections and is also used to treat Crohn’s disease, antibiotic-associated diarrhea, and rosacea.

Mechanism of Action: Unionized metronidazole is selective for anaerobic bacteria due to their ability to intracellularly reduce metronidazole to its active form. This reduced metronidazole then disrupts DNA’s helical structure, inhibiting bacterial nucleic acid synthesis and resulting in bacterial cell death.

From Antibiotics that Inhibit Nucleic Acid Synthesis

Figure 11-8. Structure of metronidazole and its mechanism of action. Metronidazole enters an aerobic bacterium where, via the electron transport protein ferrodoxin, it is reduced. The drug then binds to DNA, and DNA breakage occurs.

(An anaerobic organism is any organism that does not require oxygen for growth. Protozoa are a particular type of single cell organisms.)

This naturally leads to the followup question – if eliminating the substances that metronidazole (and for the purposes of this argument, lets include systemic antibiotics as well) is active against leads to relief from some rosacea symptoms, what does that say about the possible cause of rosacea ? Now, that is a question that there isn’t much agreement about and something worth talking about some more, later.

Further Reading ;

• focus on metronidazole
• metrogel less irritating than finacea
• collagenex: rosacea is a chronic inflammatory disease
• 1 percent metrogel from galderma
• generic metrogel soon – Fougera
• metrogel, metrolotion, metrocream, noritate, once and twice per day – all the same same
• focus on finacea (azelaic acid 15%)
• periostat and metrogel better than metrogel alone
• low dose doxycycline hyclate (SDD)

Metronidazole in the treatment of rosacea: do formulation, dosing, and concentration matter? Yoo J, Reid DC, Kimball AB., Clinical Unit for Research Trials in Skin, Harvard Medical School, Boston, MA 02114, USA.

BACKGROUND: Topical metronidazole is commonly used in the management of rosacea. No consensus on the optimal formulation, concentration, or dosing regimen exists.

PURPOSE: To assess the relative efficacy of metronidazole cream, gel, and lotion at concentrations of 0.75% and 1%, in dosing regimens of once and twice daily.

METHODS: A meta-analysis of published metronidazole efficacy rates was performed.

RESULTS: In non-weighted analysis, the mean efficacy was 28.2% (95% confidence interval [CI], 22.0%-34.4%) for the cream, 38.4% (95% CI, 18.4%-58.4%) for the gel, and 35% for the lotion. Confidence intervals for QD versus BID dosing and 0.75% versus 1% concentrations also overlapped. In weighted analysis, the mean reduction was 31.3% for the cream, 22.1% for the gel, and 35% for the lotion.

CONCLUSIONS: Metronidazole cream, gel, and lotion vehicles have similar efficacies. There were no substantial differences between concentrations of 0.75% and 1%, or between once daily and twice daily regimens.

• PubMed Extract

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Michael Gold, MD, Gold Skin Care Center, Tennessee Clinical Research Center, Nashville, TN, United States

Rosacea is a common dermatologic disorder characterized by the presence of facial erythema, visible blood vessels, and acneiform papules and pustules. With the face being the predominant site of involvement, this disease is often associated with serious psychosocial morbidity and can significantly impact quality of life. Metronidazole is a topical medication indicated for the treatment of rosacea whose efficacy has been confirmed in many controlled clinical trials. Recently, metronidazole was made available in a new gel formulation at a higher concentration (1% metronidazole). This new formulation has been shown to be well tolerated and nonirritating despite the higher concentration of metronidazole. Intense pulsed light (IPL) therapy over the past 15 years has also shown good results in case studies for the treatment of erythema and telangiectasia in rosacea patients. To enhance treatment efficacy in roscaea, IPL is being investigated in combination with pharmacologic agents. We present several case studies of patients with mild to moderate rosacea who were treated with IPL followed by once-daily metronidazole 1% gel for a period of 8 weeks. Assessments included investigator’s global assessment of rosacea severity, investigator’s assessment of rosacea improvement, and tolerability/adverse events. Photographs were taken at each visit and will be presented with discussion of results.

Author disclosure: Nothing disclosed at press time. Study and poster support provided by Galderma Laboratories, L.P.

Poster Discussion Session P574, American Academy of Dermatology, 64th Annual Meeting, March 3-7 2006, San Francisco.

Supplement to Journal of The American Academy of Dermatology, March 2006, Volume 54, Number 3.

• JAAD Poster Abstracts Online
• Rosacea News: focus on metronidazole
• Rosacea News: focus on finacea (azelaic acid 15%)
• Rosacea News: focus on metronidazole
• Rosacea News:1 percent metrogel from galderma

Compatibility of skin care formulations containing licochalcone A with commonly prescribed medications for rosacea

Teresa Weber, PhD, Beiersdorf Inc, Norwalk, CT, United States; Ronald Rizer, PhD, Thomas J, Stephens & Associates, Colorado Springs, CO, United States; Anette Buerger, PharmD, Andrea Schoelermann, MD, Beiersdorf AG, Hamburg, Germany

Rosacea can often be managed by pharmacologic treatment, the use of appropriate daily skin care products, and the avoidance of flushing triggers. We examined the stability and compatibility of several commonly prescribed pharmaceutical actives with skin care formulations containing licochalcone A. These formulations were previously tested and shown to be suitable for the daily skin care of patients with erythematotelangiectatic (type 1) rosacea. Chemical stability of the active agents metronidazole and azelaic acid was evaluated by HPLC analytical methods after formulation in an SPF 15 moisturizing cream containing green- and redness concealing pigments, and a night moisturizing cream, both containing licochalcone A. The actives were postadded to the formulations at final concentrations of 0.75% for metronidazole and 15% for azelaic acid, respectively. After 2, 4 and 6 weeks, no loss of actives or changes were observed in samples stored at both room temperature and 378C. Skin compatibility of the drug and skin care formulations was also assessed in subjects with mild to moderate type 1 and 2 rosacea who participated in an in-use test. All subjects applied the drug product alone daily two weeks, followed by the drug and the skin care regimen containing licochalcone A for an additional 2 weeks. Clinical grading of erythema and subjective irritation as well as inflammatory lesions (type 2 rosacea subjects) was made at baseline, and at 2 and 4 weeks. The subjects showed improvements in clinical scores compared to baseline at week 2, and further improvements at week 4. We conclude that the skin care formulations with licochalcone A are compatible with metronidazole and azelaic acid, treatments commonly prescribed for patients with rosacea.

Author disclosure: Nothing disclosed at press time. 100% sponsored by Beiersdorf Inc

Poster Discussion Session P1134, American Academy of Dermatology, 64th Annual Meeting, March 3-7 2006, San Francisco.

Supplement to Journal of The American Academy of Dermatology, March 2006, Volume 54, Number 3.

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