Clinical ChallengeRosacea is a common chronic inflammatory skin condition that impacts 2-22% of fair-skinned populations.1 There are four clinical subtypes of rosacea: erythematotelangiectatic, papulopustular, phymatous, and ocular.2 However, most patients present with the morphologic characteristics of multiple subtypes, and in clinical practice facial erythema is common amongst all subtypes. This facial redness can be a significant challenge. Survey data indicate that the adverse impact of rosacea on quality of life increases with the severity of facial erythema.3 Recently, two new medications, brimonidine sulfate 0.33% and oxymetazoline HCL 1%, were approved by the FDA in 2014 and 2017 respectively for management of facial redness. Both medications act as vasoconstrictors: brimonidine acts as an alpha-2 agonist, while oxymetazoline is an alpha-1a agonist.4,5 These agents, while beneficial to many patients, are limited by a variable patient response rate, cost, and varied insurance coverage.2 One 30 g tube of oxymetazoline HCL may cost patients over $570, and a 30g tube of brimonidine may cost about $494.4 Despite these costs, many patients are nonresponders to the medication and do not demonstrate a significant improvement.5-7 These facts may lead to frustration for the physician and the patient who may be paying for an expensive medication only to quickly find out it is unsatisfactory.SolutionIn our clinic, we leverage the short acting time of these agents and the evident clinical outcome for better patient selection. Brimonidine acts within 30 minutes of application, and while the effect time of oxymetazoline in rosacea is not well described, our clinical experience indicates a similar time to effect.4,6,8 While the patient is in clinic and after discussion of the medications’ benefits, adverse effects and alternatives, we apply a small amount of brimonidine sulfate to one cheek, and oxymetazoline HCL to the other (Figure 1; Figure 2). The patient
