Rosacea Classification Rosacea can be broadly classified into the following subtypes: Erthematotelangiectatic: Consisting of erythema, telangiectasia and flushing. Papulopustular: Encompasses papules and pustules. Phymatous: Marked skin thickening and irregular nodularities of nose, chin, etc. Ocular: Blepharitis, conjunctivitis, etc. General measures Minimise factors that may aggravate symptoms: Tea and coffee, especially taken hot or strong Alcohol Mustard, pepper, vinegar, pickles or spicy foods Excessive heat Direct sunshine Topical steroids - - - - - - Emollientsare generally helpful and soothing Sun protection Recommended Treatment 1. Erthematotelangiectatic Topical azelaic acid –first choice. Available as15% gel, 20% cream (cream may be less irritant [cream off-label for rosacea]). Apply twice daily. Topical brimonidine (0.33%) gel - Brimonidine is a selective alpha2- adrenoceptor agonist, which is a treatment to reduce facial redness in rosacea by cutaneous vasoconstriction. It is indicated for: patients with moderate to severe persistent facial erythema, particularly where this is causing distress; patients who are severely affected by facial erythema while a response to treatment of the rosacea is awaited; or in those who have patterns of rosacea unlikely to respond well to laser treatment. Patients should be reviewed after 1-2 months of starting topical brimonidine and only continued if benefit, with further regular reviews (4 monthly) recommended thereafter. Apply thinly once daily to affected erythematous skin (max. 1g of gel (equivalent to 5mg brimonidine tartrate) daily divided over the forehead, chin, nose, and cheeks).
Topical metronidazole (0.75%) gel or cream –may have an effect but is generally more effective if there is concurrent element of papulopustular rosacea. This type of rosacea tends not to respond to antibiotics. If no improvement and patients have moderate/severe disease, refer to the camouflage clinic (can refer directly from primary care) or secondary care for consideration of vascular laser. Flushing may be helped by a non-selective cardiovascular beta-blocker. 2. Papulopustular Topical Therapy Topical Metronidazole or Azelaic acid gel or cream for at least 8 weeks – first choice. Topical Ivermectin (1%) cream for patients with moderate to severe inflammatory lesions of rosacea – The mechanism of action for treating the inflammatory lesions of rosacea is not known, but may be linked to the anti-inflammatory effects of ivermectin, as well as causing the death of Demodex folliculorum mites which has been associated with rosacea. Apply once daily to affected area. Other topical treatment - Topical benzoyl peroxide or retinoid as monotherapy or in combination with antibiotics as well as topical calcineurin inhibitor (tacrolimus or pimecrolimus) has also been used. If topical treatment fails or severe presenting symptoms, use: Oral antibiotics Oxytetracycline 500mg twice daily (first choice) Lymecycline 408mg daily – likely to have better adherence due to once daily dosage. Erythromycin 500mg twice daily (first choice in pregnancy) Doxycycline 40mg, 50mg or 100mg daily – 40mg sustained release is licensed for rosacea but is more expensive. 50mg daily has also been seen to be effective and cheaper though more severe/resistant cases may require 100mg daily. Lower doses may cause fewer side-effects. Initial treatment should be for at least 3 months. If treatment needs to be continued, review every 6 months. For very severe or unresponsive disease, refer to secondary care for consideration of oral isotretinoin. Other treatments that are sometimes used for severe/resistant cases include minocycline, trimethoprim, azithromycin, clarithromycin, co-trimoxazole,
dapsone, etc. Higher doses of antibiotics may also be used in severe/resistant cases. These treatments are usually started in secondary care. 3. Phymatous Less likely to respond to treatment but could try: Oral antibiotics (first line) Oxytetracycline 500mg twice daily (first choice) Lymecycline 408mg daily – likely to have better adherence due to once daily dosage. Erythromycin 500mg twice daily (first choice in pregnancy) Doxycycline 40mg, 50mg or 100mg daily – 40mg sustained release is licensed for rosacea but is more expensive. 50mg daily has also been seen to be effective and cheaper though more severe/resistant cases may require 100mg daily. Lower doses may cause fewer side-effects. Initial treatment should be for at least 3 months. If treatment needs to be continued, review every 6 months. If unresponsive, refer for consideration of oral isotretinoin or ablative laser. 4. Ocular Lid hygiene - clean the eyelids using cotton wool soaked in cooled, boiled water Artificial tears Oral antibiotics – tetracyclines generally most effective. Retinoids should be avoided in patients with significant ocular problems as they can worsen symptoms and lead to a severe keratitis. If unresponsive, refer to ophthalmologist. For (http://www.pcds.org.uk/clinical-guidance/rosacea) more information on rosacea and management click here All treatment suggested as first choice are deemed the most cost effective but alternatives may be more appropriate depending on patients’ tolerability, etc. The formulary is also simply a guideline. Ultimately, clinicians should prescribe what is felt best for patients. Dr S Ghaffar Consultant Dermatologist NHS Tayside Dermatology Department May 2016 Review date May 2018