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Therapeutic Strategies


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Acne Rosacea

Rosacea is a follicularly based inflammatory process of unknown cause. Those affected by rosacea may have facial erythema, telangiectasia, papules and pustules, or sebaceous hyperplasia of the nose (rhinophyma). Effective medical treatment is available only for the papular and pustular components. The telangiectasia and rhinophyma may be surgically treated (see below), but only after the patient has had adequate medical therapy. Mild-to-moderate improvement of the erythema may occur during therapy. The initial therapeutic strategy is to suppress the follicular inflammation.

First Steps

  1. Stop or taper off all topical corticosteroids. If the patient has been using them, anticipate a flare when they are discontinued.
  2. Educate the patient on photoprotection. Sunscreens should be noncomedogenic. In general rosacea patients have very sensitive skin and are intolerant to many facial products, including sunscreens. Moisturizing-cream-based products with UVA coverage are best tolerated and most effective.
  3. Advise reduction or elimination of alcohol ingestion.
  4. For mild-to-moderate papulopustular rosacea, topical metronidazole 0.75% cream or gel twice daily or 1% cream once daily is recommended. The cream-based products are tolerated better by those patients with sensitive skin or intolerance to topical products.
  5. For moderate-to-severe papulopustular rosacea, prescribe oral tetracycline 250 mg to 500 mg twice daily, or doxycycline 50 mg to 100 mg once daily.
  6. Patients with rosacea often have ocular involvement. Ask all rosacea patients whether they have ocular symptoms (red, scratchy eyes or the feeling of grit or a foreign body in the eye). Examine their eyes for redness. Referral to an ophthalmologist is recommended for symptomatic patients. Ocular rosacea may necessitate oral antibiotic therapy.

Alternative Steps

  1. Cases of mild rosacea may be controlled with topical antibiotics, such as clindamycin.
  2. For mild papulopustular rosacea, creams or washes containing sodium sulfacetamide and sulfur can be very effective alone, or as an adjunct to oral antibiotics. They are especially useful in patients with coexistent seborrheic dermatitis. Some are available with green cover-up tint.
  3. Patients with rosacea have sensitive skin in general and tolerate topical agents poorly. Tretinoin and benzoyl peroxide, while potentially effective, are not usually recommended owing to this sensitivity. In patients with oily skin and rosacea, these agents may be useful.

Subsequent Steps

Most patients with rosacea (except those in whom the rosacea was induced or exacerbated by topical steroids) will require some form of maintenance therapy.

Initially Improved

  1. Taper the oral or topical therapy by 50% each month until the patient begins to improve. Often very low dose tetracycline (eg, 250 mg twice weekly) is an adequate maintenance dose.
  2. Cases controlled with oral agents may occasionally require only topical antibiotics for maintenance.

Initially Unimproved

  1. Increase the tetracycline dosage to 1-2 g/day.
  2. Oral metronidazole 250 mg 2 or 3 times daily.
  3. Oral minocycline 100 mg once or twice daily will occasionally control cases failing to respond to oral tetracycline/doxycycline.
  4. Oral amoxicillin 250 mg to 500 mg 2 to 3 times daily may be effective in refractory cases. While oral quinolones (ciprofloxacin) and macrolides (clarithromycin) can be effective in refractory cases, they are considerably more expensive than amoxicillin.
  5. In severe, refractory cases, isotretinoin in low doses (0.5-1.0 mg/kg/day) will usually control the rosacea. Effective contraception must be ensured in all potentially fertile female patients treated with isotretinoin. Monthly pregnancy tests during treatment are required.


  1. Tetracycline, doxycycline, minocycline, and isotretinoin are contraindicated in pregnancy. Two effective methods of contraception, two negative pregnancy tests, and extensive counseling are required before a woman of childbearing potential is administered isotretinoin.
  2. Patients taking oral metronidazole may develop a disulfiram reaction when ingesting alcohol. Oral metronidazole should be used only to control the rosacea, and not as ongoing maintenance therapy.
  3. Patients whose rosacea is induced or exacerbated by topical steroids may suffer a severe flare after they discontinue the steroid. The care provider must warn the patient of this, and explain that although the topical steroid appears to improve the rosacea, it is actually causing it as well. Oral antibiotics may be required, even for mild steroid rosacea, to help suppress this rebound flare.

Surgical Treatment

Telangiectasia and Erythema

  1. Individual telangiectases may be treated with bipolar electrosurgery.
  2. Laser therapy may be used for both the persistent erythema and the telangiectasia. The telangiectasia responds better than the background erythema, and response is variable from patient to patient.


Surgical procedures for the reduction of rhinophyma are uniformly successful, have a low complication rate, and give high patient satisfaction. Patients who are psychologically distressed by their appearance should be encouraged to seek dermatologic surgery consultation.

  1. Laser ablation may also be used for the treatment of rhinophyma.
  2. Cold-steel surgery, electrosurgery, and dermabrasion are also effective, but they are more difficult owing to the vascularity of the nose, and have largely been replaced by laser treatment.

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