Tips for Physicians to Increase Adherence to Rosacea Therapy

Have you ever seen a patient’s life seemingly changed by treating their condition? For patients with rosacea, it can be terribly embarrassing, especially because of the age group it affects.¹ Many adjust their work schedules and their social lives, making changes to their life because their face is red or bumpy, or both. When you can treat somebody and clear up those things enough that they are not having to make major adjustments to their life and schedule, you have a big impact on their quality of life. It is not infrequent for an adult patient to get a little bit teary-eyed about how their rosacea bothers them. For example, one of my patients, a male attorney who was frequently in the courtroom, was mortified because of his enlarged red nose that was always full of bumps. When we were able to make that better, it changed his life.

But we also know that adherence can be an issue. One of our main goals is getting our patients with rosacea as close to clear as we can. Not only does this improve their quality of life, but it also makes maintenance therapy easier for them. Although a patient may be able to have an alternative treatment plan after getting clear, they still need to remain consistent with it, even if it is every other day. Part of our job is educating patients that they are going to need to stay on long-term treatment. What can we do to help our patients be comfortable with their treatment plan and increase adherence?

The Impact of Recent Research

For a long time, we only used metronidazole to treat rosacea. This is still a good medication, but it was never intended to treat every facet of rosacea. Some patients think their rosacea is just not treatable or manageable because they had 1 treatment a long time ago that was trying to treat every characteristic of the disease. We now recognize that we need to target treatments to all the pathogenesis and to all the physical components we see clinically, and this typically means combination therapy.

From a dermatologist’s point of view, patients come into the clinic, and they say, “I have rosacea.” They have already done some homework online and a lot of times they are right, but it is our job to really identify everything they have. Matching the treatment with the patient’s signs and symptoms is imperative. One of the critical things to remember is that there is not one medication or one recipe that is going to work for every patient because
rosacea is not all one thing. If you have a patient who has bumps, then there is a list of potential US Food and Drug Administration (FDA)–approved medications for that component. However, if you have a patient who is more concerned about redness, you have to delve a little bit deeper. Is the redness flushing or blushing? Is it broken blood vessels? Is it background redness? And then we can consider the medications for that facet of disease.

For patients with bumps, the only FDA-approved oral medication to treat rosacea is modified-release doxycycline, 40 mg once a day.² There are some other oral medications that have been studied off-label, such as different doses of doxycycline; the newer sarecycline, which has been shown in 1 small study to be beneficial;³ and sometimes we even use isotretinoin. Topically, we have topical ivermectin; topical metronidazole, which comes in different types of vehicles and generics; topical azelaic acid, which comes as a gel or foam; the old-school sodium sulfacetamide and sulfur products; and the relatively new topical minocycline foam.² And then we have an encapsulated benzoyl peroxide that is coming.⁴

For patients with redness, we have a much smaller list. There are only 2 products that are FDA approved for redness: topical oxymetazoline cream and topical brimonidine gel.² There are some medications we can use off-label. For example, if the patient has flushing or blushing, we can use oral ß-blockers; if they have broken vessels, we can use lasers and energy-based devices.²

We are also learning more about comorbidities through researching large databases, which point to links such as migraines, Parkinson disease, Alzheimer disease, basal cell carcinoma, thyroid cancer, and several gastrointestinal illnesses.⁵ Although we do not know exactly what this information means at this point, it does give us an indication that maybe the inflammatory response happening in rosacea is a bigger systemic inflammatory response than we first thought. This is something we will be learning more about.

The Adherence Challenge

Adherence to therapy can be a challenge for patients with rosacea for a variety of reasons. Number 1, I think it is just human nature to not be as diligent as we should be. Number 2, I think often patients have had inadequate control of their disease before, so they come in to get another opinion and treatment plan with low expectations, and they do not always give the medications enough time to work. And number 3, which we do not like to admit, is that sometimes we may be in a hurry, and we do not really emphasize the importance of consistent treatment and long-term maintenance therapy—because rosacea does not go away. I think cost may also play a role in nonadherence to treatment. Especially now, patients are buying gas to get to and from clinic visits, and they may want to save money on their prescriptions by using them less frequently. For example, maybe they try to go to every other day or every 3 days.

The best chance we have for adherence is getting the treatment plan right the first time; however, if you have a patient who is having difficulty with adherence, find out why. There might be a very good reason why they are not adhering to the treatment plan. For example, the patient may say, “I do not like the way the gel feels,” or “This product is too expensive.” Whatever the reason, we can make adjustments.

Tips for Success

First, start off strong by tailoring the treatment to the patient’s signs and symptoms. If you have a patient who is only concerned about redness, then you are probably doing them a disservice if you give them a medication that only treats bumps. Because we all know that as soon as our patients see some improvement, we have a chance to get them to really stick with us.

Setting expectations at the first visit is also essential. I like to tell my patients, “My goal is to get you as close to clear as I possibly can.” I let them know that it will probably take more than 1 visit and it may take more than 1 treatment plan because if the first plan does not work, we will need to adjust. Talk about maintenance and how critical maintaining treatment is going to be. This is where follow-up appointments come into play. These are not patients to whom you can say, “Call me back if you are having a problem.” I tell my patients, “I want to see you back in the clinic in 6 to 8 weeks because I want to see how you are doing.”

Another crucial element is listening to your patients. If your patient says their last doctor put them on a medication that did not work well, or it stung or burned, or their insurance did not pay for it, we need to hear that and learn from it. We do not want to repeat what did not work because we want our patients to know that we are truly their advocates. Providing patient-oriented resources can also help increase adherence. For example, the National Rosacea Society’s website has educational information for patients, including what to expect from their treatment plan, when they should contact their doctor, what they need to know about skin care, and a list of common triggers to avoid.⁶

Overall, the first rosacea visit is not a short one. We need to cover a lot, such as assessing the patient and seeing what signs and symptoms they have, coming up with a treatment plan,
talking about skin care and sun protection, discussing triggers, looking into access to the medication and its cost, sharing expectations for when they should see improvement and encouraging them not to quit in 2 weeks, and of course scheduling the follow-up appointment.

In a fast-paced clinic, it can be easy to leave something out of the first visit, so I came up with the mnemonic STOP:

• S: Look for signs and ask about symptoms.

• T: Discuss triggers.

• O: Determine what outcome is important to the patient, such as getting rid of bumps or being less red.

• P: Develop a plan, including medication, skin care, sun protection, and follow up.

Adherence Is a Two-Way Street

We may start out thinking that adherence is all a patient issue, but it is actually a two-way street. We want our patients to have confidence in us and believe that we want to make them better. We need to say, “I hear you, and I hear what did not work before, and I hear what your triggers are. And because of all of that, here is what we are going to do. I know you do not want to be better; you want to be clear. But you have got to stick with me. I may not be able to do it in our first 8 weeks, but that is where we are headed.” Building rapport and trust through the patient-provider relationship and demonstrating empathy are key aspects of making patients better. When we start with that foundation, we set our patients up for successful outcomes.

References
1. Rosacea awareness month: partner with your physician for clear skin. News release. National Rosacea Society. April 1, 2022. Accessed April 6, 2022. https://www.rosacea.org/press/2022/april/rosacea-awareness-month-partner-with-your-physician-for-clear-skin

2. FDA approved treatments for rosacea. National Rosacea Society. Accessed April 6, 2022. https://www.rosacea.org/patients/management-options/fda-approved-rosacea-treatments

3. Rosso JQ, Draelos ZD, Effron C, Kircik LH. Oral sarecycline for treatment of papulopustular rosacea: results of a pilot study of effectiveness and safety. J Drugs Dermatol. 2021;20(4):426-431. doi:10.36849/JDD.2021.5923

4. Bhatia N, Lain E, Baldwin H, Brantman S, Del Rosso J, Sivamani R. Encapsulated benzoyl peroxide (E-BPO): a novel formulation of BPO for long-term management of rosacea. J Cutaneous Med. 2022;6(2):s14. https://doi.org/10.25251/skin.6.supp.14

5. Haber R, Gemayel ME. Comorbidities in rosacea: a systematic review and update. J Am Acad Dermatol. 2018;78(4):786-792.e8. doi:10.1016/j.jaad.2017.09.016

6. Patient education materials. National Rosacea Society. Accessed April 6, 2022. https://www.rosacea.org/physicians/patient-education-materials

Disclosure: The author has received speaker honoraria from Almirall, Ortho Dermatologics, EPI Health, Vyne Therapeutics, and Galderma. She has been a paid consultant or paid advisory board member for Cutera, Almirall, Sun Pharmaceuticals, La Roche-Posay, Ortho Dermatologics, EPI Health, BioPharmX, Cassiopeia, Cutanea, Vyne Therapeutics, Galderma, Dermira, and Sol-Gel.