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Prescription Medications that may be Harmful to Rosacea Sufferers
Topics Discussed Below
- Topical retinoids (tretinoin)
- Caution on other topical retinoids and retinoid-like compounds
- Azelaic acid
- Benzoyl peroxide (prescription-based cleansers and creams)
Many anti-acne products
are known to worsen rosacea symptoms. Medical experts strongly urge
rosacea sufferers to stop using these products. There are several
classes of topical prescription medications that rosacea sufferers
should not use because the risks far out way their benefits.
II. Topical Retinoids
Topical retinoids such
as retinoic acid and Vitamin A derivatives are used for the treatment
of acne. Many general dermatologists also use topical retinoids
to treat rosacea papules and pustules. There is mounting evidence
indicating that topical retinoids such as tretinoin should not be
used for treating rosacea papules or pustules because they make
the underlying vascular disease worse. In a recent medical review,
"Rosacea: Pathophysiology and Treatment", Dr. Jonathan
Wilkin discusses numerous reasons why rosacea patients should not
use topical retinoids such as tretinoin: (114)
- He states, "Tretinoin may provoke severe erythema in
patients with rosacea."
- He further cautions that with tretinoin therapy, "Flushing
reactions will have a more intense redness, and there will be
an enhancement of the inflammatory process."
- Dr. Wilkin stresses, "Irritation from the tretinoin
may directly exacerbate the underlying inflammatory reaction."
- He also warns, "Tretinoin may cause angiogenesis in
the rosacea distribution. The tretinoin-induced erythema may mask
the worsening angiogenesis and telangiectasia. I have seen several
patients who have bright red faces during treatment with topical
- He ends his discussion on tretinoin by stating, "Since
rosacea appears to be in its most fundamental elements a vascular
disorder, it would be wise to first do no harm."
III. Caution on
Other Topical Retinoids and Retinoid-Like Compounds
Due to their irritant
qualities, extreme caution must be given to all topical forms of
retinoic acid and vitamin A derivatives. Newer formulations have
been developed to lessen the potential for irritation; however,
these are still too harsh for many rosacea sufferers. Below are
a few quotes on the irritant qualities of these newer formulations:
- Retin-A Micro(tretinoin gel, Ortho Pharma-ceutical
Corporation): Although this newer gel was designed to be less
irritating, Retin-A Micro is still irritating to sensitive
skin. The Physicians' Desk Reference (2000) warns, "The
skin of certain individuals may become excessively dry, red, swollen,
or blistered," and that, "A transitory feeling
of warmth or slight stinging may be noted on application".
Additionally, it is warned that, "Weather extremes, such
as wind or cold, may be irritating to patients being treated with
- Avita (tretinoin gel, DPT Laboratories): The Physicians'
Desk Reference (2000) warns that, "The skin of certain
individuals may become excessively red, edematous, blistered,
or crusted", and that, "Application may cause
a transient feeling of warmth or slight stinging". Additionally,
it is warned, "Some patients also notice that their skin
begins to take on a blush".
- Differin (adapalene gel, Galderma Labor-atories,
Inc.): The Physicians' Desk Reference (2000) warns that
during treatment with this retinoid-like gel, "Some adverse
effects such as erythema, scaling, dryness, pruritus, and burning
will occur in 10-40% of patients", and that, "Weather
extremes, such as wind or cold, may be irritating to patients
under treatment with adapalene".
IV. Azelaic Acid
Azelaic acid is a dietary
substance derived from whole grain cereals that can be used topically
for the treatment of acne. Although a few studies demonstrate that
azelaic acid is effective in the treatment of rosacea papules and
pustules, there is evidence indicating that this treatment is very
irritating to rosacea skin. In a recent medical study investigators
found that topical azelaic acid caused adverse skin reactions in
40% of the rosacea patients (30 out of 76 patients). (137) These
reactions included, "Burning, skin irritation, stinging,
itching, facial edema, and scaling." Furthermore, before
the actual study began, 5 patients dropped out because azelaic acid
caused one or more of the following skin reactions: "Burning,
erythema, skin irritation, and contact dermatitis." As
discussed earlier in this chapter, rosacea experts stress that any
topical product that causes adverse skin reactions should be avoided.
V. Benzoyl Peroxide
(Prescription cleansers or creams)
Benzoyl peroxide is a
popular medication that is used for acne blemishes. Rosacea experts
caution that benzoyl peroxide usually worsens rosacea because it
is very irritating and drying to sensitive facial skin. (130, 136)
In a recent rosacea review article, "Recognizing Rosacea",
Dr. Millikan from the Department of Dermatology, Tulane University
Medical School, indicates that benzoyl peroxide should never be
used on rosacea skin. (136) In fact, Dr. Millikan indicates that
benzoyl peroxide can actually induce rosacea in some patients. In
cleanser or cream form, benzoyl peroxide should be avoided in most
110. National Rosacea
Society. "Rosacea Review". Summer. 1996. Drake,L.
111. Wilkin, J.K. Rosacea. Int J Dermatol 22: 393-400,
112. Gifford-Jones. "That rosy blush may be bad". Inside
Health Column, 1998.
113. Wilkin, J.K. "Recognizing and managing rosacea".
Drug Therapy 41-45, 1993.
114. Wilkin, J.K. Rosacea. Pathophysiology and treatment. Arch
Dermatol 130: 359-362, 1994.
115. De Kort, W.J. and A.C. De Groot. Clindamycin allergy presenting
as rosacea. Contact Dermatitis 20: 72-73, 1989.
116. National Rosacea Society. "Rosacea Review". Spring.
117. Plewig, G. and A.M. Kligman. Rosacea. In: Acne and Rosacea,
edited by G. Plewig and A.M. Kligman. Berlin: Springer-Verlag,
1993, p. 433-475.
118. National Rosacea Society. "Rosacea Review". In:
edited by J.K. Wilkin. 1994.
119. National Rosacea Society. "Rosacea Review". Fall.
120. Prins, M., O.Q. Swinkels, E.G. Kolkman, E.W. Wuis, Y.A. Hekster,
and d. van, V. Skin irritation by dithranol cream. A blind study
to assess the role of the cream formulation. Acta Derm Venereol
78: 262-265, 1998.
121. De Groot, A.C., J.W. Weyland, and J.P. Nater. "Toxic
and irritant contact dermatitis". In: Unwanted effects
of cosmetics and drugs used in dermatology, edited by A.C.
131. Ale, S.I., J.P. Laugier, and H.I. Maibach. Differential irritant
skin responses to tandem application of topical retinoic acid
and sodium lauryl sulphate: II. Effect of time between first and
second exposure. Br J Dermatol 137: 226-233, 1997.
132. Webster, G.F. Acne and rosacea. Med Clin North Am
82: 1145-54, 1998.
133. Schaller, M., R. Steinle, and H.C. Korting. Light and electron
microscopic findings in human epidermis reconstructed in vitro
upon topical application of liposomal tretinoin. Acta Derm
Venereol 77: 122-126, 1997.
134. Matsuoka, L.Y. "Acne and related disorders". Clin
Plast Surg 20: 35-41, 1993.
135. Landow, K. "Dispelling myths about acne". Postgrad
Med 102: 94-4, 110, 1997.
136. Millikan, L. Recognizing rosacea. Postgrad Med 105:
137. Bjerke, J.R., O. Fyrand, and K. Graupe. "Double-blind
comparison of azelaic acid 20% cream and its vehicle in treatment
of papulo-pustular rosacea". Acta Derm Venereol 79(6):