Management

Rosacea is a lifelong condition, with periods of remission with intermittent flare-ups. (1)

Lifestyle changes, medical and laser/surgical treatment can minimise or control symptoms but there is no cure and regimens with more than two distinct treatments are reserved for more severe rosacea (1).

Lifestyle changes may help to reduce symptoms such as flushing, facial redness, skin sensitivity, and dryness, and should be considered in all patients with rosacea (2).

• Mild to moderate rosacea
  • for people with few papules or pustules and mild to moderate persistent erythema, topical treatment is recommended
    • topical metronidazole is the preferred topical treatment - note that gel preparations that contain alcohol may be more irritating to the skin
      • gel (0.75%) applied twice a day, or cream (1%) applied once a day (2)
        
        
    • topical azelaic acid may be considered for people who are intolerant of or not responding to topical metronidazole
      • may cause a mild burning or stinging sensation when initially applied to the skin
      • azelaic acid 15% gel, applied twice a day (2)
      • the 20% cream available in the UK is not licensed for the treatment of rosacea
        
        
    • ivermectin 10 mg/g cream
      • mechanism of action is unknown but may be due to a combination of its anti-inflammatory effects and its antiparasitic effects on the Demodex mite, which lives on the skin and may contribute to the symptoms of rosacea (2) (3)
      • studies have shown ivermectin cream to be safe with no serious adverse effects - rate of adverse effects was similar to those of vehicle, metronidazole gel, and azelaic acid
      • will produce clearing or almost clearing of rosacea lesions in the majority of patients with moderate to severe symptoms after three months of treatment (3)
        
        
• patients who do not respond to topical treatment and/or have severe rosacea (i.e. extensive papules, pustules, or plaques) (3):
  • prescribe an oral tetracycline or erythromycin
  • in an adult:
    • use a tetracycline eg oxytetracycline 500 mg BD, lymecycline 408 mg OD - both on an empty stomach;
      • doxycycline 100 mg once daily (off-label) is an alternative if the person has any degree of renal impairment or prefers once-daily dosing
      • doxycycline modified-release 40 mg once daily in the morning for up to 16 weeks (licensed) is also available for the treatment of papulo-pustular acne rosacea without ocular involvement. This should be discontinued if no improvement is seen after 6 weeks
      • full doses are given initially but gradually reduced once the condition has been controlled - usually after 1-3 months. Antibiotics should not be stopped suddenly because this may result in rebound rosacea
    • erythromycin 500 mg BD is an alternative - an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
    • initial treatment should be for at least three months, although if the patient is responding well the dose may be reduced after one month
    • there is evidence of benefit for the use of low dose isotretinoin (10mg per day) in rosacea (3) - the use of isotretinoin in rosacea can only be initiated by a specialist

Patients with ocular symptoms should be referred to an ophthalmologist: (2)

• Urgent referral - if keratitis is suspected (eye pain, blurred vision, sensitivity to light).
  Routine referral - if ocular symptoms are severe or resistant to maximal treatment in primary care
  
• Mild eye symptoms are usually treated with a combination of eyelid hygiene measures, ocular lubricants (for dry eye symptoms), and oral tetracyclines but topical azithromycin is as effective as oral doxycycline for treating ocular rosacea and has fewer adverse effects. (4) Topical ciclosporin drops may also be effective in decreasing inflammation (1)

Routine referral to dermatologist is advised for people with: (2)

• flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress
• papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
• an uncertain diagnosis

Flushing / erythema / telangiectasia (2)

• can sometimes be the predominant symptoms
• tend not to respond to antibiotics
• flushing may he helped by a non-selective cardiovascular beta-blocker such as propranolol 40 mg BD, or clonidine 50 micrograms BD
• persistent erythema / telangiectasia - laser therapy using a pulsed-dye laser can be very effective although improvement is not permanent. (2) The British Association of Dermatologists recommends neodymium-doped yttrium aluminium garnet (Nd:YAG) or intense pulsed light to treat persistent facial erythema (2)
• the most effective topical treatments for persistent facial erythema are topical alpha agonists (e.g., brimonidine, oxymetazoline). (2) Applied thinly once a day, these will benefit some, but not all, patients with persistent erythema. Adverse reactions include erythema, flushing, skin burning sensation and contact dermatitis
• Carvedilol - there is some evidence of efficacy in treatment of rosacea - can take 3-6 months for the optimal response
• consider camouflage eg green cream (2) or refer to the British Red Cross, which run free clinics across the UK, normally in association with hospital dermatology departments

Reference:

1. van Zuuren EJ et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 28;(4)

2. Hampton PJ et al. British Association of Dermatologists guidelines for the management of people with rosacea 2021. Br J Dermatol. 2021 Oct;185(4):725-35.

3. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: the 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020 Jun;82(6):1501-10.

4. Yildiz E, Yenerel NM, Turan-Yardimci A, et al. Comparison of the clinical efficacy of topical and systemic azithromycin treatment for posterior blepharitis. J Ocul Pharmacol Ther. 2018 May;34(4):365-72.