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Paradoxical Erythema Reaction to Long-Term Brimonidine Gel for Facial Erythema of Rosacea
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This case report describes a paradoxical erythema reaction in a Caucasian woman with Fitzpatrick type II skin who successfully used topical brimonidine gel for 2 years for the treatment of rosacea facial erythema. With the onset of the reaction, she initially developed pruritic papules, then bilateral, burning erythematous patches of the infraorbital, upper malar, and bilateral zygoma regions without urticarial, scaling, or edema.
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The reaction resolved upon discontinuation of brimonidine gel.
– Anna Wile, MD
abstract
This abstract is available on the publisher's site.
Access this abstract nowIn 2013 brimonidine tartrate gel 0.33% (Mirvaso Gel, Galderma Laboratories, LP, Fort Worth, TX) was approved by the US Food and Drug Administration for the treatment of facial erythema of rosacea. It is the first and only drug on the market to address the hallmark redness of this chronic, inflammatory disease. Commonly reported adverse events include erythema/flushing worse than at baseline, most often occurring with the first application. We report a unique case of facial erythema of rosacea that responded to brimonidine gel with effective blanching for two years until the patient developed a paradoxical erythema reaction. This is an adverse reaction physicians should be aware of with continued prescription of brimonidine gel for their rosacea patients.
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Paradoxical Erythema Reaction of Long-Term Topical Brimonidine Gel for the Treatment of Facial Erythema of Rosacea
J Drugs Dermatol 2016 Jun 01;15(6)763-765, E Lowe, S LimFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
A new drug with a new mechanism of action, topical brimonidine, provides the clinician with a new tool to treat previously unmanageable problems, such as diffuse facial redness of rosacea. However, when taking a new class of therapeutic agents to the clinic, practitioners need to be aware of the potential for side effects that are not necessarily well-characterized in the initial clinical trials. This case report highlights one such example.
The patient with paradoxical erythema following 2 years of use exhibits an unusual side effect of this alpha-2 adrenergic agonist. A small, but not well-characterized group of patients display redness with inflammatory changes usually 3 to 6 hours after application of this drug. This reaction is self-limited and usually resolves within 24 to 48 hours after brimonidine is discontinued. In the long-term trials of this agent, this side effect was seen, albeit typically early in the treatment course, but was not well-described in the publication. Once the paradoxical erythema subsided, some patients were able to resume therapy without recurrence of this problem.
A number of mechanisms might be responsible for this problem. The patient in the case report was using brimonidine in twice the recommended applications per day. Perhaps a large dose of this drug or a reservoir effect of this agent was responsible for an unusual vascular event. Alternatively, there are alpha receptors on immune cells such as macrophages and mast cells that could theoretically cause an unusual inflammatory event.
Historically in dermatology, we have had agents such as topical retinoids that have bothersome adverse side effects. We learned to recognize and prevent the problems with this class of drug, permitting the agents to have a very important place in the treatment of acne. It behooves us to utilize newer therapeutic agents and to observe and characterize the side effects that appear. Brimonidine is an important addition to our therapeutic tool kit. Its side-effect profile appears to be manageable, but needs to be better understood and characterized.