What is the role of biological creams in treating rosacea?

Biological Creams for Rosacea: Role in Treatment

Biological creams are not first-line treatments for rosacea, but specific topical agents targeting different phenotypical presentations are recommended based on a phenotype-led approach rather than the traditional subtype-based classification. 1, 2

First-Line Topical Treatments by Phenotype

• For inflammatory papules/pustules:

  • Topical ivermectin 1% cream is recommended as first-line therapy for mild presentations 3
  • Topical azelaic acid 15% gel/foam is an effective alternative first-line option 3, 4
  • Encapsulated benzoyl peroxide 5% (E-BPO 5%) is a newly FDA-approved topical treatment showing rapid improvement by week 2 and sustained efficacy for up to 52 weeks 3
  • Topical minocycline foam 1.5% is recommended for moderate to severe inflammatory lesions 3

• For persistent erythema:

  • Topical α-adrenergics (specifically brimonidine) are recommended as first-line therapy 1, 3
  • Topical oxymetazoline is an alternative option 3

• For transient erythema (flushing):

  • Limited evidence exists for effective topical treatments 1
  • Topical α-adrenergics may provide some benefit based on clinical experience 1

Treatment Approach

• Phenotype-based treatment:

  • Treatment should target specific signs and symptoms observed by the clinician and those most bothersome to the patient 2, 1
  • The traditional subtype-based approach has been replaced by a phenotype-led approach to better address the spectrum of clinical presentations 1, 2

• Combination therapy:

  • Multiple cutaneous features can be treated with more than one agent simultaneously 1, 3
  • Moderate and severe presentations typically require combination treatments, which could include general skincare or physical modalities as well as pharmaceutical agents 1
  • If first-line treatment fails, consider either an alternative first-line option or add an additional first-line agent 1

• Treatment duration:

  • Treatments should be allowed sufficient time to take effect before considering alternatives 1
  • Previous suggestions for initial therapy range from 6-12 weeks, with topical treatments requiring shorter duration and oral treatments requiring longer duration 1

Maintenance Therapy

• The minimum treatment necessary to maintain control should be used 1, 3
• Without maintenance therapy, up to two-thirds of patients may relapse when treatment is discontinued 3
• The approach to maintenance depends on treatment modality and patient desire for ongoing therapy 1

General Skincare Measures

• General skincare underlies the treatment approach to managing cutaneous features 1
• Sun protection (SPF 30+) is recommended 3
• Gentle cleansers and moisturizers should be used 3
• Trigger factor avoidance is important, though limited RCT evidence exists for this approach 1

Special Considerations for Ocular Rosacea

• Lid hygiene and artificial tears are recommended for mild ocular symptoms 1, 3
• Oral doxycycline is recommended for moderate to severe cases of ocular rosacea 3
• Ophthalmological referral should be considered for all but the mildest ocular features 2

Common Pitfalls and Caveats

• Insufficient treatment duration: Many studies evaluating rosacea treatments lasted less than 8 weeks, which is considered inadequate to demonstrate efficacy of many interventions 1
• Subtype-based treatment: Treating based on traditional subtypes rather than phenotypes may lead to inadequate management of the full spectrum of presenting features 1
• Overlooking maintenance therapy: Without proper maintenance, relapse is common 3
• Ignoring ocular manifestations: Ocular rosacea is often underdiagnosed and undertreated 2
• Skin irritation: Some topical treatments may cause irritation, particularly in patients with sensitive skin associated with rosacea 5