rosacea
ROSACEA
Rosacea is a chronic cutaneous disease of the convexities of the central face (cheeks, chin, nose and central forehead) w/ periorbital and perioral skin sparing. This condition is attributed to chronic vasodilation.
Remissions and exacerbations are common.
It typically appears after 30 years of age but may occur at any age.  It commonly affects fair-skinned individuals.
The common presenting symptoms are facial flushing, stinging/burning erythema, telangiectasia, edema, papules, pustules, ocular lesions, and hypertrophy of the sebaceous glands of the nose with fibrosis.
A history of episodic flushing often heralds onset of rosacea.

Principles of Therapy

  • Rosacea is a chronic disease w/ relapses; therefore, long-term treatment is usually required
    • Treatment should start early to prevent progression of the disease to the stages of edema & irreversible fibrosis
  • Mild rosacea: Primary treatment is topical therapy
    • 1st-line agents: Metronidazole, Azelaic acid, Sulfacetamide/sulfur
    • 2nd-line agents: Benzoyl peroxide, Clindamycin, topical retinoids
    • Topical Metronidazole, Azelaic acid, Sulfacetamide/sulfur & Benzoyl peroxide may improve the following: Erythema, pustules & nodules
  • Moderate-severe rosacea & ocular symptoms: Topical combined w/ oral agents
    • Low-dose Isotretinoin may be given in some cases
  • Symptom recurrence
    • If recurrence is infrequent, treatment course can be repeated
    • If frequent, patient can be maintained on a lower dose of the antibiotic used in the previous treatment regimen that improved the symptoms
  • Avoid long-term use of antibiotics
    • Slowly reduce the dose of oral antibiotics after 6-12 wk then switch to topical agents

Pharmacotherapy

Topical Therapy

Antibiotics

  • Topical treatment is frequently used for mild symptoms & maintenance of remission after discontinuance of systemic therapy
  • Topical maintenance therapy for 6 mth is generally advised
  • Topical application should be across the entire face rather than only on the lesions
  • For mild ocular rosacea, topical antibiotics are used together w/ artificial tears
    • Eyelid hygiene using application of warm compresses twice daily also helps improve symptoms
  • Metronidazole
    • Effectiveness is supported by several valid, well-controlled trials
    • Recommended treatment for papulopustular rosacea; generally well tolerated w/ few local adverse reactions to skin (eg burning & stinging sensation)
    • May be initiated at the same time as oral antibiotic & continued after discontinuation of oral drug
      • May be used as indefinite maintenance therapy after clearance w/ oral treatment
      • Helps to prevent relapse
  • Sulfacetamide/sulfur
    • Some studies support its use as an alternative to topical Metronidazole
    • Sulfacetamide has antibacterial action while Sulfur has antidemodectic, antifungal & keratolytic effects
  • Erythromycin & Clindamycin
    • These agents combined w/ Benzoyl peroxide have been shown in two different randomized controlled trials (RCTs) to be effective for inflammatory rosacea; adverse reactions include burning sensation & itching at site of treatment

Azelaic Acid

  • Two double-blind RCTs concluded that Azelaic acid is comparable to or exceeds Metronidazole in clinical effectiveness in treating erythema, nodules, papules & pustules
  • Has antibacterial, anti-inflammatory, & antikeratinizing activities
  • Not effective for telangiectasia
  • Adverse reactions were insignificant & short-lived

Retinoids

  • Useful for actinically damaged skin which is common in rosacea
    • Has beneficial effect on vascular component of the disease (eg flushing, redness, & thread veins)
  • Adverse reactions & slow onset of effect tend to limit use; however, better tolerated agents (eg Adapalene) may be considered

Oral Therapy

Antibiotics

  • Indicated for moderate-severe papulopustular rosacea & when topical therapy failed
  • May also be used for erythematotelangiectatic subtype if there is significant inflammation
  • A number of agents can be used:
    • Tetracycline & its derivatives (Doxycycline, Lymecycline, Minocycline, & Oxytetracycline), macrolides & Metronidazole are commonly used
    • Two RCTs have shown subantimicrobial dose of Doxycycline, alone or w/ topical Metronidazole, reduces inflammatory lesions in moderate-severe rosacea
    • Tetracyclines may be used for moderate-severe ocular symptoms
  • It is continued until inflammatory lesions resolve or for 3 mth, whichever comes first
  • Since long-term use of antibiotics may lead to resistant bacterial strains, subantimicrobial dosing should be considered

Retinoid

  • Low-dose Isotretinoin therapy has been used to treat refractory rosacea
  • One small RCT reported that low-dose oral Isotretinoin reduced erythema, papules & telangiectasia by 9th wk of treatment
    • In patients w/ rhinophyma, there was decrease in size and number of sebaceous glands w/ oral Isotretinoin
  • Adverse effects & teratogenicity may limit use
    • Avoid in patients w/ significant ocular symptoms as this can lead to worsening of symptoms & severe keratitis

Other Therapies

Nonselective Beta-blockers

  • Eg Propranolol, Nadolol
  • May be used to relieve erythema & flushing

Clonidine

  • Low dose may be effective in controlling flushing esp in postmenopausal women

Emollients

  • May help soothe & repair damaged skin

Topical Steroids

  • May be used short term for severe inflammation
  • Potential for exacerbation & long-term side effects limit its use

Brimonidine

  • An alpha2-adrenergic agonist that reduces facial erythema through direct cutaneous vasoconstriction
  • Has minimal effects on cardiovascular or pulmonary hemodynamics & is used as an alternative in patients in whom topical beta-blocker therapy is contraindicated

Ivermectin

  • A synthetic derivative of avermectins that is used for the treatment of inflammatory lesions, bumps or pimples of rosacea produced by Streptomyces avermitilis
  • Exerts anti-inflammatory effects by inhibiting lipopolysaccharide induced production of inflammatory cytokines

Non-Pharmacological Therapy

Other Forms of Therapy

Ablation therapy

  • May be useful when telangiectatic component is prominent in moderate-severe erythematotelangiectatic rosacea
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