Rosacea

Published on 18/03/2015 by admin

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Last modified 22/04/2025

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Rosacea

John Berth-Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Rosacea is a common inflammatory skin disease, generally confined to the face, principally the cheeks, forehead, nose, and chin. In some cases lesions may extend on to the scalp, and occasionally also onto the neck and the upper part of the body. A common early feature is flushing, often accompanied by a burning sensation. Inflammatory lesions (papulation and pustulation) are characteristic and may become florid. Vascular changes (telangiectasia and erythema) are also frequently observed. These are initially mild, but may later become very conspicuous. Other later features are the development of lymphedema, thickening, and induration. On the nose and, less often the ears, forehead or chin, hypertrophy and lymphedema of subcutaneous tissue may develop into distinct swellings known as phymas, of which rhinophyma is most familiar. Ocular involvement is frequent and manifests as a sensation of grittiness, which may be accompanied by conjunctivitis, blepharitis, episcleritis, chalazion, hordeolum, iritis, and occasionally severe keratitis. The etiology and pathogenesis of rosacea remain poorly understood. Hopefully, improvements in our understanding of the etiology will one day facilitate a more rational approach to treatment, which has so far developed rather empirically.

Management strategy

Patients may find it beneficial to avoid alcohol, spicy food, hot drinks, etc. which may induce flushing and promote the development of telangiectasia. Exposure to irritants should be avoided, and emollients can be helpful. Cosmetic camouflage of the erythema and telangiectasia can be helpful. Facial massage may promote lymphatic drainage and reduce the development of lymphedema. Papulation, pustulation, and erythema can be effectively suppressed using a variety of topical and systemic antibiotics, retinoids, and other agents described below. Unfortunately, these modalities are usually not very effective for suppressing flushing and have little effect on established telangiectasia. Telangiectasia and erythema can be effectively treated by physical measures to ablate the vessels, such as intense pulsed light or vascular lasers. Flushing is usually the most difficult feature to treat, but sometimes improves during treatment of telangiectasia. Ocular rosacea is often treated symptomatically with a range of ‘artificial tears’ (the ophthalmic equivalent of emollients). Systemic tetracyclines, used as for cutaneous rosacea, and topical ophthalmic formulations of fusidic acid are also helpful. The use of retinoids for rosacea requires special care in patients with eye involvement and may be poorly tolerated. Treatments are discussed below in sections focused on inflammatory rosacea, erythematotelangiectatic rosacea, flushing, lymphedema, ocular rosacea, and rosacea fulminans. Treatments for rhinophyma and perioral dermatitis are described in separate chapters.

Inflammatory rosacea

First-line treatments

image Topical metronidazole A
image Topical azelaic acid A
image Oral tetracyclines A
image Oral erythromycin C
image Emollients C

Steroid rosacea in prepubertal children.

Weston WL, Morelli JG. Arch Pediatr Adolesc Med 2000; 154: 62–4.

A retrospective evaluation of 106 children younger than 13 years with steroid rosacea. Abrupt cessation of topical corticosteroid use and initiation of treatment with oral erythromycin stearate for 4 weeks produced complete clearing in 86% of children within 4 weeks and in 100% by 8 weeks.

The efficacy of oral tetracyclines seems to be well established, although most of the trials on the use of these antibiotics have been against active comparators rather than placebo. Both tetracycline and oxytetracycline are generally used at the dose of 250–500 mg twice daily in rosacea. Other systemic tetracyclines, such as minocycline 100 mg daily, doxycycline 40 mg or 100 mg daily, and lymecycline 408 mg daily, are also often prescribed. These offer the advantage of once-daily administration and their absorption is less influenced by dietary calcium, so they can be taken with food. Erythromycin 250–500 mg twice daily is also often prescribed and widely held to be effective, and can be useful when rosacea occurs in children, for whom tetracyclines are contraindicated.

Second-line treatments

image Topical erythromycin C
image Topical clindamycin C
image Oral metronidazole A
image Topical benzoyl peroxide A
image Ampicillin A
image Azithromycin B

Third-line treatments

image Systemic isotretinoin B
image Topical tretinoin C
image Topical adapalene B
image Topical sulfur B
image Topical corticosteroids D
image Topical ketoconazole D
image Systemic ketoconazole D
image Topical bifonazole D
image Photodynamic therapy D
image Spironolactone D
image Demodex eradication B
image Helicobacter pylori eradication D
image Sunscreens E
image Topical tacrolimus C
image Topical pimecrolimus D
image Octreotide C
image Inhibition of ovulation C
image Topical NADH C
image Topical 1-methylnicotinamide C
image Oral nicotinamide with zinc C
image Zinc sulphate B
image Trichloroacetic acid peels E

Continuous microdose isotretinoin in adult recalcitrant rosacea.

Hofer T. Clin Exp Dermatol 2004; 29: 204–5.

In this report on 12 patients, isotretinoin was commenced at 10 mg or 20 mg daily for a period of 4 to 6 months, then reduced individually to lower doses. The treatment was well tolerated and quality of life, assessed using the Dermatology Life Quality Index (DLQI), was improved relative to a control group.

There have been several reports of the use of isotretinoin at doses of 10–60 mg/day or 0.5–1 mg/kg/day for 6 to 28 weeks. Variable relapse rates have been reported after discontinuing the drug, and there being a trend towards more frequent relapse in those given lower total doses. However, doses often need to be kept low to avoid aggravating ocular symptoms. Partly for this reason, other investigators have advocated the use of continuous low-dose therapy with isotretinoin.

Erythematotelangiectatic rosacea

First-line therapies

image Brimonidine tartrate A
image Oxymetazoline E
image Cosmetic camouflage C
image Intense pulsed light B
image Vascular lasers C
image Ondansetron E

Once-daily topical brimonidine tartrate gel 0.5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies.

Fowler J, Jarratt M, Moore A, Meadows K, Pollack A, Steinhoff M, et al. Br J Dermatol 2012; 166: 633–41.

Two placebo-controlled trials. One study examined response to a single application using a range of concentrations. The other examined results from 4 weeks of treatment once or twice daily and followed by 4 weeks washout. Reduced redness was apparent at 30 minutes and persisted for 12 hours. There was no evidence of tachyphylaxis or rebound.

This effect has also been observed when brimonidine eydrops (used in treatment of glaucoma) have run down the cheeks of patients with rosacea. Although not an ideal formulation, the ophthalmic drops can also be effective.

Rosacea flushing

The flushing associated with rosacea is often the most difficult symptom to treat. This symptom often persists even when the inflammatory component is effectively treated. However, some improvement of flushing is not uncommon when erythematotelangiectatic disease is treated with the various modalities described above. Additional approaches used for flushing are described here.

First-line therapies

image Clonidine D
image Rilmenidine D
image β-Blockers D
image Naloxone D
image Cosmesis C
image Pulsed dye laser D
image Intense pulsed light D
image Hypnosis E
image Granisetron D

Rosacea lymphedema (morbihan’s disease)

This is a particularly refractory, chronic form of rosacea which has received little attention in the literature. Indurated edema develops mainly over the upper half of the face. Treatment is difficult and the evidence base is very limited. Measures that are generally employed include control of underlying inflammatory rosacea using broad-spectrum antibiotics, and facial massage to improve lymphatic drainage.

First-line therapies

image Broad-spectrum antibiotics E
image Facial massage E
image Isotretinoin with ketotifen and H1 antagonist E
image Prednisolone with metronidazole E
image CO2 laser blepharoplasty E
image Surgical debulking of the eyelids E
image Prednisolone and doxycycline E

Ocular rosacea

Ocular involvement in rosacea is very common and may even be seen in isolation or before the onset of cutaneous features. Symptoms are most frequently related to the occurrence of blepharitis, episcleritis, chalazion, or hordeolum. Rosacea keratitis can be a serious complication and may occur in adults and children. Severe or refractory cases of ocular disease require specialist ophthalmologic supervision. Particular care is required if systemic retinoids are to be used for inflammatory rosacea when ocular features are present. Retinoids impair meibomian gland secretion, impairing tear film formation and aggravating the dryness and ‘grittiness’ of the eyes.

First-line therapies

image Tear substitutes, e.g., carbomers, liquid paraffin, hypromellose C
image Oral tetracyclines A
image Topical cyclosporine A
image Fusidic acid (topical) C
image Helicobacter pylori eradication D
image Ondansetron E

Rosacea fulminans

Rosacea fulminans (pyoderma faciale) is a very severe facial eruption of sudden onset with prominent pustulation and abscess formation. In addition to conventional treatment modalities for rosacea, a short course of systemic steroids is often indicated to reduce the acute inflammation. Isotretinoin seems to be useful in this condition.

First-line therapies

image Systemic corticosteroids C
image Topical corticosteroids D
image Isotretinoin C
image Systemic antibiotics C

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