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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 32-34

Application of topical timolol 0.5% solution for management of rosacea-related flushing and erythema: A case report


1 Resident of Dermatology, National Guard Hospital, King Abdul Aziz Medical City, Jeddah, KSA
2 Resident of Dermatology, Hera General Hospital, Ministry of Health, Makkah, KSA

Date of Web Publication13-Aug-2020

Correspondence Address:
MD Tahani S Magliah
Makkah, Western Region
KSA
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Rosacea is a common chronic skin condition that affects the face, characterized by flushing, redness, pimples, pustules and dilated blood vessels. Some treatment options for rosacea can improve symptoms and sometimes control the disease from getting worse. A female Saudi patient aged 41 years presented with flushing for the past two months. She has been diagnosed as a case of erythrematotelangiectatic rosacea, for which she received metronidazole topical gel twice daily, but she developed skin irritation after two weeks’ application. Topical timolol 0.5% ophthalmic solution 0.5% (one drop on each side of the face over the cheeks, twice per day for 8 weeks) was tried with her. Eight weeks later, the patient showed marked improvement. She denied complaining of skin irritation, flushing attacks, redness or any medication-related side effects. No systemic symptoms due to topical application were documented. She also expressed her satisfaction with treatment. Topical timolol (0.5%) solution can provide subjective improvement in cases of erythrematotelangiectatic rosacea associated with flushing and erythema, with no documented systemic or local side effects. However, further studies are still needed to settle its efficacy among patients with different phases of rosacea.

Keywords: Rosacea, beta blocker, timolol, topical, flushing, erythema


How to cite this article:
Magliah TS, Turkistani E. Application of topical timolol 0.5% solution for management of rosacea-related flushing and erythema: A case report. King Khalid Univ J Health Scii 2017;2:32-4

How to cite this URL:
Magliah TS, Turkistani E. Application of topical timolol 0.5% solution for management of rosacea-related flushing and erythema: A case report. King Khalid Univ J Health Scii [serial online] 2017 [cited 2020 Dec 3];2:32-4. Available from: https://www.kkujhs.org/text.asp?2017/2/1/32/291936




  Introduction Top


Rosacea is a common chronic skin condition that affects the face. It is characterized by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people.

A range of treatment options are available, e.g., low-dose antibiotics, skin creams that contain azelaic acid, brimonidine, or metronidazole but it is still not clear which are the most effective.[1]

Although the exact cause for rosacea is still not known, it may be of vascular origin.[2] Moreover, mast cells have been implicated as contributing agents by promoting localized vasodilatation, angiogenesis and tissue fibrosis.[3]

Timolol ophthalmic solution is an FDA-approved non-selective β-blocker for the treatment of glaucoma. Recently, it has become a popular topical alternative to the more well-studied oral propranolol for the treatment of hemangioma, particularly in children.[4]

Chakkittakandiyil et al.[5] applied timolol 0.5%-0.1% gel-forming solution twice daily on superficial hemangiomas among 73 children, who exhibited some improvement. Moreover, Prabha et al. [6] noted that, for superficial or small hemangiomas, in which systemic therapy may not be indicated, topical beta-blockers, especially timolol, have proven to be useful.

We report here a case of rosacea that has been successfully topically treated with timolol ophthalmic solution (0.5%).


  Cases Report Top


A female Saudi patient aged 41 years presented on January 5th, 2017 to a dermatology clinic in Makkah Al-Mukarramah City, Saudi Arabia complaining for the past two months of flushing at her face, which increases when feeling anxious, and after eating or drinking something hot [Photo 1].



She has been diagnosed as a case of erythrematotelangiectatic rosacea, for which she received metronidazole topical gel twice daily. However, she was advised to stop the metronidazole gel when she developed skin irritation after two weeks’ application. Postmenopausal flushing was excluded in this case and she was otherwise healthy.

Our patient was informed that she cannot use metronidazole gel since she proved to have hypersensitivity toward it. Therefore, we suggested to her to try applying topical timolol ophthalmic solution with a concentration of 0.5%. We fully explained to her the nature of that medication, which has been successfully tried with children with superficial hemangiomas. Moreover, her consent to try it was obtained.

Our patient was instructed to topically apply two drops of timolol 0.5% ophthalmic solution, one drop on each side of the face over the cheeks, twice per day for 8 weeks. She was also instructed not to use any other topical application on her face and to stop the medication immediately and to call us if (irritation or any unwanted skin side effects) occur.

She was followed up at our dermatology clinic every two weeks. During each follow up visit, the patient was asked about the progress of her symptoms and if there are any additional complaints. Moreover, general and local examinations were conducted.

Eight weeks after the application of topical 0.5% timolol, the patient showed marked improvement [Photo 2]. She denied complaining of skin irritation, flushing attacks, redness or any medication-related side effects. No systemic symptoms due to topical application were documented. She also expressed her satisfaction with treatment.




  Discussion Top


Rosacea is a multiphasic disease, characterized by being associated with flushing, erythrosis, papulopustule rosacea and phymas. Each phase of the disease may have its own treatment.[7]

Our case presented with flushing associated with rosacea. Postmenopausal flushing was excluded and she was otherwise clinically free. She has been previously diagnosed as a case of “erythrematotelangiectatic rosacea” for which she was treated with metronidazole topical gel twice daily. Craige and Cohen [8] stated that flushing is a periodic exaggeration of the normal blush response. It is associated with rosacea, menopause, alcohol or nicotinic acid ingestion and other rare conditions, e.g., carcinoid syndrome, pheochromocytoma, polycythemia and mastocytosis.

Rebora[7] added that metronidazole has been reported to reduce the severity of erythema. It may act as a selective suppressor of some aspects of the cell-mediated immunity. Craige and Cohen [8] noted that beta-blocker scan be tried to treat flushing associated with rosacea. Because our patient developed skin irritation after application of metronidazole topical gel, we decided to try topical timolol ophthalmic solution (0.5%), as one drop twice daily on each side of the face, for 8 weeks, since topical application of timolol showed much improvement within 4-8 weeks of topical application in cases of childhood hemangioma.[10]

The patient was followed up every two weeks. Gradual improvement of her condition was noted. After 8 weeks, her condition completely resolved, there were no detectable systemic symptoms and she expressed her satisfaction with treatment.

To-date, there are no published articles describing the efficacy of timolol in cases of rosacea, which is still being tested under phase 1 clinical trial at Johns Hopkins University. [9] Nevertheless, topical timolol can be safely applied for treatment of complicated and uncomplicated infantile hemangiomas. [10] Moreover, several beta-blockers (e.g., nadolol and propranolol) have been successfully tried to suppress flushing reactions in some patients, particularly when associated with anxiety. [11],[12]


  Conclusion Top


Topical timolol (0.5%) solution can provide subjective improvement in cases of erythrematotelangiectatic rosacea associated with flushing and erythema, with no documented systemic or local side effects. It is a promising alternative for metronidazole in topical treatment of rosacea. However, further studies are still needed to settle its efficacy among patients with different phases of rosacea.



 
  References Top

1.
van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262.  Back to cited text no. 1
    
2.
Generali JA, Cada DJ. Oxymetazoline (Topical): Rosacea. Hosp Pharm. 2013; 48(7): 558-559.  Back to cited text no. 2
    
3.
Aroni K, Tsagroni E, Kavantzas N, Patsouris E, Ioannidis E. A study of the pathogenesis of Rosacea: how angiogenesis and mast cells may participate in a complex multifactorial process. Arch Dermatol Res 2008; 300:125-131.  Back to cited text no. 3
    
4.
Semkova K, Kazandjieva J. Topical timolol maleate for treatment of infantile haemangiomas: preliminary results of a prospective study. Clin Exp Dermatol 2013; 38(2):143-6  Back to cited text no. 4
    
5.
Chakkittakandiyil A, Phillips R, Frieden IJ, Siegfried E, Lara-Corrales I, Lam J, et al. Timolol maleate 0.5% or 0.1% gel-forming solution for infantile hemangiomas: A retrospective, multicenter, cohort study. Pediatr Dermatol 2012; 29:28-31.  Back to cited text no. 5
    
6.
Prabha N, Chhabra N, Arora R. Beta-blockers in dermatology. Indian J Dermatol Venereol Leprol 2017; 83:399-407.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Rebora A. The management of rosacea. Am J Clin Dermatol 2002;3(7):489-96.  Back to cited text no. 7
    
8.
Craige H, Cohen JB. Symptomatic treatment of idiopathic and rosacea-associated cutaneous flushing with propranolol. J Am Acad Dermatol. 2005;53(5):881-884.  Back to cited text no. 8
    
9.
ClinicalTrials.gov. Timolol for the Treatment of Acne and Rosacea. Verified May 2016 by Johns Hopkins University. Website: https://clinicaltrials.gov/ct2/show/NCT02774590. Last accessed on July 18th, 2017.  Back to cited text no. 9
    
10.
Ni N, Langer P, Wagner R, Guo S. Topical Timolol for Periocular Hemangioma: Report of Further Study. Arch Ophthalmol 2011; 129 (3):377-379.  Back to cited text no. 10
    
11.
Ambika H, Sujatha C, Kumar YH. Topical Timolol: A Safer Alternative for Complicated and Un-Complicated Infantile Hemangiomas. Indian J Dermatol. 2013; 58(4): 330.  Back to cited text no. 11
    
12.
Wilkin JK. Effect of nadolol on flushing reactions in rosacea. J Am Acad Dermatol 1989; 20:202-205.  Back to cited text no. 12
    
13.
Drummond PD. The effect of adrenergic blockade on blushing and facial flushing. Psychophysiology 1997; 34:163-168.  Back to cited text no. 13
    




 

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