Brimonidine effective but may lead to significant rebound erythema
Authors: Dan Ilkovitch, Rebecca G. Pomerantz
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: The alpha-2 adrenergic agonist brimonidine (Mirvaso) 0.33% gel was approved by the US Food and Drug Administration in 2013, for the topical treatment of persistent facial erythema of rosacea, in adults 18 years of age or older. Reported adverse reactions include erythema, flushing, skin-burning sensation, and contact dermatitis. We report a case of facial erythema of rosacea that responded well to this medication, however, rebounded with significantly greater erythema than baseline for the patient. A 29-year-old white woman with erythematotelangiectatic rosacea involving cheeks and chin presented for a trial of brimonidine for persistent facial erythema. The patient had skin phototype I (Fitzpatrick), and in addition to persistent erythema had occasional flushing. Flushing in this patient was triggered typically by caffeine intake, spicy foods, and temperature changes. The patient applied a thin layer of brimonidine 0.33% gel to her entire face in the morning, and within 1 to 2 hours had complete blanching of treated facial skin (Fig 1). This effective blanching lasted for approximately 10 to 12 hours after application. However, 12 hours after application facial erythema recurred and was significantly increased from baseline, involving the cheeks, chin, nose, and forehead. This increased rebound erythema lasted for an additional 12 to 14 hours before facial erythema regressed to baseline levels. The patient trialed topical application of brimonidine 2 additional times, and had similar outcomes. Rosacea is a common condition, and various subtypes are recognized including erythematotelangiectatic, papulopustular, phymatous, and ocular rosacea.1Crawford G.H. Pelle M.T. James W.D. Rosacea, I: etiology, pathogenesis, and subtype classification.J Am Acad Dermatol. 2004; 51 (quiz 42-4): 327-341Abstract Full Text Full Text PDF PubMed Scopus (467) Google Scholar Various treatments are available but must be tailored to the individual patient, depending on the subtype of rosacea. One of the more difficult aspects to treat is the facial erythema of rosacea, which is thought to have a complex pathogenesis involving altered blood flow, vascular dilation and proliferation, and permanent dilation of superficial vessels.2Del Rosso J.Q. Management of facial erythema of rosacea: what is the role of topical alpha-adrenergic receptor agonist therapy?.J Am Acad Dermatol. 2013; 69: S44-S56Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Brimonidine is a newly approved topical medication for the treatment of facial erythema of rosacea. It is an agonist of alpha-2 adrenergic receptors, which are located in the smooth-muscle sheath that encase vessel walls of superficial cutaneous blood vessels.2Del Rosso J.Q. Management of facial erythema of rosacea: what is the role of topical alpha-adrenergic receptor agonist therapy?.J Am Acad Dermatol. 2013; 69: S44-S56Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar We report a patient who had effective vascular constriction with topical application of brimonidine, with decreased facial erythema to all areas treated. However, the patient developed a significant rebound facial erythema greater than baseline erythema approximately 12 hours after application. This rebound erythema lasted at least an additional 12 hours. Although this significant rebound erythema appears to be temporary, patients should be counseled on this potential side effect.