Rosacea Treatment: Letting the Patient Lead the Way

During her presentation at Maui Derm NP+PA Fall 2024, Hilary Baldwin, MD, discussed the current treatment landscape for rosacea, focusing on share decision-making and patient buy in.

During the presentation, titled “Acne and Rosacea Update 2024,” Baldwin was joined by James Del Rosso, DO, and Julie Harper, MD.

Transcript

Hilary Baldwin: I’m Hilary Baldwin, I run the Acne Treatment and Research Center in Brooklyn, New York, and take care of acne and rosacea all the time.

Dermatology Times: What topics did you discuss during your presentation at Maui Derm NP+PA Fall 2024?

Baldwin: Today I talked about rosacea, mostly about treatment for rosacea, but I began by recognizing that our old-fashioned way of describing rosacea was to talk about people with erythematotelangiectatic or papulopustular or phymatousor ocular and we tried to squeeze people into those individual categories. In reality, most of our patients have combination rosacea. They have a little ocular, a little erythema, a little papules, a little phyma. The newer way to look at a rosacea patient is to examine the patient as an individual and look for every single one of those phenotypes. We're going to look for erythema, papules and pustules, ocular changes, flushing, blushing, telangiectasias, and then we're going to ask them also about their symptoms of itch, sting, and burn, and then put it together into a composite treatment plan. It's very important to evaluate the patient individually. I like to give them a mirror and have them look at themselves well. I point out the salient features of their disorder, and then ask them, ‘Okay, of those things that I just told you, what do you care about?’ Because if you have 2 or 3 manifestations of rosacea, you're going to need 2 or 3 medications, or medications and procedural treatments, which might actually get quite costly.You need to know what bothers the patient the most, and never assume that you know what bothers them the most, because often you would be wrong. I had a patient who was bright red, didn't care at all. You really need to ask them and get their buy in, because this is a long-haul treatment. This is not a quickie. Since it's a marathon, not a sprint, we need to make sure that we have the patient buy in. With that in mind, we talked about topical treatment for papules and pustules, specifically ivermectin, topical minocycline and topical microencapsulated benzoyl peroxide, and how very effective those are compared to our older topicals of metronidazole and azelaic acid. Highly effective, nice tolerability profile, and can be used in combination as well. You could use 1 in the morning and 1 in the evening and really get control of rosacea. These drugs are giving success rate, meaning clear and near clear, of 40%, 50%, and 60% so just highly effective compared to our older topical treatments. And then we have our anti-inflammatory dose doxycycline, the modified release formulation, which is also highly effective. Although a doxycycline, it’s a non-antibacterial dose of it, so it's safe for long term use. That's basically what I talked about, moved on a little bit to also vascular disease, talking about oxymetazoline and brimonidine in their ability to reduce that background erythema. That's what's new in rosacea!

DT: When consulting with a patient, what are your biggest shared decision-making considerations?

Baldwin: I honestly think of the diseases that I treat most frequently, rosacea is the one where buy in is the most important. Especially for somebody who has combination disease with more than 1 manifestation, because they're going to need at least 2 drugs, 2 drugs and a procedure which is not covered by insurance, or several procedures, depending on if they have a phyma, for example, they're going to need numerous procedures. The cost is going to get quite high. I like to have them take a look specifically at their manifestations and ask them which one they care about the most, and then specifically say, ‘Okay, so for this, it would require topical medications that are covered by insurance. For this, we would need a procedure, which is you're going to have to pay for out of pocket, so that we put it all together in one package.’ One of the problems is that the newer medications are often only affordable if you can use a coupon. The coupons do not work for government insurance, which includes Medicare. Unfortunately, since this is a condition thatoften affects people of Medicare age, they may not be able to get the newest and the best in the medications.It is a huge problem and a huge disappointment, and I don't know quite how to solve that problem. But that's what samples are for!

DT: Is there any research of upcoming therapies you are excited about?

Baldwin: Unfortunately, the rosacea pipeline, as far as I know, is extremely limited. We have a huge problem in the acne and rosacea space in that reimbursement for these medications is very, very difficult. The companies that are spending millions of dollars on research and development are not getting the money back that they need to put more money into research and development for new products, especially topicals. Acne rosacea is becoming the poor cousin compared to psoriasis and atopic dermatitis. Dr. Harper made a very good point today that she doesn't understand why it's okay to be spending vast amounts of money on top medications for psoriasis and atopic dermatitis.Valuable and necessary, but making it so that acne and rosacea can't be treated at all. So unfortunately, the pipeline does not look bright and I'm not sure where we're going to be 10 years from now.

[Transcript has been edited for clarity.]

To explore more of our coverage from Maui Derm NP+PA Fall 2024, click here.