Evidence based update on facial redness

Dr Jennifer Leung and I are away to Noosa attending the 17th Annual Scientific Conference of the Australasian College of Phelbology (ACP). This is a very exciting conference as it is the premier meeting in Australasia regarding the treatment of vein disease every year. We are particuarly looking forward to talks by Prof Kurosh Parsi, who is the president of ACP and Jennifers mentor. We also eagerly await talks by Prof Alan Davies from the UK and Prof Andre Van Rij from New Zealand. A number of other local and international experts will be presenting their views.

I will write about latest developments and insights from the conference. At the conference all things vascular were discussed. One of the items on the agenda that was of great interest to me is the treatment of rosacea.

Topical vasoconstrictor for the treatment of rosacea

One of the sessions that I attended today was on the pharmacological treatment of rosacea, particularly in relation to the topical vasoconstrictor that came on the market recently. Therapeutic Goods Administration rule precludes us from mentioning this medication by name.

Most forms of rosacea involve facial redness. This has several different components. Diffuse facial redness is commonly seen. Against this backdrop of dermal redness, there may be telangiectasia (spider veins) and inflammatory lesions (red bumps).

Whilst telangiectasia and inflammatory lesions can be treated with laser and antibiotics respectively, the management of diffuse redness can be more difficult. It is often the diffuse redness that is the most distressing to the patient.

Although there have been major advances in the understanding of the pathology behind the development of rosacea, we still do not know what causes it. What we do know is that diffuse facial redness is caused by dilated blood vessels in the dermis. A certain type of muscle (smooth muscle) is present in the walls of dermal blood vessels. The smooth muscle is responsible for controlling the diameter of blood vessels, such that blood vessels can dilate (increase in diameter) to allow us to dissipate heat when we are hot, and constrict when we are cold.  It is this smooth muscle that is targeted by the recently available topical vasoconstrictor.

In randomized double blind placebo trials to measure the effectiveness of this medication, 2 scoring systems were used: Clinician Erythema Assessment (CEA) score and Patient Self Assessment (PSA) scale. An improvement in these scores by 1 is already a significant clinical improvement. To obtain FDA approval, an improvement in these scores by 2 points is needed. This medication was able to demonstrate 1-2 points improvement in either of these scoring systems in over 70% of patients.

From our experience with other vasoconstrictors, we wanted to make sure that this medication does not exhibit 2 characteristics. These are tachyphylaxis, whereby the facial redness responds less well to the medication over time, and rebound phenomenon, where facial redness comes back with a vengeance if the medication is stopped. It has been demonstrated by clinical trials that these characteristics occur with a frequency of less than 5%.

The onset of action is rapid (within 30 minutes), and the duration of action is up to 12 hours. This makes it useful for going out, events and so on. It is possible to apply this gel half an hour before a proposed event with a significant decrease in facial redness.

Are there any downsides to this medication?

In the short answer, yes. It appears that in about 10% of users, there is paradoxical worsening of their facial redness. This can happen quite quickly, it can happen when the effect of the medication wears off after 12 hours. In less than 1% of cases, the redness can also be due to the development of contact allergic dermatitis.

Whilst this topical medication works well for diffuse facial redness, it has little or no effect on telangiectasia and inflammatory lesions. Sometimes, these can become more visible as they stand out against the paler background skin.

How does it compare to other medical treatment?

This topical medication is currently the only agent that allows rapid but short term symptomatic improvement for diffuse facial redness. The other medications available work better for the inflammatory component. The different medications therefore compliment each other.

How does it compare to laser treatment?

Again, the topical vasoconstrictor medication has rapid onset and provides short term improvement. It has no effect on the larger vessels. Vascular laser and intense pulse light (IPL) on the other hand are highly effective in ablating these larger vessels. In addition, Laser Genesis encourages collagen remodeling and has a much longer term influence on reducing facial redness. They are therefore also complimentary to one another.

Where does it all fit in?

Based on our experience and the current evidence, I consider this medication to be a very good option for short term symptomatic improvement of facial redness. It is particularly useful in that it can be applied 30 minutes before attending an event or going out. Most people will experience a favourable response. However, in view of the risk of a paradoxical worsening of the redness, it may be worthwhile doing a test patch first.

For significant inflammatory component, I would still recommend other medical treatments such as topical azelaic acid, topical or oral antibiotics.

Vascular laser, IPL and Laser Genesis remains the mainstay of treatment for the larger vessels, and for longer term improvement in facial redness.

For further information on facial redness, please call us on 6255 8988 or request an appointment.

Site Images / Mirvaso Facebook Cover (large)