From the Cochrane LibrarySystematic review of rosacea treatments
Section snippets
Methods
A systematic review of randomized controlled trials (RCTs) was performed according to a prespecified protocol.1
Description of studies and methodologic quality of included studies
Searches identified 71 possible RCTs. A total of 29 RCTs were included.21, 22, 23, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 Breneman et al34 and Leyden et al51 described different outcome measures of the same study and Thiboutot et al49 reported two RCTs in one publication. Most of the participants in the included studies had papulopustular rosacea and were between 40 and 50 years old; only two studies27, 28 addressed ocular rosacea.
Topical metronidazole versus placebo
Nine trials assessed the efficacy of topical metronidazole versus placebo.21, 27, 29, 30, 32, 33, 38, 39, 42 The treatment period ranged from 8 to 9 weeks in each trial, except for that of Dahl et al,21 which was 6 months. Three studies addressed self-assessed improvement of rosacea severity.30, 32, 42 Only data from two studies30, 42 could be pooled (Fig 1, A) and there was clear evidence that metronidazole was more effective than placebo. Bleicher et al32 confirmed these data (OR 7.0; 95%
Oral metronidazole versus oral oxytetracycline
In one study, oral metronidazole and oral oxytetracycline were not statistically different at 12 weeks by both physician and patient assessment.45 No adverse events were reported in either group.
Tetracycline versus placebo
One trial28 compared oral oxytetracycline with placebo, and in two trials40, 47 oral tetracycline was compared with placebo. These are both (older) tetracyclines with a similar molecular structure and the same pharmacokinetic and pharmacodynamic profile and so the results were pooled. Study duration
Azelaic acid versus placebo
Four trials compared azelaic acid with placebo.31, 35, 49 The treatment period ranged from 9 to 12 weeks. Three studies31, 49 showed a clear improvement in the azelaic acid group as rated by both physicians and patients (Fig 1, C). A split-face, within-patient study35 confirmed these results (marginal OR 30.1; P < .0003).
The data on lesion counts did not include variability and the data in the study by Carmichael et al35 were skewed.
More side effects were reported in the azelaic group (11.5%)
Benzoyl peroxide 5%/clindamycin 1% gel versus placebo
The mean scores at 12 weeks for patient's global assessment in the study of Breneman et al34 were 1.54 (much to slightly better) in the benzoyl peroxide and clindamycin group versus 2.50 (slightly better to same) in the placebo group (authors state P = .0002). The mean scores at 12 weeks for physician's global assessment were 1.85 (marked to definite improvement) versus 2.96 for placebo (minimal improvement) (authors state P = .0026).
The data showed large variability and some data were missing.
Benzoyl peroxide acetone versus placebo
At 4 weeks, benzoyl peroxide showed an improvement on the physician's global evaluation score compared with placebo (OR 3.17; 95% CI 1.08-9.31).41 The other measurements were also in favor of benzoyl peroxide (P < .05). Irritation and burning were frequently reported in both groups.
Oral metronidazole and topical hydrocortisone 1% cream versus oral placebo and topical hydrocortisone 1% cream
The physicians considered 10 of 14 participants treated with oral metronidazole improved versus only 2 of 13 participants on placebo (OR 13.75; 95% CI 2.05-92.04).44 Only limited data were given in this study.44
Rilmenidine versus placebo
Both
Discussion
There were significant limitations in the quality of evidence available for most treatments. Although the clinical design of the included studies was in theory adequate, closer examination revealed that the quality of reported data was often low. Table III, Table IV summarize recommendations for future rosacea studies.88 It should be noted that although split-face studies can be efficient, they are subject to potential biases. Contamination may occur if active cream is accidentally transferred
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Cited by (71)
Aspirin alleviates skin inflammation and angiogenesis in rosacea
2021, International ImmunopharmacologyCitation Excerpt :The role of LL37 in rosacea was further confirmed by using a murine model where intradermal injection of LL37 on back skin of mouse resulted in inflammation, angiogenesis and telangiectasia, which mimicked the clinical and histological features of human rosacea [13]. Various therapeutic modalities are emerging in the treatment of rosacea, including tetracyclines, ivermectin, metronidazole, azelaic acid, and vascular lasers [4,15]. These treatment options for rosacea have been mainly reliant on their anti-inflammatory or anti-angiogenic effects.
Consensus on the therapeutic management of rosacea – Brazilian Society of Dermatology
2020, Anais Brasileiros de DermatologiaCitation Excerpt :It is relevant to emphasize that, although there is no cure, total improvement and long periods of remission are possible; in mild to moderate cases, topical treatments have a good level of confirmatory evidence and may be sufficient. The most cited topical treatments in the literature are: 0.75% metronidazole in gel or cream and 1% in cream; azelaic acid 15% gel or 20% cream; α-1 adrenergic receptor agonists (brimonidine tartrate 0.5% gel and oxymetazoline 1% cream); and ivermectin 1% cream.53–57,59 Although not yet commercialized in Brazil, 4% topical minocycline foam has also been described in the recent literature.59
Skin Diseases (Noncancerous)
2016, International Encyclopedia of Public HealthRosacea and rhinophyma
2014, Clinics in DermatologyNew insights into rosacea pathophysiology: A review of recent findings
2013, Journal of the American Academy of Dermatology
Funding sources: None.
Conflicts of interest: None identified.
This manuscript is based on an earlier publication by van Zuuren et al,1 copyright Cochrane Library, reproduced with permission.