Oral beta-blockers reduce rosacea-related facial erythema, flushing

Treatment with oral beta-blockers appears to be effective against rosacea-associated facial erythema and flushing that are nonresponsive to conventional therapy, suggests a study.

“[O]ral nonselective beta-blockers could be an effective treatment option for rosacea patients with persistent facial erythema and flushing,” the researchers said. “Currently, most evidence is available for carvedilol and propranolol.”

The databases of PubMed, Embase, Web of Science, and Cochrane Library were systematically searched for studies providing original data on the efficacy of oral beta-blockers in rosacea patients with facial flushing and persistent erythema. The Cochrane Risk of Bias tool, Newcastle-Ottawa scale, and Quality in Prognosis Studies tool were used to assess risk of bias.

A total of 1,941 articles were identified, of which 25 were eligible for full-text screening. Nine studies were finally included in the systematic review: one randomized controlled trial, one cohort study, one case-control study, three case reports and three case series. Beta-blockers investigated included carvedilol (n=4), propranolol (n=3), nadolol (n=1), and beta-blockers in general (n=1). [J Am Acad Dermatol 2020;83:1088-1097]

Treatment with carvedilol and propranolol resulted in a significant reduction of erythema and flushing with a rapid onset of symptom control. The most common adverse effects were bradycardia, hypotension, bronchospasm, dizziness, somnolence, and fatigue. [J Eur Acad Dermatol Venereol 2018;32:363-371; Am J Clin Dermatol 2002;3:489-496]

“One should be aware that beta-blockers may exacerbate asthma and psoriasis,” the researchers said. “Contraindications to beta-blockers are congestive heart failure, cardiogenic shock, sinus bradycardia of <50 beats/min, atrioventricular block, hyperactive airway disease, and Raynaud disease.” [Exp Ther Med 2019;18:955-959; Thorax 1983;38:108-112; J Am Acad Dermatol 1986;15:1007-1022; Indian J Dermatol Venereol Leprol 2017;83:399-407]

Carvedilol and propranolol, compared to other nonselective beta-blockers, appeared to have antioxidant and anti-inflammatory actions, which might benefit patients with rosacea since reactive oxygen species released by inflammatory cells may contribute to disease development. [Dermatol Ther 2017;30:e12501; J Cardiovasc Pharmacol 2001;37:48-54; J Pharmacol Exp Ther 2004;308:85-90; J Investig Dermatol Symp Proc 2011;15:40-47; Clin Exp Dermatol 2007;32:197-200]

However, the quality of eligible studies was low while the interstudy outcome variability was large. Meta-analysis was not possible because erythema and flushing were assessed using a wide spectrum of mostly subjective clinical and patient-based scores, and method standardization was often missing.

In addition, objectivity and precision were lacking in the evaluation of facial erythema by visual assessment alone, which is prone to inter- and intraobserver variability. [J Am Acad Dermatol 2014;71:760-763; J Am Acad Dermatol 2015;73:138-143.e4; J Am Acad Dermatol 2004;51:697-703]

“Large, prospective, clinical trials are warranted to validate the data of these small studies,” the researchers said, adding that future studies should focus on the determination of the optimal dosage, treatment duration, and long-term therapeutic effects for adequate treatment of erythema and flushing in rosacea.