Paradigm shift in Rosacea therapy

"I wanted to get across the importance of the classification system, the therapeutic benefit of aspirin, the use of topical medications in combination and the use of sub-antimicrobial doxycycline hyclate (Periostat, Collagenex) 20 mg twice daily," Dr. Bikowski says.

Modification of classification "For years, we talked about rosacea, but we never had a classification system," Dr. Bikowski tells Dermatology Times.

Last September and October, two articles appeared in JAAD further attempting to rework the definition of rosacea and, in turn, providing guidelines to establish a diagnosis and treatment algorithm.

In regard to the modifications in defining rosacea Dr. Bikowski says, "The definition of rosacea includes persistent erythema on the central portion of the face lasting for at least three months with a tendency to spare the periocular skin. The authors established secondary features including burning and stinging, plaque, dry appearance, edema, ocular manifestations, peripheral location and phymatous changes. This is important because the secondary features dictate the subtype, and, once you have dictated the subtype, that determines the therapy you are going to use."

Treatment approaches With the reworking of the rosacea classification system, Dr. Bikowski has been working on improved methods of preventing flares and increasing the efficacy of current approaches. He has established guidelines and altered standard of care regimens to include aspirin, tiered use of topical medications and subantimicrobial doses of antibiotics.

"So we also put patients on 81 mg of baby aspirin each night," he says. "The reason why we do that is there is an increased incidence in rosacea in combination with migraine headaches; they are both vascular phenomenon, and neurologists for years have used a baby aspirin prophylactically for migraines. So about two to three years ago we started using, in our practice, a baby aspirin each day as prophylaxis to decrease the flushing episodes with the hope of decreasing the resultant erythema."

Dr. Bikowski uses a tiered topical agent approach that includes a four-tiered treatment algorithm.

"For the first tier of therapy, one of the first things I consider using is metronidazole gel (Metrogel, Galderma) 0.75 percent or azelaic acid gel (Finacea Gel, Berlex) 15 percent, which are equal in efficacy. So I will use either one of the two depending on what the patient has had in the past, if they had one I will try the other or use them in combination. My second tier includes the DESI (Drug Efficacy Study Implementation) drugs, which are sodium sulfacetamide 10 percent in combination with sulfur 5 percent. You could use metronidazole gel 1 percent, but as it exists today the cream base is cosmetically unacceptable in my opinion. The fourth tier includes Protopic ointment (Fujisawa) and Elidel (Novartis) cream. We have used a lot of Elidel in the practice and it is a little bit more cosmetically acceptable than Protopic because it is in a cream base but we think that the Protopic is probably more effective, so you balance off efficacy and ointment base versus not as efficacious but a cosmetically elegant cream base," Dr. Bikowski says.

These topical agents can be used in combination with each other as well as in combination with systemic therapies. Also, Dr. Bikowski explains that dermatologists can use agents in the first tier in combination with a number of the second tier drugs, as many of those agents include cleansers.