Advances and Challenges in Rosacea Treatment: Insights From Hilary Baldwin, MD

“We talked again about the importance of the newer, branded medications like ivermectin, minocycline foam, and the new microencapsulated benzoyl peroxide, as being vastly superior to the other older topical medications that we had for treating the papules and pustules of rosacea. And lastly, we talked about isotretinoin. Don't forget isotretinoin for the treatment of recalcitrant rosacea. It works extremely well,” said Hilary Baldwin, MD, in an interview with Dermatology Times at the 2024 Society of Dermatology Physician Associates (SDPA) Fall Conference in Las Vegas, Nevada.

Baldwin, a board-certified dermatologist, medical director of the Acne Treatment & Research Center in Brooklyn, New York, and clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical Center, presented “Managing Complex Rosacea: Expert Strategies for Challenging Cases” at SDPA. Baldwin also served as the conference medical director at this year’s meeting.

In her interview, Baldwin shared her expertise on managing complex rosacea, highlighting innovative approaches to treatment and the current state of the acne and rosacea pipeline.

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Personalized Approaches to Complex Rosacea Cases

Baldwin emphasized the importance of tailoring treatments for patients with rosacea, particularly those with multifaceted symptoms, such as background erythema, papules, pustules, phymas, and ocular involvement. Drawing on insights from co-presented Julie Harper, MD, Baldwin praised the use of Harper’s "utensil analogy" to conceptualize treatment strategies:

• Forks: Target papules and pustules with therapies like ivermectin and minocycline foam
• Knives: Address telangiectasias and flushing with procedural options like laser and light-based treatments
• Spoons: Manage background erythema with alpha agonists such as brimonidine and oxymetazoline

This multi-modality approach acknowledges the diverse manifestations of rosacea, promoting a combination therapeutic strategy for optimal outcomes.

Targeting Erythema in Rosacea

Baldwin outlined the nuanced treatment of erythema, emphasizing its various subtypes:

• Background erythema: Treated effectively with alpha agonists
• Flushing: Best managed with beta blockers like carvedilol
• Erythema from papules and pustules: Resolves as the inflammatory lesions clear
• Telangiectasias: Require procedural interventions, such as laser therapy

She stressed the importance of using newer branded therapies, including microencapsulated benzoyl peroxide, which offer superior efficacy and tolerability for inflammatory rosacea lesions. For severe or recalcitrant cases, Baldwin highlighted the efficacy of isotretinoin, noting its underutilization in rosacea care.

Pipeline Challenges in Acne and Rosacea

While recent years have seen notable advancements in rosacea treatments, Baldwin expressed concern about the slow-down in the development pipeline. She observed that pharmaceutical companies are shifting their focus toward biologics, often leaving topical and oral therapies for acne and rosacea as they currently stand.

The pipeline does include some promising developments:

• Oral extended-release low-dose minocycline: A potential new option for rosacea
• Phase 1 vaccines: An exciting but uncertain trial

However, beyond these, Baldwin noted a lack of groundbreaking innovations expected in the near future.

Baldwin’s insights emphasize the evolving understanding of rosacea as a multifactorial disease requiring personalized, combination approaches. Her reflections on the diminishing innovation in topical therapies highlight the importance of maximizing existing treatment modalities while advocating for renewed research and development in the field.