The Management of Rosacea

There is no cure for rosacea. Management includes avoidance of exacerbating factors, medications to suppress the inflammatory lesions and the use of surgery or laser therapy for phymatous disease and telangectasias. Treatment is guided by the predominant subtype of rosacea the patient has.

Patients with rosacea have sensitive skin, so mild cleansers and emollients are advised. All patients with rosacea should apply sunscreens daily to prevent the development of facial photodamage that will exacerbate the redness of rosacea. Patients should attempt to identify aggravating factors to flushing and avoid these, and be advised that effective cosmetic coverage can neutralise erythema.

Erythematotelangectatic rosacea is difficult to treat. Where telangiectatic vessels are significant pulsed dye laser therapy, which causes selective photothermolysis, can be employed. This results in coagulation of the superficial vessels without associated dermal damage.

Topical and systemic antibiotics are the principal treatments for papulopustular rosacea. Topical metronidazole is both antibacterial and anti-inflammatory, and application twice daily results in less erythema and a reduction in inflammatory lesions. Topical metronidazole should be used with caution in women of child bearing age who are not taking oral contraception as it potentially can be absorbed and has mutagenic side effects.

Sodium sulfacetamide (antibacterial) and sulfur (keratolytic) topically can be used. Azelaic acid (antibacterial, anti-inflammatory) top- ically is comparable in efficacy to topical metronidazole. Topical erythromycin (antibacterial; anti-inflammatory) is another effective therapy.

Systemic agents, with or without concurrent topical treatment, are indicated in moderate to severe (grades 2 and 3) papulopustular rosacea.

Systemic agents such as oxytetracycline, doxycycline, erythromycin and minocycline, are most frequently used. Treatment should be for four to 12 weeks. Once systemic treatments are ceased, topical therapy is then continued to maintain a remission.

Rhinophyma is uncommon. Grades 2 and 3 rhinophyma can be effectively treated with surgical excision, electrosurgery or CO2 – laser therapy.

Ocular rosacea is common and usually mild. It is treated with good eyelid hygiene and warm compresses, artificial tears and topical application of metronidazole gel to the eyelid margins. Grades 2 and 3 may require treatment with systemic antibiotics. Referral to an ophthalmologist should be made if symptoms are persistent or severe.