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Low dose isotretinoin for recalcitrant rosacea: I pledge to use it sporadically

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By Warren R. Heymann, MD
June 14, 2016

While rosacea can usually be reasonably managed with a combination of topical agents (metronidazole, azelaic acid, ivermectin, sulfacetamide, brimonidine), oral antibiotics (the tetracycline family), vascular lasers, intense pulsed light and surgery (for phymatous disease), some cases are recalcitrant to standard therapy.

Sbidian et al performed a double-blind, randomized, placebo-controlled trial comparing oral isotretinoin (0.25 mg/kg/day in 108 patients) with placebo (48 patients) for difficult-to-treat papulopustular rosacea. The primary endpoint after 4 months of therapy was the response rate (at least 90% reduction of papulopustules compared to baseline). The results were that 57.4% of patients treated with isotretinoin reached the primary endpoint, compared to 10.4% taking placebo — a highly significant finding. Rosacea relapsed in 27 (58.3%) of 51 patients who agreed to be followed for an additional 4 months. The median time for recurrence was 15 weeks. The authors concluded that low-dose isotretinoin is an effective therapeutic option for rosacea that fails to respond to standard therapy. They recommend further research to determine the minimal effective isotretinoin dose to maintain remissions (1).

In the accompanying editorial by van Zuuren and Federowicz, the following were considered: 1) isotretinoin has been used off-label for rosacea since the 1980s; and 2) the mechanism of action of isotretinoin in rosacea is its effect on the pilosebaceous unit by down-regulation of the Toll-like receptor 2 expression (2).

Once in a great while I have prescribed isotretinoin for recalcitrant rosacea. (For rosacea fulminans, it is my treatment of choice.). While it is reassuring to finally have a well-designed study confirming the efficacy of isotretinoin, it is difficult to get too excited about it for two reasons: 1) as opposed to acne, isotretinoin is suppressive in rosacea, not curative; and 2) iPledge. If isotretinoin was curative for rosacea, it would be worth the hassle of prescribing it more frequently. As long as we need to go through the iPledge rigmarole, however, isotretinoin will remain a treatment option only when all else fails for my rosacea patients.

1. Sbidian E, et al. A randomized-controlled trial of oral low-dose isotretinoin for difficult-to- treat papulopustular rosacea. J Invest Dermatol 2016; 136: 1124-9.
2. van Zuuren EJ, Federowicz Z. Low-dose isotretinoin: An option for difficult-to-treat papulopustular rosacea. J Invest Dermatol 2016; 136: 1080-3.

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