This paper discusses strategies to reduce antibiotic exposure during rosacea therapy; including using combination therapy with oral antibiotics and topical therapies/agents.

This could be used as maintenance therapy for longer term benefits.

Note that the use of low dose doxycycline like Oracea is also another option when thinking about possible antibiotic resistance issues.

Preventing antibiotic resistance in the treatment of rosacea, Family Practice Recertification, Issue: July 2005, Page: 50 (free registration), John E. Wolf, Jr, MD, and G. Robert Parkerson III, MD

Oral antibiotics, usually in combination with topical therapies like metronidazole, are a mainstay of treatment for papulopustular rosacea. Since rosacea is not caused by a pathogen, bacterial resistance should not compromise its treatment, but bacterial resistance may compromise treatment of other dermatologic disorders, such as acne vulgaris. Oral antibiotics can also promote development of resistant bacteria in other physiologic areas, such as the gastrointestinal tract. Strategies to reduce exposure to oral antibiotics and the risk of bacterial resistance include using anti-inflammatory agents that have no antimicrobial effects or topical antimicrobial agents that have a narrow bacterial spectrum and minimal systemic absorption.

Oral antibiotics, in combination with a topical agent like metronidazole (MetroLotion, Metro-Gel, Noritate, etc.), are the mainstays of treatment for rosacea subtype 2 (papulopustular rosacea). The most commonly used antibiotics include the tetracycline family (tetracycline HCl [Sumycin], doxycycline [Vibramycin, Doryx, Adoxa, etc.], minocycline HCl [Dynacin, Minocin, Myrac]), erythromycin (Ery-Tab, PCE Dispertab, Eryc, etc.), and trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra). Topical treatment options include metronidazole, sulfacetamide 10%-sulfur 5% (AK-Sulf, Cetamide, Bleph, etc.) lotion or cleanser, and azelaic acid (Azelex, Finacea).

…

Minimizing bacterial resistance

Oral and topical antibiotics are effective agents in treating rosacea and should remain in therapeutic regimens, despite the issue of drug resistance. A number of strategies can be employed to help minimize the development of resistance:

• Limit use of broad-spectrum oral agents Tetracyclines and erythromycin have a wide spectrum of activity and well-defined mechanisms of resistance.
• Use low doses of oral antibiotics Oral antibiotics are used for their anti-inflammatory rather than anti-infective effects in treating rosacea.
• Use combination therapy Oral antibiotics in combination with topical therapies can enhance efficacy and reduce overall exposure to the antibiotics
• Use topical agents for maintenance Using topical agents rather than oral antibiotics as maintenance therapy is another strategy to minimize antibiotic exposure and help prevent bacterial resistance.

Conclusion

Although agents for rosacea are used for their anti-inflammatory rather than anti-infective effects, the use of oral antibiotics, in particular, can result in bacterial resistance on the skin and in other body sites. This could potentially compromise the treatment of other dermatologic, respiratory, and gastrointestinal disorders. Strategies to reduce antibiotic exposure during rosacea therapy include using combination therapy with oral antibiotics and topical therapies as well as topical agents as maintenance therapy.

Disclosure The writing of this article was supported by an independent grant from Galderma Laboratories. The authors would also like to acknowledge the assistance of Carole Post in the preparation of the manuscript.

Dr. Wolf has received grant/research support from Galderma and has served as a consultant and on the speakers’ bureau for CollaGenex, Dermik, Doak, Galderma, and Medicis. Dr. Parkerson has no relationships with commercial entities that might represent a conflict of interest with the content of this article.

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