Saturday, January 01, 2011
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
- Stop or taper off all topical corticosteroids. If the patient
has been using them, anticipate a flare when they are
- 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.
- Advise reduction or elimination of alcohol ingestion.
- 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
- 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.
- 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.
- Cases of mild rosacea may be controlled with topical
antibiotics, such as clindamycin.
- 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.
- 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.
Most patients with rosacea (except those in whom the rosacea was
induced or exacerbated by topical steroids) will require some form
of maintenance therapy.
- 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.
- Cases controlled with oral agents may occasionally require only
topical antibiotics for maintenance.
- Increase the tetracycline dosage to 1-2 g/day.
- Oral metronidazole 250 mg 2 or 3 times daily.
- Oral minocycline 100 mg once or twice daily will occasionally
control cases failing to respond to oral
- 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
- 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.
- 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
- 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
- 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
Telangiectasia and Erythema
- Individual telangiectases may be treated with bipolar
- 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
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
- Laser ablation may also be used for the treatment of
- 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.