Start brimonidine gel at low dose in rosacea, cautions MHRA

Symptom exacerbation is a very common side-effect of treatment with brimonidine gel, affecting 16% of rosacea patients in clinical studies of the drug.

Exacerbation may occur soon after the gel is applied or as a rebound in symptoms after the therapeutic effect wears off, approximately 8–12 hours after application. In most cases, the symptoms of erythema and flushing resolve after stopping treatment.

The mechanism of exacerbation is currently unknown.

Reduce starting dose

To minimise the risk of exacerbation, prescribers should advise patients to initiate treatment with a small amount of gel for at least 1 week and increase the dose gradually, based on tolerability and response to treatment. The initial dose should be less than the recommended maximum daily dose of 1g (equivalent to 5 roughly pea-sized amounts applied to the forehead, chin, nose and each cheek).

Patients should be carefully advised how to apply the gel and counselled on the importance of not exceeding the maximum daily dose. If patients experience increased redness or burning during treatment, they should stop using the gel and consult their prescriber.

Launched in 2014 as a rosacea treatment, brimonidine is an alpha₂ agonist that directly reduces the erythema of rosacea by causing cutaneous vasoconstriction.