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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


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

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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
imageHelicobacter pylori eradication D
image Sunscreens E
image Topical tacrolimus C
image Topical pimecrolimus D
image Octreotide C
image Inhibition of ovulation C