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This paper from Drugs R&D, details an extensive treatment regimen undertaken to deal with a patient with a severe case of rosacea. Click the photo above for a larger view of their symptoms and how they improved over time. Note that only one side of their face was treated with Mirvaso in the hours before the last two photos were taken.
The patient had a large number of papules and pustules with a severe background of erythema. The following treatments were undertaken;
- short course of antibiotics – 8-week regimen of azithromycin 500 mg three times weekly
- 8 week regime of prednisolone 30 mg once daily (reduced to 10 mg once daily after 1 week)
- after 4 weeks – azithromycin 500 mg three times weekly and the prednisolone dose was reduced to 5 mg once daily.
- isotretinoin 10 mg once daily (taken with the main meal)
- after 4 months, Mirvaso, in the morning, initially just to the left hand side of the face.
- continuous use of metrogel 0.75% twice a day
Steroids?
The use of corticosteroids over the short term is not strictly contraindicated in the treatment of rosacea and can be considered as an option to reduce inflammation in patients who present with signs of rosacea fulminans.
Failed Treatments
According to the paper, the patient had previously been treated with
- metronidazole 0.75%
- permethrin 0.5%
- doxycycline 40mg daily (Oracea) for 18 months
but this was unsuccessful.
Why so many treatments?
In patients with very severe, inflamed rosacea, a multimodal, tailored approach with a short course of macrolide antibiotics in combination with corticosteroids is needed to strongly address the inflammatory component upfront and improve patient outcomes; corticosteroids are not strictly contraindicated in the treatment of rosacea if used for a short period to reduce inflammation showing signs of rosacea fulminans.
In these patients, long-term therapy is needed to improve outcomes, with isotretinoin being effective in further reducing inflammatory lesions count and in maintaining remission.
but the warning about combining many treatments together is also worth noting.
For complex cases such as this one, it has been acknowledged that careful selection and use of a combination of clinical treatments is essential to treat the individual. However, appropriate treatment recommendations and guidelines for such complex cases are still lacking.
Article Abstract
Drugs R&D. 2016 Sep; 16(3): 279–283.
Martin Schaller and Lena Gonser, Department of Dermatology, Eberhard Karls University Tübingen.
Rosacea is a chronic inflammatory disease that can manifest as a spectrum of symptoms including erythema, inflammatory lesions, edema, and telangiectasia. Treatment decisions need to be adapted to reflect the nature and severity of the different symptoms present.
In this report, we discuss the case of a female patient diagnosed with severe, inflamed papulopustular rosacea (PPR) presenting with a large number of inflammatory lesions and severe background erythema.
This patient responded well to a treatment regimen consisting of a short course of antibiotics in combination with a corticosteroid, followed by monotherapy with isotretinoin to reduce the inflammation.
Brimonidine gel, used as needed, was then added to isotretinoin to target the remaining background erythema.
This case of severe PPR required a combinatorial treatment regimen to effectively target all symptoms present. The patient continued to apply topical metronidazole throughout the different treatment regimens prescribed over the course of almost 1 year.
Use of topical metronidazole helped to repair and protect the skin barrier, which minimized the occurrence of dermatological adverse events when topical treatments were used.
We conclude that in patients with severe disease and an important inflammatory component, a rapid response can be obtained with a multimodal, tailored approach that also includes treatment to repair and protect the skin barrier.
Conflict of Interest Statement
Professor Dr. Martin Schaller has been a member of advisory board panels over the past 2 years, and has received lecture fees from AbbVie, Bayer Healthcare, Galderma, Marpinion, and La Roche Posay. Dr. Lena Gonser declares that she has no conflicts of interest.
Comment from facebook thread – “suggest Brimonidine antibiotics unnecessary and that improvement could have been achieved with accutane and prednisolone alone”
You state “after 4 weeks – azithromycin 500 mg three times weekly and the prednisolone dose was educed to 5 mg once daily.”
What was the azithromycin reduced to as you state it was started at 500 mg 3 times per week.
Thanks
Dr Grisoli
The azithromycin continued 3 times per week in the second month.
“After 4 weeks of treatment, a reduction in the inflammatory lesion count was observed (Fig. 1b). A slight decrease in the severity of facial redness was also seen, especially on the forehead, most likely resulting from a reduction in lesional and perilesional erythema.
The patient continued to take azithromycin 500 mg three times weekly and the prednisolone dose was reduced to 5 mg once daily. In addition, the patient continued to apply metronidazole 7.5 mg/g cream twice daily.”
David,
So just to recap:
azithromycin 500 mg 3 times per week for 8 weeks
prednisolone 30 mg qd for week 1 then 10 mg qd for weeks 2, 3, & 4 then 5 mg weeks 5-8
isotretinoin 10 mg qd for 4 months( or perhaps longer)
metrogel 0.75% bid for 4 months
mirvaso applied daily starting at week 16
May I ask “how long do you typically keep them on isotretinoin?”
Do you see a role for ivermectin anywhere in this approach?
Thanks ,
Dr Grisoli
Hello Dr. Grisoli,
I’m not a doctor, just quoting from the paper.
You can read the full paper here
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5045832/
for more details on the actual treatment regime undertaken.
The paper author’s email address was easy to find at uni-tuenbingen.de and he replied – if you are looking for his contact details.
regards
davidp.