Treatment Algorithms for Patients

Rosacea sufferers have more options than ever before — but what is the best option for your personal condition? The National Rosacea Society created a treatment algorithm to assist healthcare providers in deciding what treatment options may be most effective for a particular patient’s combination of signs and symptoms.

While rosacea was once classified into four subtypes, the most up to date model of the disease identifies its individual characteristics (also known as phenotypes) which may appear in different combinations and at different times. This model recognizes that rosacea is different in every patient, and treatment should be tailored for each individual case.

The following are guides to the recommended treatment approaches for each sign and symptom of rosacea, at every level of severity from mild to severe. It may be helpful to share this with your healthcare provider as you discuss therapeutic options for the signs and symptoms you personally experience.

Persistent Redness (aka Erythema)

Persistent redness (which may appear brown or purplish in darker skin tones) in the center of the face that may grow more intense. This is the most common sign of rosacea. Many sufferers have a history of blushing and flushing, and burning and stinging sensations are also common.

GradeTypical FeaturesTreatment Approach

Mild

 

Faint persistent redness
  • Identifying and avoiding environmental and lifestyle triggers.
  • An appropriate skin care regimen using mild moisturizers and cleansers.
  • Strong sun protection with a minimum of 30 SPF sunscreen.
  • Concealing redness with nonirritating cosmetics.

Moderate

 

Moderate persistent redness

In addition to the above:

  • Daily application of topical medication, including oxymetazoline or brimonidine.
  • Intense pulsed light (IPL) therapy
  • Laser treatment may reduce redness in patients with pale to very light skin tone.

Severe

 

Pronounced persistent redness

In addition to the above:

  • Oral medication, including low-dose minocycline or doxycycline, or carvedilol.

 

Skin Thickening (Phymatous Changes)

The skin may thicken and enlarge from excess tissue, most commonly on the nose (known as rhinophyma, pronounced “rye-no-FYE-muh”) but the chin, forehead, cheeks and ears may also be affected. While this condition is less common, in severe cases, abnormal tissue growth can lead to facial disfigurement and trouble breathing.

GradeTypical FeaturesTreatment Approach

Mild fixed
 
or
 
Active any grade

 

Inflammation leading to enlarged pores and skin thickening with minimal changes to the shape and contours of the affected area.

Active swelling and tissue growth, no matter how severe the underlying changes are
  • Carefully monitored oral isotretinoin may also reduce enlargement of the nose in the early stages.
  • Topical retinoids or oral antibiotics, in combination with surgical intervention for growth of the nose, as described below.

Moderate or severe fixed

 

Noticeable change in the shape and contour of the skin in the affected area, with or without excess tissue growth

In addition to the approaches above:
 

  • Dermabrasion to remove thickened skin. Surgery may be required to reshape the affected area. Surgical options include certain lasers, cryosurgery, electrosurgery, cold steel and other techniques.

 

Bumps and Pimples (Papules and Pustules)

Dome-shaped red bumps (papules) with or without accompanying pimples (pustules). These may occur in groups and are usually most pronounced in the center of the face. Patients who also have acne may develop blackheads, but this is unrelated to rosacea. Sometimes bumps and pimples may join together to form larger raised areas of skin, known as plaques.

GradeTypical FeaturesTreatment Approach

Mild

 

A few bumps and pimples, with mild redness
  • Topical medication such as microencapsulated benzoyl peroxide, ivermectin, azelaic acid, minocycline or metronidazole.
  • Oral antibiotics may be prescribed initially to control symptoms before or at the same time as a topical therapy. Alternatively, low-dose oral minocycline or doxycycline may be used long-term on its own.
  • Topical sulfacetamide sodium/sulfa may also be effective.

Moderate

 

Several to many bumps and pimples without plaques, with moderate redness

In addition to the approaches above:
 

  • Low-dose minocycline or doxycycline to achieve remission, along with or followed by long-term topical or oral therapy.
  • Topical oxymetazoline or brimonidine may be used to reduce redness around bumps and pimples

Severe

 

Numerous and/or extensive bumps and pimples with or without plaques, accompanied by severe redness and potential burning and stinging sensations

In addition to the approaches above:
 

  • In cases that resist treatment, alternative therapies such as topical clindamycin or retinoids, or oral antibiotics, isotretinoin or trimethoprim/sulfamethoxazole may be used.

 

Telangiectasia

Telangiectasia are fine capillary blood vessels that may be red to purplish, appearing alone or in spidery clusters on the cheeks, nose, forehead or chin. Special equipment may be required to detect them in patients with darker skin.

GradeTypical FeaturesTreatment Approach

All

 

Telangiectasia on the nose, cheeks, forehead or chin
  • Certain types of lasers, intense pulse light (IPL) treatment, or electrosurgery can remove the blood vessels and reduce associated redness.
  • Topical retinoids may also eliminate telangiectasia.

 

Flushing

Many people with rosacea have a history of frequent blushing or flushing. This temporary facial redness may be accompanied by a sense of heat, warmth or burning that comes and goes, and is often an early sign of the disorder. In contrast with persistent redness (erythema), flushing may occur within seconds to minutes in response to a trigger factor.

GradeTypical FeaturesTreatment Approach

Mild

 

Occasional mild flushing/redness
  • Cool compress on face or neck.
  • Intense Pulsed Light (IPL) therapy may reduce the flushing response.

Moderate

 

Frequent flushing accompanied by burning and stinging sensations

In addition to the above:

  • Topical medications like oxymetazoline, brimonidine or ivermectin, and oral therapies like carvedilol, clonidine or propranolol may reduce the flushing response.

Severe

 

Frequent severe flushing extending beyond the face to the neck and chest, accompanied by severe burning and stinging

In addition to the above:

  • KTP (green-light) laser treatment may reduce the flushing response.
  • Medications addressing individual causes may also be prescribed: nonsteroidal anti-inflammatory drugs (NSAIDs) for dry flushing, alpha-agonists or beta-blockers for wet flushing (off-label), or hormone replacement therapy (HRT) for menopausal flushing.
  • Rising core body temperature can activate thermoregulatory flushing, and may be reduced by cooling the neck and mouth. Emotionally induced flushing may benefit from psychological counseling or biofeedback.

In addition, gentle skin care may help reduce flushing. Because sun exposure is a major trigger for flushing and persistent redness, sun protection is important. Mineral sunscreens that contain zinc oxide or titanium dioxide are preferable, because they do not produce heat as a byproduct. Skin-care products that contain anti-inflammatory ingredients, such as allantoin, licorice root extract, sulfur or aloe vera, may also be helpful.

 

Eye Involvement (Ocular Rosacea)

In many rosacea patients, the eyes may be irritated and appear watery or bloodshot, a condition commonly known as ocular rosacea. The eyelids also may become red and swollen, and styes are common. Crusts and scale may accumulate around the eyelids or eyelashes, and patients may notice visible blood vessels around the lid margins. Severe cases can result in corneal damage and loss of vision without medical help. Approximately 20% of patients experience eye signs and symptoms from rosacea before any skin involvement, and some only experience ocular rosacea.

Any patient experiencing ocular signs and symptoms should see an ophthalmologist for treatment.

GradeTypical FeaturesTreatment Approach

Mild

 

Signs and symptoms affecting the eyelid margin and oil-producing (meibomian) glands along the eyelashes
  • Apply a warm compress to the eyes.
  • Gently cleanse the eyelashes once or twice a day with baby shampoo.
  • Artificial tears may help with dry eye or styes.

Moderate

 

Signs and symptoms affecting the inner eyelid, tear creation, and/or surface of the eye

In addition to the approaches above:
 

  • Antibiotic eyedrops or tacrolimus ointment applied to eyelashes.
  • Cyclosporine eyedrops may reduce inflammation.
  • A health provider may prescribe oral cyclosporine or another subantimicrobial antibiotic for two to three months.
  • Treatment with an intense pulse light (IPL) device may improve eye surface health and meibomian gland function.

Severe

 

Advanced disease of the eyelid margin or surface of the eye, including inflammation of the “white” of the eye, iris, or cornea; corneal damage; or vision loss

In addition to the above:

  • Treatment by an ophthalmologist is required, and may include topical steroids, alternative oral medications, and potentially surgery.

 

 

Treatment Brand Name Index

  • Topical azelaic acid: Finacea
  • Topical microencapsulated benzoyl peroxide: Epsolay
  • Topical brimonidine: Mirvaso
  • Oral doxycycline: Oracea
  • Topical ivermectin: Soolantra
  • Topical metronidazole: Metrogel, Noritate, Rosadan, others
  • Oral minocycline: Emrosi
  • Topical minocycline: Zilxi
  • Topical oxymetazoline: Rhofade
  • Topical sulfacetamide sodium/sulfa: Plexion,Avar, Sulfacleanse, others

 

Acknowledgment: This section was reviewed and edited by Dr. Zoe Diana Draelos, FAAD.

This page is made possible by funding from Mayne Pharma.