Approach

Rosacea is a lifelong condition, with periods of remission with intermittent flare-ups.[20][39][40]

Initial presentation may be as a single phenotype or a combination. See Diagnostic criteria for more information on rosacea phenotypes.

The condition may progress not only in severity but also to include additional phenotypes.[1][16] Lifestyle changes, medical and laser/surgical treatment can minimise or control symptoms but there is no cure. Treatment should be tailored to individual patient phenotype/s.[16] Regimens with more than two distinct treatments are reserved for more severe rosacea.[39][40][41][42] Treatment should be continued until there is an improvement, or be continued indefinitely for maintenance, based on individual response.

Lifestyle changes for all patients with rosacea

Lifestyle changes may help to avoid exacerbation of symptoms such as flushing, facial redness, skin sensitivity, and dryness, and should be considered in all phenotypes.[14][15][16]

Avoidance of individual triggers

Advise patients to keep a diary recording exacerbations and anything they think may have contributed to them to help identify triggers.[16] Avoidance of individual triggers may help to maintain remission.

Common triggers include:[14][15][16]

  • Sun/ultraviolet exposure

  • Hot, cold, or windy weather

  • Humidity, indoor heating, hot baths, hot beverages

  • Heavy exercise

  • Alcohol consumption

  • Spicy foods

  • Emotional stress

  • Some skincare and toiletry products (e.g., those that contain menthol, camphor, or sodium lauryl sulfate)

  • Some medicines (e.g., amiodarone; nasal corticosteroids; and, paradoxically, topical corticosteroids)

  • Some fruits and vegetables, or certain dairy products.

Identify and treat potential causes of hot flushes (e.g., menopause, hyperthyroidism) to help prevent exacerbations of rosacea.

Skincare and sun protection

Patients should wash with emollients and moisturise regularly.[14][16] Yellow- or green-tinted cosmetics may help camouflage erythema.[14][43]

Sun cream containing zinc oxide or titanium dioxide is recommended.[16] Advise patients to avoid the midday sun and to wear a wide-brimmed hat when out in the sun.

Fixed centrofacial erythema (diagnostic phenotype)

Topical alpha agonists

The most effective topical treatments for persistent facial erythema are topical alpha agonists (e.g., brimonidine, oxymetazoline).[14][15][16][44]

Laser treatment

Pulsed-dye and potassium titanyl phosphate (KTP) lasers effectively reduce erythema.[15][16][44] The British Association of Dermatologists recommends neodymium-doped yttrium aluminium garnet (Nd:YAG) or intense pulsed light to treat persistent facial erythema.[14]

Phymatous changes (diagnostic phenotype)

Management depends on the stage (early vs. fibrotic) and whether inflammation is active or burnt out.[15]

Early soft changes due to sebaceous hyperplasia may improve with oral isotretinoin.[15] As isotretinoin is teratogenic, all women should have a pregnancy test before starting the drug and subsequently monthly while taking it. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme. MHRA: oral retinoids - pregnancy prevention Opens in new window In the US, isotretinoin can only be prescribed through the iPledge system. iPledge system (for isotretinoin prescribing) Opens in new window These initiatives are aimed at decreasing the number of birth defects associated with this medicine.

Surgical options should be considered for fully developed phymatous changes. They include ablative lasers; carbon dioxide laser, erbium-doped yttrium aluminium garnet (YAG); electrosurgery; radiofrequency and surgical shaving; and dermabrasion.[15][16][45][46][47]

Papules and pustules (major phenotype)

Combined topical and systemic therapy is often used in the initial treatment of papules and pustules, with long-term use of a single therapy to maintain remission.[16] There is no simple treatment algorithm that is suitable for all, and these drugs are often attempted in a trial-and-error fashion until an optimal regimen is reached.

Topical therapy

Topical azelaic acid, ivermectin, or metronidazole should be offered as first-line treatment options to patients with papulopustular rosacea.[14][15][16] [ Cochrane Clinical Answers logo ]

Alternative topical treatments include sulfacetamide/sulfur, a calcineurin inhibitor (e.g., tacrolimus, pimecrolimus), a retinoid (e.g., adapalene), or permethrin.[16][48][49]

Systemic therapy

Low-dose delayed-release oral doxycycline is recommended as initial systemic therapy. It has been shown to be safe for long-term use with few adverse effects, and has not been associated with the development of bacterial resistance.[16]

For refractory symptoms, options include an alternative oral antibiotic (e.g., tetracycline or azithromycin) or a retinoid (e.g., isotretinoin).[16] As isotretinoin is teratogenic, all women should have a pregnancy test before starting the drug and subsequently monthly while taking it. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme. MHRA: oral retinoids - pregnancy prevention Opens in new window In the US, isotretinoin can only be prescribed through the iPledge system. iPledge system (for isotretinoin prescribing) Opens in new window These initiatives are aimed at decreasing the number of birth defects associated with this medicine.

The use of tetracycline during pregnancy may cause tooth staining in the baby.[16]

Flushing (major phenotype)

Treatment of transient erythema and flushing beyond lifestyle changes, skincare, and sun protection is unclear and there is no randomised controlled trial evidence.[44] The use of oral medications to control flushing is off-label and not routine practice. 

Telangiectasia (major phenotype)

People with rosacea should be advised that telangiectasia will become more prominent with the treatment of erythema.

Pulsed-dye and KTP lasers are effective in obliterating telangiectasia.[15][16][44] Laser therapy may be offered at any time during treatment.[50]

Ocular manifestations (major phenotype)

Avoidance of triggers

Medicines (e.g., antidepressants and anxiolytics) that could trigger dry eye should be identified and changed.[14]

Patients should avoid eye make-up and environments that are smoky, have air conditioning, or have excessive central heating.[14]

Eyelash hygiene

Warm compresses, lid hygiene wipes, and ocular lubricants or liposomal sprays can alleviate symptoms in people with ocular rosacea.[14]

Omega-3 fatty acids

Advise patients to take omega-3 fatty acid supplements.[15][16] One randomised controlled trial found that symptoms of ocular rosacea were reduced for patients taking omega-3 fatty acids for 6 months.[44][51]

Topical therapy

A topical ophthalmic antibiotic (e.g., azithromycin), a topical calcineurin inhibitor (e.g., tacrolimus, pimecrolimus), or topical ivermectin may be used if there is blepharitis and to aid the removal of any collarettes.[15][16]

Topical azithromycin is as effective as oral doxycycline for treating ocular rosacea and has fewer adverse effects.[52][53]

Use of topical ciclosporin drops may be effective in decreasing the topical inflammation.[16][40][44][50][54]

Systemic therapy

An oral tetracycline, such as low-dose delayed-release doxycycline, may be used.[16][44] A macrolide antibiotic may also be considered as an alternative.[15]

Referral to ophthalmologist

Refer patients to an ophthalmologist if:[14][16]

  • Eye discomfort and/or sticky eye discharge persist for >12 months despite ocular lubricant use >6 times/day and other adequate eyelash hygiene

  • 'Red flag' symptoms are present (e.g., reduced vision, pain on eye movement, pain that keeps the patient awake at night).

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