Joslyn Kirby, MD, currently serves as associate professor of dermatology; director of the dermatology residency program; and vice chair of education at Penn State University in Hershey, PA. In her clinical and research work, she is interested in acneiform conditions including acne, rosacea and hidradenitis suppurativa. She spoke with The Dermatologist about recent developments in rosacea diagnosis and treatment.
Q: In your presentation at the Winter Clinical meeting, you stated that the definition of rosacea is expanding. How so?
A: The classification for rosacea when I was coming up through dermatology was more rigid. When the classification was updated in 2018,1 it added flexibility for us as practitioners. It aligns better with all the variation we see in our clinical practice. The new classification helps me feel more confident that what I am seeing in my clinic, I do not have to make it fit perfectly into one of those subtypes listed in older literature.
It also acknowledges some of the new things we are learning about the mechanisms. Some of the redness is not just vascular dilation but inflammation, sometimes, neurogenic inflammation. We previously thought of nerves as having an effect on the size of vessels and contributing to redness in that way, but nerves can also instigate inflammation.
Q: What stands out in terms of triggers for this disease?
A: Many of the things our patients tell us worsen their rosacea—heat, alcohol, UV light—are triggers of the innate immune system in the skin and it is overactive in people with rosacea. People want to understand why they have a skin condition, and a lot of them worry that a part of them is ‘not working’ or underperforming. Sometimes I reframe my explanation about rosacea to highlight for people that their immune system is actually working too well.
Q: What has been the most significant recent change in treatment options?
A: Topicals are still a mainstay of therapy, and may work outside their ‘label.’ For example, metronidazole is approved for inflammatory lesions of rosacea, but part of what causes the flat or patchy erythema is also inflammation, so the topical works for both findings. This impacts how we counsel our patients because if we see a patient who is experiencing both, we can counsel them that the topical medication may treat both findings.
One of the other big things is combining topicals and orals. It is a similar approach to what we use for acne, where we can use an oral antibiotic in combination with topicals. Together, they work better than either one alone, then after 2 to 3 months the oral antibiotic is stopped and the topical can reduce the chance of a flare.
Q: Is antibiotic resistance a concern? You stated that nearly 80% of courses matched recommendations but about 20% were longer.
A: We need to understand why antibiotics are being used longer. It could be a sign that a subset of patients is really having trouble controlling their condition with the available tools and we need more tools or options.
Part of why I think I had some patients on longer courses was to manage the inflammation that causes ocular rosacea. But, there are other options for ocular rosacea that we, as dermatologists, currently use for the cutaneous aspects of rosacea—topicals and laser and light therapies, which can also help with the ocular inflammation.
Q: How have you changed the way you treat ocular rosacea?
A: I have my patients use the topicals on the lower lid, just like they do on the other parts of their face. Also, for laser and light therapies, which we use on the face to treat rosacea, the same modalities can be applied in a fan shape on the lower lid and have been shown to treat ocular rosacea. Intense pulsed light therapy (IPL) was sort of a happy accident, because a patient was having IPL for cutaneous rosacea noticed her eye symptoms were better. Follow up studies confirmed it again and again.
Q: Any other techniques that are effective?
A: There is data that cyclosporine eyedrops are better than the oral doxycycline and saline eye drops. They are safe and well-tolerated, but I didn ot feel comfortable prescribing them because I had not read the data and I did not know how to counsel people on how to use them and what to expect. Luckily, I have an ophthamologist friend who coached me through it. I learned that, a small proportion of people get mild stinging for about 3 to 4 minutes during the first week of use. The stinging goes away on its own in a few minutes. Also, after a week the stinging stops happening. This felt a lot like the talk I already have related to topical tacrolimus and pimecrolimus for other conditions, making it easier for me to add into my practice.
Q: What do you see as the greatest challenge regarding the use of topicals?
A: There is a paucity of studies on how to use combination topicals: How to combine topicals to maximize patient outcomes, and when doing so will not make a difference. We do not want people to pay for 2 medications if it is not going to work better.
Q: What is the biggest misconception about rosacea?
A: The idea that drinking causes rosacea is an urban myth, and abstaining is not totally protective. Alcohol continues to be a trigger for people who are predisposed, but not all types of alcohol are going to trigger flushing in the same way for every person. For some people red wine is worse, but that’s not true for everyone. Sometimes it is nice to be able to tell people that they do not have to give up the things they enjoy in life because of this condition.
Reference
1. Gallo et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018; 78(1): 148-155. doi:10.1016/j.jaad.2017.08.037.
