Diagnosis
History and Physical
Differential diagnosis.
Treatment
Treatment goals: 1) Decrease exposure to triggers, 2) Reduce bacterial burden, 3) Reduce inflammation.
Nonpharmacologic treatment
-Sunscreen with both UVA/ UVB protection via physical barriers (titanium dioxide or zinc oxide),
-Moisturizers.
-Avoid harsh cleansers with acetone & vasodilating drugs (e.g., CCBs or nicotinic acid).
-Avoid triggers!
Pharmacologic therapy:
“FDA-approved first-line agents for treating rosacea include metronidazole 0.75% lotion, 0.75% cream, and 1% gel; azelaic acid 15% gel; sulfacetamide 10%/sulfur 5% cream, foam, lotion, and suspension; brimonidine 0.33% gel; and ivermectin 1% cream.” ABFM
| Type | Treatment |
| Papulopustular rosacea (Inflammatory lesions) |
Topical tx: for mild disease, Metronizadole 0.75% gel or cream QD– BID (1st-line); Sulfacetamide / Sulfur 10%/5% cream and other formulations; QD or BID; azelaic acid 15% gel QD or BID, and several other options. Systemic tx: If mod/ severe, doxycycline 40mg QD or BID × 6– 12 wks; or minocycline 50– 100 mg BID × 6– 12 wks; or metronidazole 200 mg QD or BID × 4– 6 wks. Consider using this with topical maintenance treatment. Doxycycline is the only FDA-approved systemic tx for Rosacea. |
| Phymatous rosacea | Treat primarily with laser or light-based therapies and with surgical excision. |
| Erythematotelangiectatic | Focus on behavioral modification and trigger avoidance. These are hard to treat. The topical tx used for papulopustular subtype may actually irritate sensitive skin. The evidence is limited for light-based therapies for the destruction of vessels. |
| Ocular | Eyelid hygiene (flush lids with water BID). Use artificial tears for mild sx. Cyclosporine 0.5% ophthalmic emulsion (better than artificial tears). Refer promptly to ophthalmology for serious or persistent sx. Systemic abx may be used if local Rx fails |
Ivermectin 1% Cream (Soolantra) – works but is expensive.
Inflammation refers to papules, pustules, lesional and perilesional erythema, etc. Inflammation usually responds to medical treatment.
References and Further Reading
N Engl J Med 2017; 377:1754-1764. Rosacea. http://www.nejm.org/doi/full/10.1056/NEJMcp1506630
Am Fam Physician. 2015 Aug 1;92(3):187-196. Rosacea: Diagnosis and Treatment. https://www.aafp.org/afp/2015/0801/p187.html
N Engl J Med 2005; 352:793-803. Rosacea. http://www.nejm.org/doi/full/10.1056/NEJMcp042829
Cochrane Database Syst Rev. 2011 Mar 16;(3):CD003262. Interventions for rosacea. https://www.ncbi.nlm.nih.gov/pubmed/21412882
Pocket Primary Care.