Mirvaso

Mirvaso contains brimonidine, a selective alpha-2 adrenergic receptor agonist, formulated as a topical gel for the symptomatic treatment of facial erythema (redness) associated with rosacea in adults.

Brimonidine acts by causing vasoconstriction of the superficial facial blood vessels responsible for the persistent redness characteristic of erythematotelangiectatic rosacea.

Onset of effect occurs within 30 minutes of application, reaching peak effect at approximately 3-6 hours, with a duration of up to 12 hours.

In phase III clinical trials, significantly more patients treated with brimonidine gel achieved at least a 2-grade improvement on the Clinician's Erythema Assessment and Patient Self-Assessment scales compared to placebo.

Mirvaso is the first topical treatment specifically licensed for rosacea-associated facial erythema.

It addresses redness only and does not treat the papulopustular component of rosacea, which requires separate management with topical metronidazole, ivermectin, or systemic antibiotics.

It is important that patients understand this is a symptomatic treatment; underlying rosacea triggers should still be identified and avoided.

Apply a pea-sized amount of gel to each of the five facial regions (forehead, chin, nose, each cheek) once daily.

Spread as a thin, uniform layer, avoiding the eyes, eyelids, lips, mouth, and the inside of the nose. Wash hands immediately after application.

Allow the gel to dry before applying sunscreen, moisturiser, or makeup. Avoid triggers known to worsen rosacea (e.g. alcohol, spicy food, extreme temperatures, hot beverages).

Do not use more than the recommended dose, as excessive application may increase the risk of rebound erythema. Mirvaso should not be applied to irritated, broken, or sunburned skin.

Apply a maximum of 1 g of gel (approximately 5 pea-sized amounts) once daily to the face. Do not exceed the recommended daily amount.

No dose adjustment is required for elderly patients, though clinical experience in patients >65 years is limited.

Mirvaso has not been studied in patients with severe hepatic or renal impairment and should be used with caution. It is not recommended for children under 18 years.

If a dose is missed, skip it and apply the next day's dose as usual; do not double the dose.

Side effects per SmPC frequency categories and post-marketing data.

Common (≥1/100 to <1/10): Erythema (paradoxical worsening or rebound redness), flushing, skin burning sensation, contact dermatitis at the application site.

Uncommon (≥1/1,000 to <1/100): Skin warmth, pruritus, acne, pain at application site, dry skin, nasal congestion, papules, oedema at application site.

Rare (≥1/10,000 to <1/1,000): Angioedema, bradycardia, hypotension, dizziness (systemic absorption).

Rebound erythema is the most clinically significant concern: after the vasoconstrictive effect wears off, facial redness may transiently worsen beyond baseline.

This has been reported in up to 10-20% of patients in post-marketing experience and typically occurs within the first 2 weeks.

It can be managed by gradual introduction (applying to a small area first) and using a thinner layer.

The MHRA has received reports of rebound erythema and flushing worse than baseline after Mirvaso use. Patients should be informed of this possibility before starting treatment.

Consider test application to a small facial area for several days before full-face use.

Brimonidine is an alpha-2 agonist with potential systemic effects; though absorption through intact skin is minimal, caution is advised in patients with cardiovascular disease (severe or unstable), Raynaud's phenomenon, depression, cerebral or coronary insufficiency, and in those taking concurrent systemic antihypertensives, cardiac glycosides, or CNS depressants.

Avoid contact with the eyes, as brimonidine is also used as an ophthalmic preparation (for glaucoma) and ocular exposure may cause miosis and lid retraction.

Mirvaso is contraindicated in patients with hypersensitivity to brimonidine tartrate or any excipient, and in children under 2 years of age (risk of serious systemic effects).

It should be used with caution and only after risk-benefit assessment in patients taking MAO inhibitors, tricyclic or tetracyclic antidepressants (which may affect alpha-adrenergic receptor activity).