From the Guidelines
Brimonidine is a highly effective treatment for rosacea, specifically for reducing facial erythema, with a significant improvement in symptoms observed in approximately 70% of treated subjects. Brimonidine is available as a topical gel (brand name Mirvaso) in a 0.33% concentration that is applied once daily to affected areas of the face [ 1 ]. The medication works quickly, often reducing redness within 30 minutes of application, with effects lasting up to 12 hours.
Key Points to Consider
- Brimonidine is a selective alpha-2 adrenergic receptor agonist that causes constriction of the dilated facial blood vessels responsible for rosacea-related redness [ 1 ].
- It's essential to note that brimonidine only treats the redness component of rosacea and not other symptoms like papules, pustules, or ocular manifestations.
- Some patients may experience side effects, including rebound redness when the medication wears off, skin irritation, or worsening of rosacea in some cases, so it's advisable to test on a small area first [ 1 ].
- The durability of brimonidine-induced erythema reduction, without significant tachyphylaxis, was confirmed in a 1-year open-label study [ 1 ].
- A postmarketing publication reported that 10–20% of patients may experience paradoxical erythema, and an algorithm for management of this phenomenon has been proposed [ 1 ].
Treatment Recommendations
- Brimonidine can be used as a first-line treatment for persistent erythema, as recommended by the global rosacea consensus (ROSco) panel [ 1 ].
- A pea-sized amount of brimonidine gel should be applied to each of the five facial regions: central forehead, chin, nose, and each cheek.
- General skincare, including sun protection factor 30+, moisturizers, gentle cleansers, and trigger avoidance, should also be recommended to patients with rosacea [ 1 ].
From the Research
Treatment of Rosacea with Brimonidine
- Brimonidine is a highly selective alpha 2 agonist that induces direct vasoconstriction of small arteries and veins, thereby reducing vasodilation and edema 2
- Topical brimonidine gel 0.33% is indicated for persistent facial erythema of rosacea and has been shown to be effective in reducing erythema in patients with rosacea 3, 2, 4
- The efficacy of brimonidine gel may be achieved within 30 minutes of administration, with maximal reductions in erythema 3-6 hours after administration 2
- Patient satisfaction with the use of brimonidine topical gel is superior to vehicle gel for facial appearance, treatment effect, facial redness, and daily control of facial redness 2, 5
Safety and Adverse Effects
- Brimonidine topical gel 0.33% is associated with mild, transient skin-related adverse reactions 2
- A minority of patients may experience adverse effects, most of which are cutaneous in nature, mild-to-moderate in degree, and often resolve spontaneously with continued use or after discontinuation of use 4
- Two distinct manifestations of worsened erythema have been described, including "rebound" erythema, which may occur in approximately 10-20% of patients treated with brimonidine 3
Combination Therapy
- Brimonidine gel can be integrated into a treatment regimen along with concomitant therapies for facial papules and pustules with no increased risk of adverse events with combination therapy 4
- Education about optimal application methods, setting reasonable expectations for treatment, and minimizing inflammation are important factors for the successful use of brimonidine gel as part of a patient's overall rosacea treatment regimen 4
Clinical Evidence
- Several studies have evaluated the efficacy and safety of brimonidine gel for the treatment of persistent facial erythema of rosacea, including randomized, double-blind, vehicle-controlled studies 3, 2, 4, 5
- A systematic review of interventions for rosacea based on the phenotype approach found high-certainty evidence for topical brimonidine in reducing temporarily persistent erythema 6