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Rosacea is a common skin condition with characteristic symptoms and signs, including symmetric flushing, stinging sensation, inflammatory lesions papules and pustules , and telangiectasias on the face. It may also cause inflammation of the eyes and eyelids. In most patients, the central area of the face is affected, such as the nose, forehead, chin, and perioral areas.
Phymatous changes include thickened skin and large pores. Clinical findings represent a spectrum of disease with one or several predominating characteristics, including a pattern of exacerbations and relative inactivity. The National Rosacea Society classifies rosacea into four subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular.
Rosacea affects an estimated 14 million patients in the United States. Rosacea is somewhat more likely to occur in women. It generally emerges when patients are in their 30s, although it can develop in younger age groups. However, one survey suggests that first- and second-degree relatives of patients with rosacea have a higher rate of rosacea, and persons of Irish, English, or German ancestry are more likely to develop the disease. The differential diagnosis of rosacea includes acne vulgaris, systemic lupus erythematosus, polymyositis, sarcoidosis, photodermatitis, drug eruptions particularly from iodides and bromides , granulomas of the skin, and perioral dermatitis.
The differential diagnosis of ocular rosacea may include staphylococcal and seborrheic blepharokeratoconjunctivitis, and sebaceous gland carcinoma. A Cochrane review concluded that the quality of studies evaluating rosacea treatments is generally poor. The initial therapeutic approach for rosacea, especially the erythematotelangiectatic and papulopustular subtypes, is avoidance of known triggers or exacerbating factors Table 2 8 when possible.
These factors may be specific to individual patients. Patients with rosacea should avoid sun exposure, wear wide-brimmed hats when outdoors, and use a broad-spectrum sunscreen daily that has a sun protection factor of at least Because sunscreen products can be irritating, patients with rosacea may better tolerate formulations with a simethicone or dimethicone base that contain titanium dioxide or zinc oxide.
Emollient, noncomedogenic moisturizers and fragrance-free, soap-free products with a nonalkaline or neutral pH level are recommended. Although few studies have examined nonpharmacologic treatments for erythematotelangiectatic and phymatous rosacea, vascular lasers are the mainstay of nonpharmacologic therapy and have been useful for treating resistant telangiectasias, persistent erythema, and recalcitrant rosacea.
Topical regimens are first-line therapies for mild papulopustular rosacea because there is less risk of adverse events, drug interactions, and antibiotic resistance. The severity of the patient's presentation helps guide the decision to initiate topical therapy alone or in combination with systemic therapy. Systemic therapy should be withdrawn when adequate response occurs.
Topical therapies for rosacea are summarized in Table 3. Metronidazole Metrogel is one of two topical medications approved by the U. Its effectiveness is based on several valid, well-controlled trials.
Azelaic Acid. The effectiveness and safety of the acne drug azelaic acid Azelex has been supported by two double-blind, randomized controlled trials RCTs , leading the FDA to approve its use for the treatment of rosacea. Adverse events were insignificant. Azelaic acid may be used as a first- or second-line therapy for rosacea. Other Effective Topical Treatments. One study compared the cream with placebo, 5 and two compared it with metronidazole. Adapalene Differin , a retinoic acid receptor agonist used for treating acne vulgaris, has been shown to effectively reduce papules and pustules, but not erythema or telangiectasias.
Studies have shown that silymarin combined with methylsulfonylmethane improves papules, erythema, hydration, and itching, but not pustule number, making it an option for patients with erythematotelangiectatic rosacea.
Evidence for using oral antibiotics to treat rosacea is limited and is often based on clinical experience or older, low-quality studies instead of on well-designed RCTs. Initial therapy for moderate to severe rosacea should include oral treatment or a combination of topical and oral treatments. Because rosacea is a chronic disease, the long-term use of antibiotics can lead to adverse effects.
Additionally, concerns about long-term use of antibiotics leading to resistant bacterial strains need to be addressed. One potential management strategy is to taper the dosage of oral antibiotics after six to 12 weeks of successful treatment, transitioning to topical agents only.
Licorice is the only herbal therapy studied in clinical trials that reduced erythema in patients with mild to moderate rosacea. Subantimicrobial dose antibiotics may act as anti-inflammatory agents without creating bacterial resistance.
Doxycycline is the only drug approved by the FDA to specifically treat papulopustular rosacea. Two RCTs with a total of patients have shown that subantimicrobial dose doxycycline, alone or added to topical metronidazole therapy, reduces inflammatory lesions in patients with moderate to severe rosacea.
Three to four weeks of therapy with a tetracycline is required before substantial improvement occurs; typical duration of therapy ranges from six to 12 weeks. Three small, older studies evaluating the use of tetracycline in patients with rosacea concluded that tetracycline is significantly more effective than placebo, but specific outcomes were not included.
Second-Generation Macrolides. Second-generation clarithromycin and azithromycin have been studied in patients with rosacea, but study quality is poor. Azithromycin mg three times per week appeared to be as effective as doxycycline mg daily in decreasing facial lesions in two unblinded trials of total patients. In two studies with a total of 69 patients, oral metronidazole Flagyl was as effective as oral tetracycline in reducing papules and pustules; however, study quality was poor.
Isotretinoin Accutane has been reported to be effective for treating rosacea, including rhinophyma, and appears to positively affect more than one subtype of the disease.
In patients with rhinophyma, the size and number of sebaceous glands have decreased with oral isotretinoin. Isotretinoin may be an alternative therapy, especially in men and in women beyond childbearing.
Although this treatment does not cause antibiotic resistance, vigilance is required because of adverse effects. In one RCT, topical clindamycin lotion Cleocin was shown to be a safe alternative to oral tetracycline and appeared to be superior in eradicating pustules. Nearly 60 percent of persons with rosacea have ocular involvement. Symptoms include foreign body sensation, photophobia, lid margin telangiectasia, meibomian gland inflammation and inspissation, marginal corneal ulcers, and vascularization.
In one study, 20 percent of patients with rosacea presented with ocular symptoms before skin lesions, 53 percent presented with skin lesions before ocular symptoms, and 27 percent had simultaneous onset of ocular and skin findings.
Mild ocular rosacea usually responds well to topical agents and eyelid hygiene. A small blinded RCT demonstrated that eyelid hygiene using metronidazole 0.
In one small randomized, non—placebo-controlled trial, oral tetracycline and doxycycline appeared to equally control the symptoms of ocular rosacea; however, the outcome in this study was physician opinion. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. C 12 , 13 Initial drug therapy for mild rosacea should include appropriate topical regimens, such as antibiotics, immunomodulators, or retinoids.
First-line topical regimens e. A 5 , 14 — 16 Initial therapy for moderate to severe rosacea should include oral treatment or a combination of topical and oral treatments. First-line oral medications include tetracycline, doxycycline, and minocycline Minocin. Subantimicrobial dosing should be considered. B 5 , 20 , 22 — 26 Subantimicrobial dose, once-daily doxycycline alone or added to metronidazole therapy may reduce inflammatory lesions. B 20 , 22 Mild ocular rosacea should be treated with eyelid hygiene e.
C 5 , 32 Moderate ocular rosacea should be treated with oral drug therapy tetracycline class. Erythematotelangiectatic rosacea subtype 1.
A Mild. B Moderate. C Severe. J Am Acad Dermatol. Papulopustular rosacea subtype 2. Phymatous rosacea subtype 3. Ocular rosacea subtype 4. Nonpharmacologic Therapy. Topical Therapy. Systemic Therapy. Ocular Rosacea. Continue Reading. More in AFP. More in Pubmed. All Rights Reserved.
Drug therapy should be based on rosacea classification, severity, and response to previous treatment regimens. Dermatologic laser therapy may be considered for background erythema and telangiectasia. Initial drug therapy for mild rosacea should include appropriate topical regimens, such as antibiotics, immunomodulators, or retinoids. Subantimicrobial dose, once-daily doxycycline alone or added to metronidazole therapy may reduce inflammatory lesions.
Mild ocular rosacea should be treated with eyelid hygiene e. Moderate ocular rosacea should be treated with oral drug therapy tetracycline class. Marked skin thickening and irregular nodularities of nose, chin, ears, forehead, or eyelids.
Teratogenicity, hypercholesterolemia, hypertriglyceridemia, musculoskeletal changes, hepatotoxicity, decreased night vision, mood changes e.
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