Frequency of Flushing with Topical Brimonidine
Topical brimonidine causes flushing or worsening erythema in approximately 10-20% of patients treated for rosacea, with this adverse effect most commonly occurring after the first application. 1
Evidence from Clinical Practice and Trials
The frequency of flushing with topical brimonidine varies based on the indication and formulation:
For Rosacea (Brimonidine 0.33% Gel)
Real-world clinical experience demonstrates that approximately 10-20% of rosacea patients experience worsening erythema or flushing when treated with brimonidine gel 0.33% 1
This adverse reaction is most frequently observed with the first application of the medication 2
The flushing reaction has been described as "paradoxical erythema" and can occur even after prolonged successful use—one case report documented effective blanching for two years before the patient developed this reaction 2
Clinical trials supporting FDA approval showed brimonidine had clinically significant efficacy with good safety data, though the specific percentage experiencing flushing was characterized as mild and transient skin-related adverse reactions 3
For Glaucoma (Ophthalmic Brimonidine)
- When used as ophthalmic drops for glaucoma, dermatological side effects including periorbital contact dermatitis have been reported, though these are rare and typically occur after more than six months of use 4
Clinical Context and Management Implications
Important distinction: The panel of rosacea experts noted that the term "rebound" has been used to describe several physiologically distinct events, and they recommend more specific terminology for different types of erythema worsening 1
The flushing reaction should be differentiated from:
- True rebound erythema (return of baseline redness)
- Paradoxical worsening beyond baseline
- Transient application-site reactions 1
Patient counseling is critical: Setting appropriate expectations before initiating treatment and having strategies to optimize treatment initiation can minimize problems with this 10-20% incidence of flushing 1