Rosacea Treatment Algorithms

Ongoing research has suggested that rosacea may be caused or triggered by various possible factors, including defects of the immune system, nervous system, facial blood vessels and genetics, as well as the presence of microbes and Demodex mites. Meanwhile, there is now an expanding range of treatment options for its many potential signs and symptoms.

Rosacea often encompasses various combinations of signs and symptoms reflecting the chronic inflammatory and vascular pathophysiology of the disease, including the primary features of central facial flushing (transient erythema), nontransient erythema, papules and pustules, and telangiectasia, as well as secondary features that may include burning or stinging, plaques, dry appearance, edema, ocular manifestations, peripheral location and phymatous changes. All of these potential signs and symptoms are covered within the standard subtypes, which are common patterns found in rosacea, and management options are described in the following tables.1Recently approved therapies are presented in italics and referenced below.
 

Management Options for Subtype 1 (Erythematotelangiectatic) Rosacea

Clinical Features
Flushing and persistent erythema of the central face; possible telangiectases; easily irritated facial skin; burning and stinging may be reported; edema, roughness, or scaling may be present.

Grade

Typical Features by Grade

Therapeutic Approach

1
(mild)

Occasional mild flushing; faint persistent erythema; rare telangiectases

Identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation may be especially important in addition to an appropriate skin care regimen (including mild moisturizers and cleansers, and broad spectrum sun protection); nonirritating cosmetics may conceal the appearance of erythema and telangiectases.

2
(moderate)

Frequent troublesome flushing; moderate persistent erythema; several distinct telangiectases

In addition to above: prescription therapy is now available specifically for relief of persistent facial redness associated with rosacea.2 Long-pulsed dye or KTP lasers or IPL device or electrosurgery can remove telangiectases and reduce vascular erythema, and may reduce flushing.

3
(severe)

Frequent severe flushing; pronounced persistent erythema; possible edema; many prominent telangiectases; possible burning, stinging, roughness or scaling

In addition to above: flushing may be modulated by drugs specific to individual causes, such as NSAIDs for dry flushing, alpha-agonists or beta-blockers for neurally induced flushing (off-label), HRT for menopausal flushing; thermoregulatory flushing can be reduced by cooling the neck and mouth; emotionally induced flushing may benefit from psychological counseling or biofeedback.

Abbreviations: KTP, potassium-titanyl phosphate; IPL, intense pulsed light; NSAIDs, nonsteroidal anti-inflammatory drugs; HRT, hormone replacement therapy.
 

Management Options for Subtype 2 (Papulopustular) Rosacea

Clinical Features
Persistent erythema with transient papules and/or pustules of the central face; burning and stinging may be reported.

Grade

Typical Features by Grade

Therapeutic Approach

1
(mild)

Few to several papules or pustules without plaques; mild persistent erythema

Topical therapy, possibly with an initial course of oral antibiotic, to bring symptoms under control, and use topical medication alone to maintain remission; a controlled-release, subantimicrobial anti-inflammatory dose of oral antibiotic may be used. Topical therapy for persistent redness may also be considered.

2
(moderate)

Several to many papules or pustules without plaques; moderate persistent erythema

In addition to above: possibly an oral antibiotic in divided doses or a subantimicrobial anti-inflammatory dose until remission is achieved, with or followed by long-term topical or oral anti-inflammatory therapy. A topical therapy for inflammatory lesions of rosacea is now available that demonstrated superior results in moderate to severe cases in clinical trials.3

3
(severe)

Numerous and/or extensive papules or pustules with or without plaques; severe persistent erythema; possible burning and stinging

In addition to above: in refractory cases, alternative oral and topical therapies may be used; skin care regimen may address burning and stinging.

Management Options for Subtype 3 (Phymatous) Rosacea

Clinical Features
Skin thickening, irregular surface nodularities and enlargement; rhinophyma is most common, but other affected locations may include chin, forehead, cheeks and ears; patulous follicles and telangiectases may occur.

Grade

Typical Features by Grade

Therapeutic Approach

1
(mild)

Patulous follicles with no contour changes

Topical and systemic therapy as described for subtype 1 and 2 rosacea if persistent erythema and inflammatory lesions are present; carefully monitored isotretinoin may reduce incipient rhinophyma.

2
(moderate)

Change in contour without nodular component

In addition to above: may require surgical therapy, including cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting and dermabrasion; CO2 or erbium: YAG lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose.

3
(severe)

Change in contour with nodular component

See above.

Management Options for Subtype 4 (Ocular) Rosacea

Clinical Features
Watery or bloodshot appearance; foreign body sensation; burning or stinging; dryness; itching; light sensitivity; blurred vision; telangiectases of lid margins; lid and periocular erythema; blepharitis; recurrent conjunctivitis; styes (chalazion, hordeolum); episcleritis; iritis; and decreased visual acuity due to corneal complications (keratitis or ulcers) may occur.

Grade

Typical Features by Grade

Therapeutic Approach

1
(mild)

Signs and symptoms affecting the eyelid margin and meibomian glands

Artificial tears and cleansing of eyelashes.

2
(moderate)

Signs and symptoms affecting the inner eyelid, tear secretion, and/or ocular surface

In addition to above: ophthalmic antibiotic ointment may be applied to eyelashes; an oral antibiotic may also be effective; if severity increases, consultation with an ophthalmologist may be needed.

3
(severe)

Advanced or nonresponsive disease of the eyelid margin or ocular surface; episcleritis, iritis, or keratitis in addition to corneal damage and potential vision loss

Care by an ophthalmologist is required and may include a topical steroid, alternative oral medications and potential surgery.

 

References

1. Odom R, Dahl M, Dover J, et al. Standard management options for rosacea, part 2: Options according to subtype. Cutis 2009;84:97-104.

2. Fowler J Jr, Jackson M, Moore A, et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol 2013;12:650-656.

3. Stein Gold L, Kircik L, Fowler J, et al. on behalf of the Ivermectin Phase III Study Group. Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: Results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol 2014;13:316-323.

 

Acknowledgment: This section was reviewed and edited by Dr. Richard Odom, professor of clinical dermatology at the University of California - San Francisco and former president of the American Academy of Dermatology.

This page is made possible by funding from Galderma Laboratories, L.P.

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The National Rosacea Society is a 501(c)(3) nonprofit organization whose mission is to improve the lives of people with rosacea by raising awareness, providing public health information and supporting medical research on this widespread but little-known disorder. The information the Society provides should not be considered medical advice, nor is it intended to replace

consultation with a qualified physician. The Society does not evaluate, endorse or recommend any particular medications, products, equipment or treatments. Rosacea may vary substantially from one patient to another, and treatment must be tailored by a physician for each individual case. For more information, visit About Us.