Rosacea: Diagnosis and Treatment

 

Am Fam Physician. 2015 Aug 1;92(3):187-196.

  Patient information: See related handout on rosacea, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Rosacea is a chronic facial skin condition of unknown cause. It is characterized by marked involvement of the central face with transient or persistent erythema, telangiectasia, inflammatory papules and pustules, or hyperplasia of the connective tissue. Transient erythema, or flushing, is often accompanied by a feeling of warmth. It usually lasts for less than five minutes and may spread to the neck and chest. Less common findings include erythematous plaques, scaling, edema, phymatous changes (thickening of skin due to hyperplasia of sebaceous glands), and ocular symptoms. The National Rosacea Society Expert Committee defines four subtypes of rosacea (erythematotelangiectatic, papulopustular, phymatous, and ocular) and one variant (granulomatous). Treatment starts with avoidance of triggers and use of mild cleansing agents and moisturizing regimens, as well as photoprotection with wide-brimmed hats and broad-spectrum sunscreens (minimum sun protection factor of 30). For inflammatory lesions and erythema, the recommended initial treatments are topical metronidazole or azelaic acid. Once-daily brimonidine, a topical alpha-adrenergic receptor agonist, is effective in reducing erythema. Papulopustular rosacea can be treated with systemic therapy including tetracyclines, most commonly subantimicrobial-dose doxycycline. Phymatous rosacea is treated primarily with laser or light-based therapies. Ocular rosacea is managed with lid hygiene, topical cyclosporine, and topical or systemic antibiotics.

Rosacea is a chronic facial skin condition characterized by marked involvement of the central face with transient or persistent erythema, inflammatory papules or pustules, telangiectasia, or hyperplasia of the connective tissue.1,2 Transient erythema, or flushing, usually lasts less than five minutes and may spread to the neck and chest, often accompanied by a feeling of warmth. Less common findings include erythematous plaques, scaling, edema, phymatous changes (thickening of skin due to hyperplasia of sebaceous glands), and ocular symptoms. Rosacea can be associated with low self-esteem, embarrassment, and diminished quality of life. In a national survey, 65% of patients with rosacea reported symptoms of depression.3

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Mild cleansers and moisturizers, broad-spectrum sunscreens (sun protection factor [SPF] 30 or greater), and sun avoidance measures should be used to manage all cutaneous rosacea subtypes.

C

13, 15, 16

First-line therapy for mild to moderate inflammatory rosacea includes topical metronidazole (Metrolotion, Metrocream, Metrogel) or azelaic acid (Finacea).

A

19

Brimonidine (Mirvaso) can be used to treat persistent facial erythema associated with rosacea.

A

17, 21

Topical ivermectin (Soolantra) may be used for the treatment of papulopustular rosacea.

B

18

Subantimicrobial-dose doxycycline (Oracea) can be used to treat inflammatory lesions of papulopustular rosacea.

A

19, 27

Subantimicrobial-dose doxycycline in combination with topical azelaic acid or metronidazole can be used to treat moderate to severe inflammatory lesions or mild inflammatory lesions that have not responded to initial therapy.

C

17, 26, 29

Mild ocular rosacea should be treated with eyelid hygiene and topical antibiotic agents, such as metronidazole and erythromycin.

C

30, 31

Topical ophthalmic cyclosporine drops (Restasis) are more effective than artificial tears in the management of mild ocular rosacea.

B

19


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Mild cleansers and moisturizers, broad-spectrum sunscreens (sun protection factor [SPF] 30 or greater), and sun avoidance measures should be used to manage all cutaneous rosacea subtypes.

C

13, 15, 16

First-line therapy for mild to moderate inflammatory rosacea includes topical metronidazole (Metrolotion, Metrocream, Metrogel) or azelaic acid (Finacea).

A

19

Brimonidine (Mirvaso) can be used to treat persistent facial erythema associated with rosacea.

A

17, 21

Topical ivermectin (Soolantra) may be used for the treatment of papulopustular rosacea.

B

18

Subantimicrobial-dose doxycycline (Oracea) can be used to treat inflammatory lesions of papulopustular rosacea.

A

19, 27

Subantimicrobial-dose doxycycline in combination with topical azelaic acid or metronidazole can be used to treat moderate to severe inflammatory lesions or mild inflammatory lesions that have not responded to initial therapy.

C

17, 26, 29

Mild ocular rosacea should be treated with eyelid hygiene and topical antibiotic agents, such as metronidazole and erythromycin.

C

30, 31

Topical ophthalmic cyclosporine drops (Restasis) are more effective than artificial tears in the management of mild ocular rosacea.

B

19


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The exact prevalence of rosacea in the United States is unknown4,5; however, it is probably between 1.3% and 2.1%, and may be as high as 5%.6 Women are affected more often than men, but men are more likely to have phymatous changes, especially rhinophyma.7

Subtypes

The National Rosacea Society Expert Committee defined four subtypes (Table 1) and one variant.8 Granulomatous rosacea is the sole variant with firm, indurated papules or nodules. Many dermatologists consider rosacea fulminans and perioral dermatitis as rosacea variants. Patients may experience fluctuation in symptoms and overlapping of symptoms between subtypes.9

View/Print Table

Table 1.

Subtypes and Variants of Rosacea and Their Characteristics

ClassificationCharacteristics

Subtype

Erythematotelangiectatic

Flushing and persistent central facial erythema with or without telangiectasia

Papulopustular

Persistent central facial erythema with transient, central facial papules or pustules or both

Phymatous

Thickening skin, irregular surface nodularities and enlargement; may occur on the nose, chin, forehead, cheeks, or ears

Ocular

Foreign body sensation in the eye, burning or stinging, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera or other parts of the eye, or periorbital edema

Variant

Granulomatous

Noninflammatory; hard; brown, yellow, or red cutaneous papules; or nodules of uniform size


note: Photos of these subtypes of acne rosacea are available at http://www.aafp.org/afp/2009/0901/p461.html.

Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):586. http://www.sciencedirect.com/science/journal/01909622/.

Table 1.

Subtypes and Variants of Rosacea and Their Characteristics

ClassificationCharacteristics

Subtype

Erythematotelangiectatic

Flushing and persistent central facial erythema with or without telangiectasia

Papulopustular

Persistent central facial erythema with transient, central facial papules or pustules or both

Phymatous

Thickening skin, irregular surface nodularities and enlargement; may occur on the nose, chin, forehead, cheeks, or ears

Ocular

Foreign body sensation in the eye, burning or stinging, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera or other parts of the eye, or periorbital edema

Variant

Granulomatous

Noninflammatory; hard; brown, yellow, or red cutaneous papules; or nodules of uniform size


note: Photos of these subtypes of acne rosacea are available at http://www.aafp.org/afp/2009/0901/p461.html.

Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):586. http://www.sciencedirect.com/science/journal/01909622/.

Pathophysiology

The etiology of rosacea is unknown but is likely multifactorial. Factors involved in the pathophysiology include the dense presence of sebaceous glands on the face, the physiology of the nerve innervation, and the vascular composition of the skin.10  Numerous triggers initiate or aggravate the clinical manifestations of rosacea, including ultraviolet light, heat, spicy foods, and alcohol (Table 2).4,11

View/Print Table

Table 2.

Triggers Associated with Worsening Rosacea Symptoms

TriggerPatients with rosacea who report trigger (%)

Sun exposure

81

Emotional stress

79

Hot weather

75

Wind

57

Strenuous exercise

56

Alcohol consumption

52

Cold weather

46

Spicy foods

45

Certain skin care products

41

Heated beverages

36

Certain cosmetics (comedogenic)

27

Medications (topical steroids, niacin, beta blockers)

15

Dairy products

8

Other factors

24


Information from references 4 and 11.

Table 2.

Triggers Associated with Worsening Rosacea Symptoms

TriggerPatients with rosacea who report trigger (%)

Sun exposure

81

Emotional stress

79

Hot weather

75

Wind

57

Strenuous exercise

56

Alcohol consumption

52

Cold weather

46

Spicy foods

45

Certain skin care products

41

Heated beverages

36

Certain cosmetics (comedogenic)

27

Medications (topical steroids, niacin, beta blockers)

15

Dairy products

8

Other factors

24


Information from references 4 and 11.

A predilection for fair-skinned individuals of Celtic or northern European descent suggests a genetic component to rosacea.10 However, no specific gene has been identified.4 Patients with the genetic predisposition have a receptor that mediates neovascular regulation. When exposed to triggers, neuropeptide release (flushing, edema) occurs, resulting in recruitment of proinflammatory cells to the skin.10

Diagnosis

Rosacea is diagnosed based on a compatible history and physical examination12  (Table 38). One of the following centrofacial features is required: flushing, nontransient erythema (Figures 1A and 1B), telangiectasia (Figure 1C), or papules/pustules8 (Figures 2A and 2B). Laboratory testing is not useful.

View/Print Table

Table 3.

Guidelines for the Diagnosis of Rosacea

Presence of one or more of the following primary features:

May include one or more of the following secondary features:

Flushing (transient erythema)

Burning or stinging

Nontransient erythema

Plaque

Papules and pustules

Dry appearance

Telangiectasia

Edema

Ocular manifestations

Peripheral location

Phymatous changes


Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):585. http://www.sciencedirect.com/science/journal/01909622/.

Table 3.

Guidelines for the Diagnosis of Rosacea

Presence of one or more of the following primary features:

May include one or more of the following secondary features:

Flushing (transient erythema)

Burning or stinging

Nontransient erythema

Plaque

Papules and pustules

Dry appearance

Telangiectasia

Edema

Ocular manifestations

Peripheral location

Phymatous changes


Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):585. http://www.sciencedirect.com/science/journal/01909622/.

View/Print Figure

Figure 1.

Facial erythema with telangiectasia. (A) Frontal view of centrofacial erythema. (B) Close-up view of centrofacial erythema with scaling. (C) Close-up view of telangiectasias on lateral chin.


Figure 1.

Facial erythema with telangiectasia. (A) Frontal view of centrofacial erythema. (B) Close-up view of centrofacial erythema with scaling. (C) Close-up view of telangiectasias on lateral chin.

View/Print Figure

Figure 2.

Inflammatory lesions (papules and pustules). (A) Papulopustular lesions and scaling on the lateral nose. (B) Close-up view of papulopustular rosacea.


Figure 2.

Inflammatory lesions (papules and pustules). (A) Papulopustular lesions and scaling on the lateral nose. (B) Close-up view of papulopustular rosacea.

Patients may receive a misdiagnosis of skin conditions that share similar features. Rosacea is commonly misdiagnosed as adult acne vulgaris, photodermatitis, seborrheic dermatitis, or contact dermatitis. Table 4 lists features that distinguish these conditions from rosacea. Less common mimicking conditions include systemic lupus erythematosus, atopic dermatitis, folliculitis, bromoderma, and mastocytosis.

View/Print Table

Table 4.

Skin Conditions That Share Similar Features with Rosacea

ConditionDistinguishing features

Acne vulgaris

Comedone formation

No ocular symptoms

Contact dermatitis

Associated with itching and often improves over time when causative agent is removed

Photodermatitis

Rash appears on multiple body parts with sunlight exposure

Seborrheic dermatitis

Has distinct distribution pattern involving the scalp, eyebrows, and nasolabial folds

Systemic lupus erythematosus

Rarely has pustules

Table 4.

Skin Conditions That Share Similar Features with Rosacea

ConditionDistinguishing features

Acne vulgaris

Comedone formation

No ocular symptoms

Contact dermatitis

Associated with itching and often improves over time when causative agent is removed

Photodermatitis

Rash appears on multiple body parts with sunlight exposure

Seborrheic dermatitis

Has distinct distribution pattern involving the scalp, eyebrows, and nasolabial folds

Systemic lupus erythematosus

Rarely has pustules

Treatment

GENERAL MEASURES

Although rosacea findings may change over time, no proven natural progression exists.13  Treatment decisions are based on the patient's current clinical manifestations (Table 5).

View/Print Table

Table 5.

Management of Rosacea

Central facial erythemaPhymatousOcular

Without papulopustular lesionsWith papulopustular lesions

Mild to moderateModerate to severe

General measures

Evaluate severity of erythema, inflammation, telangiectasia, and associated symptoms

Begin mild nonalkaline skin cleansing and moisturizing regimen

Avoid astringents, toners, abrasives, fragrances, and sensory stimulants (e.g., camphor, menthol, alcohol, acetone)

Use broad-spectrum sunscreen; sun protection factor (SPF) 30 or greater (zinc oxide or titanium dioxide)

Educate on trigger avoidance

Consider use of yellow- or green-tinted cosmetics to conceal redness

Same as for mild to moderate

Same as for central facial erythema

Lid hygiene (warm compresses and cleansing of lashes and lids with baby shampoo scrubs)

First-line therapy

Topical metronidazole (Metrogel, Metrocream, Metrolotion); azelaic acid (Finacea), or brimonidine (Mirvaso) for erythema

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for erythema and telangiectasia

Topical metronidazole or azelaic acid for inflammation and erythema

Topical brimonidine for erythema if needed as adjunctive therapy; may be used in combination with metronidazole or azelaic acid for erythema

Topical ivermectin for inflammation; may be used in combination with azelaic acid or metronidazole

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for telangiectasia

Topical metronidazole or azelaic acid for inflammation plus subantimicrobial (anti-inflammatory) dose of doxycycline (Oracea), 40 mg once per day or 20 mg twice per day

Topical brimonidine for erythema if needed as adjunctive therapy

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for telangiectasia

Isotretinoin, 0.3 to 1 mg per kg per day for 12 to 28 weeks

Microdose therapy for maintenance

Topical antibiotics (metronidazole or erythromycin)

Second-line therapy

Alternate topical therapies (sulfacetamide/sulfur, benzoyl peroxide, erythromycin, clindamycin)

or

Subantimicrobial (anti-inflammatory) dose doxycycline, 40 mg once per day or 20 mg twice per day, alone or in combination with topical agents

If limited or no response at 8 to 12 weeks, consider antimicrobial (antibiotic) dose of doxycycline (100 to 200 mg once per day)

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser, and carbon dioxide laser)

Dermabrasion, electroscalpel, electrosurgery, loop cautery

Oral tetracyclines (preferred), or metronidazole or azithromycin (Zithromax)

Cyclosporine ophthalmic emulsion (Restasis)

Ophthalmologic referral

Third-line therapy

If limited or no response at 8 to 12 weeks, consider antimicrobial (antibiotic) dose of doxycycline (100 to 200 mg once per day)

Topical retinoids

If limited or no response at reassessment, consider alternative oral antibiotic (tetracycline, minocycline [Minocin], metronidazole [Flagyl], azithromycin) and/or topical treatment (sulfacetamide/sulfur, benzoyl peroxide, erythromycin, clindamycin, permethrin [Elimite])

Refractory

Consider treatment in the moderate to severe category

If refractory to treatment, consider oral isotretinoin (requires participation in online risk reduction program, iPledge: https://www.ipledgeprogram.com)


Nd:YAG = neodymium:yttrium-aluminum-garnet.

Table 5.

Management of Rosacea

Central facial erythemaPhymatousOcular

Without papulopustular lesionsWith papulopustular lesions

Mild to moderateModerate to severe

General measures

Evaluate severity of erythema, inflammation, telangiectasia, and associated symptoms

Begin mild nonalkaline skin cleansing and moisturizing regimen

Avoid astringents, toners, abrasives, fragrances, and sensory stimulants (e.g., camphor, menthol, alcohol, acetone)

Use broad-spectrum sunscreen; sun protection factor (SPF) 30 or greater (zinc oxide or titanium dioxide)

Educate on trigger avoidance

Consider use of yellow- or green-tinted cosmetics to conceal redness

Same as for mild to moderate

Same as for central facial erythema

Lid hygiene (warm compresses and cleansing of lashes and lids with baby shampoo scrubs)

First-line therapy

Topical metronidazole (Metrogel, Metrocream, Metrolotion); azelaic acid (Finacea), or brimonidine (Mirvaso) for erythema

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for erythema and telangiectasia

Topical metronidazole or azelaic acid for inflammation and erythema

Topical brimonidine for erythema if needed as adjunctive therapy; may be used in combination with metronidazole or azelaic acid for erythema

Topical ivermectin for inflammation; may be used in combination with azelaic acid or metronidazole

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for telangiectasia

Topical metronidazole or azelaic acid for inflammation plus subantimicrobial (anti-inflammatory) dose of doxycycline (Oracea), 40 mg once per day or 20 mg twice per day

Topical brimonidine for erythema if needed as adjunctive therapy

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) for telangiectasia

Isotretinoin, 0.3 to 1 mg per kg per day for 12 to 28 weeks

Microdose therapy for maintenance

Topical antibiotics (metronidazole or erythromycin)

Second-line therapy

Alternate topical therapies (sulfacetamide/sulfur, benzoyl peroxide, erythromycin, clindamycin)

or

Subantimicrobial (anti-inflammatory) dose doxycycline, 40 mg once per day or 20 mg twice per day, alone or in combination with topical agents

If limited or no response at 8 to 12 weeks, consider antimicrobial (antibiotic) dose of doxycycline (100 to 200 mg once per day)

Vascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser, and carbon dioxide laser)

Dermabrasion, electroscalpel, electrosurgery, loop cautery

Oral tetracyclines (preferred), or metronidazole or azithromycin (Zithromax)

Cyclosporine ophthalmic emulsion (Restasis)

Ophthalmologic referral

Third-line therapy

If limited or no response at 8 to 12 weeks, consider antimicrobial (antibiotic) dose of doxycycline (100 to 200 mg once per day)

Topical retinoids

If limited or no response at reassessment, consider alternative oral antibiotic (tetracycline, minocycline [Minocin], metronidazole [Flagyl], azithromycin) and/or topical treatment (sulfacetamide/sulfur, benzoyl peroxide, erythromycin, clindamycin, permethrin [Elimite])

Refractory

Consider treatment in the moderate to severe category

If refractory to treatment, consider oral isotretinoin (requires participation in online risk reduction program, iPledge: https://www.ipledgeprogram.com)


Nd:YAG = neodymium:yttrium-aluminum-garnet.

Because rosacea can be triggered by a variety of stimuli, avoidance of known triggers is recommended. To identify potential triggers, patients should be encouraged to keep a journal documenting exposures, diet, and activities that cause flare-ups.14

Properly selected skin care products improve and maintain the integrity of the stratum corneum permeability barrier and reduce skin sensitivity.15 Mild cleansing and moisturizing regimens improve patient satisfaction. Cleansers should be fragrance- and abrasive-free with a mildly acidic to neutral pH. Recommended skin cleansers include lipid-free, nonalkaline cleansers (e.g., Cetaphil) and sensitive skin synthetic detergent bars (e.g., Dove Sensitive Skin Bar).16 Patients should cleanse gently with their fingertips, avoid use of abrasive materials, and pat dry for better absorption of moisturizers. Moisturizers should contain emollients and occlusives.14

Although no individual skin care product has been well studied, some products found to improve dryness include polyhydroxy acid (Neostrata), lipid-free nonalkaline (Cetaphil), and ceramide-based formulas (Cerave).16 Patients should avoid astringents, toners, sensory stimulants, and potentially irritating ingredients.16 Photoprotection is universally recommended, including the use of wide-brimmed hats and broad-spectrum sunscreens (minimum sun protection factor [SPF] of 30).13 Dimethicone- and simethicone-based products containing titanium dioxide and zinc oxide may be better tolerated.2 Cosmetics with green or yellow tint applied to the central facial erythema may conceal redness.14

FDA-APPROVED TOPICAL THERAPIES

Topical agents are first-line therapy in the treatment of mild to moderate rosacea (Table 6).17,18 Medication therapy is based on the presence or absence of persistent central facial erythema or inflammation (e.g., papules, pustules, lesional and perilesional erythema), the severity of symptoms, and the patient's response to previous therapeutic interventions.

View/Print Table

Table 6.

Topical Therapies for Rosacea

TherapyFormulation and dosageEffectivenessAdverse effectsMechanism of actionEvidenceCost*

Metronidazole† (Metrogel, Metrocream, Metrolotion)

0.75% gel, cream, or lotion: twice per day

1% gel: once per day

Papules, pustules, erythema

Pruritus, stinging, irritation, dryness

Antioxidant, anti-inflammatory

RCTs

$$$ ($$$$)

45- to 60-g tubes of cream or gel; 59-mL bottle of lotion

Azelaic acid† (Finacea)

15% gel once or twice per day

Papules, pustules, erythema

Stinging, irritation, burning

Antioxidant; decreases KLK5 and cathelicidin

RCTs

NA ($$$$)

50-g tube

Sulfacetamide/sulfur† (several brands)

10%/5% cream and other formulations; once or twice per day

Papules, pustules, erythema

Irritation, malodorous, avoid in persons with sulfa allergy

Antibacterial

Small studies and historical precedent

$$ to $$$$

28- to 57-g tube

Brimonidine† (Mirvaso)

0.33% gel once per day

Erythema

Pruritus, burning, irritation, dryness, erythema; use with caution in patients with CAD or CVD

Vasoconstriction

RCTs

NA ($$$$)

30-g tube

Ivermectin† (Soolantra)

1% cream once per day

Papules, pustules

Burning, skin irritation

Antiparastic/anti-inflammatory

RCTs

NA ($$$$)

30-g tube

Permethrin (Elimite)

5% cream once per day

Papules, erythema

Irritation, burning

Antiparasitic

Limited studies

$$ ($$)

60-g tube

Benzoyl peroxide

5% gel once or twice per day

Papules, pustules, erythema

Erythema, burning

Antibacterial

Limited studies

$ ($$)

90-g tube

Clindamycin

1% gel twice per day

Papules, pustules

Pruritus, burning, irritation, dryness

Antibiotic

Limited studies

$$ ($$$)

60-g tube

Erythromycin

2% gel twice per day

Papules, pustules

Pruritus, erythema, irritation, dryness

Antibiotic

Limited studies

$ (NA)

60-g tube

Pimecrolimus (Elidel)

1% cream twice per day

Erythema

Burning

Anti-inflammatory

Limited studies

NA ($$$$)

60-g tube

Tretinoin

Cream: 0.025%, 0.05%, 0.1%

Gel: 0.01%, 0.025%

Once per night at bedtime

Papules, pustules, erythema, possibly telangiectasia

Peeling, erythema, pruritus, dryness, irritation, may exacerbate rosacea photosensitivity

Stimulates epithelial cell turnover

Limited studies

$ ($$$)

20-g tube of cream

15-g tube of gel

Oxymetazoline (Afrin)

0.05% nasal solution every six hours

Erythema

Irritation, burning

Vasoconstriction

Case studies

$ ($)

Available OTC

Cyclosporine (Restasis)

0.5% ophthalmic emulsion every 12 hours

Ocular

Hyperemia, burning, blurred vision, tearing

Immunomodulation

RCTs

NA ($$$)

30 vials of 0.4 mL


CAD = coronary artery disease; CVD = cardiovascular disease; KLK5 = kallikrein-related peptidase 5; NA = not available; OTC = over the counter; RCTs = randomized controlled trials.

*—Estimated retail price based on information obtained from http://www.goodrx.com (accessed April 3, 2015). Discounts available from multiple retailers. Generic price listed first; brand price listed in parentheses. Cost: $ = less than $50; $$ = $50 to $100; $$$ = $100 to $250; $$$$ = more than $250.

†—U.S. Food and Drug Administration–approved therapies.

Information from references 17 and 18.

Table 6.

Topical Therapies for Rosacea

TherapyFormulation and dosageEffectivenessAdverse effectsMechanism of actionEvidenceCost*

Metronidazole† (Metrogel, Metrocream, Metrolotion)

0.75% gel, cream, or lotion: twice per day

1% gel: once per day

Papules, pustules, erythema

Pruritus, stinging, irritation, dryness

Antioxidant, anti-inflammatory

RCTs

$$$ ($$$$)

45- to 60-g tubes of cream or gel; 59-mL bottle of lotion

Azelaic acid† (Finacea)

15% gel once or twice per day

Papules, pustules, erythema

Stinging, irritation, burning

Antioxidant; decreases KLK5 and cathelicidin

RCTs

NA ($$$$)

50-g tube

Sulfacetamide/sulfur† (several brands)

10%/5% cream and other formulations; once or twice per day

Papules, pustules, erythema

Irritation, malodorous, avoid in persons with sulfa allergy

Antibacterial

Small studies and historical precedent

$$ to $$$$

28- to 57-g tube

Brimonidine† (Mirvaso)

0.33% gel once per day

Erythema

Pruritus, burning, irritation, dryness, erythema; use with caution in patients with CAD or CVD

Vasoconstriction

RCTs

NA ($$$$)

30-g tube

Ivermectin† (Soolantra)

1% cream once per day

Papules, pustules

Burning, skin irritation

Antiparastic/anti-inflammatory

RCTs

NA ($$$$)

30-g tube

Permethrin (Elimite)

5% cream once per day

Papules, erythema

Irritation, burning

Antiparasitic

Limited studies

$$ ($$)

60-g tube

Benzoyl peroxide

5% gel once or twice per day

Papules, pustules, erythema

Erythema, burning

Antibacterial

Limited studies

$ ($$)

90-g tube

Clindamycin

1% gel twice per day

Papules, pustules

Pruritus, burning, irritation, dryness

Antibiotic

Limited studies

$$ ($$$)

60-g tube

Erythromycin

2% gel twice per day

Papules, pustules

Pruritus, erythema, irritation, dryness

Antibiotic

Limited studies

$ (NA)

60-g tube

Pimecrolimus (Elidel)

1% cream twice per day

Erythema

Burning

Anti-inflammatory

Limited studies

NA ($$$$)

60-g tube

Tretinoin

Cream: 0.025%, 0.05%, 0.1%

Gel: 0.01%, 0.025%

Once per night at bedtime

Papules, pustules, erythema, possibly telangiectasia

Peeling, erythema, pruritus, dryness, irritation, may exacerbate rosacea photosensitivity

Stimulates epithelial cell turnover

Limited studies

$ ($$$)

20-g tube of cream

15-g tube of gel

Oxymetazoline (Afrin)

0.05% nasal solution every six hours

Erythema

Irritation, burning

Vasoconstriction

Case studies

$ ($)

Available OTC

Cyclosporine (Restasis)

0.5% ophthalmic emulsion every 12 hours

Ocular

Hyperemia, burning, blurred vision, tearing

Immunomodulation

RCTs

NA ($$$)

30 vials of 0.4 mL


CAD = coronary artery disease; CVD = cardiovascular disease; KLK5 = kallikrein-related peptidase 5; NA = not available; OTC = over the counter; RCTs = randomized controlled trials.

*—Estimated retail price based on information obtained from http://www.goodrx.com (accessed April 3, 2015). Discounts available from multiple retailers. Generic price listed first; brand price listed in parentheses. Cost: $ = less than $50; $$ = $50 to $100; $$$ = $100 to $250; $$$$ = more than $250.

†—U.S. Food and Drug Administration–approved therapies.

Information from references 17 and 18.

Five topical agents are approved by the U.S. Food and Drug Administration (FDA) for the treatment of rosacea: metronidazole 0.75% lotion (Metrolotion), 0.75% cream (Metrocream), and 1% gel (Metrogel); azelaic acid 15% gel (Finacea); sulfacetamide 10%/sulfur 5% cream, foam, lotion, or suspension; brimonidine 0.33% gel (Mirvaso); and most recently, topical ivermectin 1% cream (Soolantra).

Metronidazole. Metronidazole is hypothesized to reduce oxidative stress, and has proven effective in reducing erythema and inflammation.19 No significant difference in clinical benefit was found using different vehicles (gel, cream, or lotion) or strengths (0.75% or 1%). Adverse effects were mild, including pruritus, irritation, and dryness.14

Azelaic Acid. Azelaic acid is effective against erythema and inflammatory lesions via inhibiting production of reactive oxygen species in neutrophils.19 No difference in effectiveness was found between once- or twice-daily dosing.20 Adverse events include mild and transient burning, stinging, and irritation.19

Metronidazole vs. Azelaic Acid. Three studies assessed the effectiveness of metronidazole vs. azelaic acid. Although physician-assessed outcomes suggested that azelaic acid may be more effective than metronidazole, patient evaluations found no statistically significant differences. Azelaic acid had a higher incidence of adverse events, including dryness, stinging, scaling, itching, and burning. Symptoms were mild to moderate, and transient in both groups. Neither agent was found to be effective against telangiectasia.19

Sulfacetamide/Sulfur. FDA approval of sulfacetamide/sulfur was granted primarily based on historical use before the implementation of more rigorous standards. Studies demonstrated effectiveness, but were also characterized by high or uncertain risk of bias.17,19 Transient application site reactions occur, and some patients comment about the odor. Use of this second-line agent should be avoided in persons with sulfa allergy.

Brimonidine. Topical metronidazole, topical azelaic acid, and oral doxycycline reduce erythema related to vascular inflammation; however, they have negligible effects on background erythema caused by permanently dilated superficial vessels. Conversely, alpha-adrenergic receptor agonists promote vasoconstriction but have no effect on papulopustular rosacea. Once-daily brimonidine, a topical alpha-adrenergic receptor agonist, is effective in reducing erythema. No tachyphylaxis, rebound erythema, or aggravation of inflammatory lesions was noted. Adverse events were mild, including irritation, burning, dry skin, pruritus, and erythema.21 Oxymetazoline 0.05% nasal solution (Afrin), also an alpha-adrenergic receptor agonist, applied once daily reduces diffuse central erythema based on case reports.22

Ivermectin. Topical ivermectin was approved by the FDA in 2014 for the treatment of papulopustular rosacea.23 Two studies demonstrated effectiveness vs. placebo, and a third found that ivermectin was slightly more effective than topical metronidazole in patient- and physician-assessed outcomes and quality of life.18,23

NON–FDA-APPROVED TOPICAL THERAPIES

One study of permethrin (Elimite) vs. azelaic acid vs. metronidazole demonstrated similar effectiveness in reducing erythema and lesion counts. Two additional studies of permethrin vs. metronidazole demonstrated comparable effectiveness in reducing erythema and papules but not pustules.19

Benzoyl peroxide alone or in combination with clindamycin has proven effective; however, adverse events included burning, stinging, and itching.19 Erythromycin 2% gel had no statistically significant effectiveness in physician- or patient-assessed outcomes.17,19

Pimecrolimus 1% cream (Elidel), when compared with placebo, did not improve participant-assessed outcomes. Experts recommend considering use in patients with erythema that does not respond to other treatments.17,19

Topical retinoids have limited data to support their use. One small study suggested a reduction in papulopustular lesions. A randomized, double-blind, placebo-controlled study of combination clindamycin 1.2%/ tretinoin 0.025% gel (Veltin; Ziana) suggested benefit in the reduction of telangiectasia and erythema.17,24

Cream containing 1% extract of a flavonoid-rich plant (Chrysanthellum indicum) demonstrated effectiveness based on patient and physician assessment of rosacea severity.19

THERAPIES FOR DIFFUSE CENTRAL ERYTHEMA AND TELANGIECTASIA

Pulsed dye laser, intense pulsed light, and near infrared lasers appear to be effective in treating facial erythema and telangiectasia, although not papulopustular lesions. The cost of these modalities is significant and may not be covered by insurance. Intermittent retreatment is necessary. Adverse events include blistering, purpura, loss of pigmentation, ulceration, and scarring. Near infrared lasers have a greater risk of complications and should be reserved for prominent telangiectasias.25

SYSTEMIC THERAPIES FOR FACIAL ERYTHEMA WITH PAPULOPUSTULAR ROSACEA

Tetracycline and its derivatives have historically been used for the treatment of papulopustular and ocular rosacea. However, the only FDA-approved oral agent is modified-release doxycycline capsule, 40 mg (Oracea). Subantimicrobial-dose doxycycline at 40 mg once daily or 20 mg twice daily is recommended as initial oral therapy 26  (eTable A). Use of subantimicrobial-dose doxycycline avoids development of bacterial resistance while enhancing safety and tolerability.19,27 Adverse reactions include photosensitivity, candidal vaginitis, pill esophagitis, diarrhea, and pseudotumor cerebri. Minocycline (Minocin) has limited data to support its use and uncommon but serious complications, including autoimmune hepatitis, cutaneous hyperpigmentation, vertigo, and drug-induced eosinophilia with systemic symptoms. Patients with symptoms that do not respond to initial therapy may be prescribed antimicrobial-dose doxycycline, tetracycline, minocycline, or other antibiotics.19,26

View/Print Table

eTable A.

Systemic Therapy for Rosacea

TherapyDosageAdverse effectsCaveatsEvidenceCost*

Doxycycline (Oracea; anti-inflammatory/subantimicrobial dose)†

40 mg once per day (30 mg per 10-mg modified-release capsule)

20 mg twice per day

Dose-related phototoxicity, GI adverse effects, pill esophagitis, pseudotumor cerebri, cutaneous hyperpigmentation (bluish/brownish discoloration of skin, mucous membranes)

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

No generation of antibiotic resistance demonstrated

RCTs and open-label studies (large, high-quality studies)

NA ($$$$$) for 40 mg

$$ for 20 mg

Doxycycline (antimicrobial dose)

100 mg once or twice per day

Tetracycline-related adverse effects as above

Candidiasis

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

RCTs (few) and historical use

$ for 60 capsules

$$ for 60 tablets

Tetracycline

250 to 500 mg twice per day

Tetracycline-related adverse effects as above

Candidiasis

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

Must be taken at least one hour before or two hours after meal

RCTs (few) and historical use

$

Minocycline (Minocin)

50 to 100 mg twice per day or once per day for long-acting

Tetracycline-related adverse effects as above

Vertigo/dizziness, autoimmune hepatitis, drug-induced lupus-like syndrome

Drug rash with eosinophilia and systemic symptoms

Contraindicated in pregnancy and lactation

Historical use

$ ($$$$$)

Metronidazole (Flagyl)

250 mg once per day

Disulfiram (Antabuse) reaction with alcohol, seizures, neuropathy

Candidiasis

Drug interaction with lithium, anticoagulants, phenytoin (Dilantin)

Small studies

$ ($$$)

Azithromycin (Zithromax)

500 mg once per day for three consecutive days per week

250 mg once per day for three days per week

GI adverse effects, prolonged QT interval, hepatotoxicity, cholestasis

Candidiasis

Caution in older patients

Small studies, case reports

$ ($$$) for 500 mg

$ ($$) for 250 mg

Erythromycin

250 mg twice per day

High incidence of GI adverse effects, prolonged QT interval

High incidence of drug interactions

Caution in older patients

Small studies

$$$$

Clarithromycin (Biaxin)

250 to 500 mg twice per day

High incidence of GI adverse effects, prolonged QT interval

High incidence of drug interactions

Caution in older patients

Small studies

$$$ ($$$$$) for 250 mg

$$$ ($$$$$) for 500 mg

Isotretinoin

0.3 mg per kg per day or 10 to 20 mg per day initially for 4 to 6 months, followed by microdose therapy (0.03 to 0.17 mg per kg per day)

Teratogenicity, hyperlipidemia, hepatotoxicity, depression, dry skin, photosensitivity, impaired night vision

Patients must enroll in National iPledge Program; physicians require special training to prescribe

Refractory papulopustular and phymatous subtypes

RCTs (few)

$$$$ to $$$$$, depending on which generic is used and the dosage


note: Therapies are listed in order of preference.

GI = gastrointestinal; NA = not available; RCTs = randomized controlled trials.

*—Estimated retail price for one month's treatment based on information obtained at http://www.goodrx.com (accessed April 3, 2015). Discounts are available for multiple retailers. Generic price listed first; brand price listed in parentheses. Cost: $ = less than $50; $$ = $50 to $100; $$$ = $100 to $250; $$$$ = $250 to $500; $$$$$ = more than $500.

†—Only U.S. Food and Drug Administration–approved systemic therapy for the treatment of rosacea.

Information from: Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies. Cutis. 2014;93(1):18–28.

eTable A.

Systemic Therapy for Rosacea

TherapyDosageAdverse effectsCaveatsEvidenceCost*

Doxycycline (Oracea; anti-inflammatory/subantimicrobial dose)†

40 mg once per day (30 mg per 10-mg modified-release capsule)

20 mg twice per day

Dose-related phototoxicity, GI adverse effects, pill esophagitis, pseudotumor cerebri, cutaneous hyperpigmentation (bluish/brownish discoloration of skin, mucous membranes)

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

No generation of antibiotic resistance demonstrated

RCTs and open-label studies (large, high-quality studies)

NA ($$$$$) for 40 mg

$$ for 20 mg

Doxycycline (antimicrobial dose)

100 mg once or twice per day

Tetracycline-related adverse effects as above

Candidiasis

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

RCTs (few) and historical use

$ for 60 capsules

$$ for 60 tablets

Tetracycline

250 to 500 mg twice per day

Tetracycline-related adverse effects as above

Candidiasis

Decreased absorption with vitamins, antacids, metal ions

Contraindicated in pregnancy and lactation

Must be taken at least one hour before or two hours after meal

RCTs (few) and historical use

$

Minocycline (Minocin)

50 to 100 mg twice per day or once per day for long-acting

Tetracycline-related adverse effects as above

Vertigo/dizziness, autoimmune hepatitis, drug-induced lupus-like syndrome

Drug rash with eosinophilia and systemic symptoms

Contraindicated in pregnancy and lactation

Historical use

$ ($$$$$)

Metronidazole (Flagyl)

250 mg once per day

Disulfiram (Antabuse) reaction with alcohol, seizures, neuropathy

Candidiasis

Drug interaction with lithium, anticoagulants, phenytoin (Dilantin)

Small studies

$ ($$$)

Azithromycin (Zithromax)

500 mg once per day for three consecutive days per week

250 mg once per day for three days per week

GI adverse effects, prolonged QT interval, hepatotoxicity, cholestasis

Candidiasis

Caution in older patients

Small studies, case reports

$ ($$$) for 500 mg

$ ($$) for 250 mg

Erythromycin

250 mg twice per day

High incidence of GI adverse effects, prolonged QT interval

High incidence of drug interactions

Caution in older patients

Small studies

$$$$

Clarithromycin (Biaxin)

250 to 500 mg twice per day

High incidence of GI adverse effects, prolonged QT interval

High incidence of drug interactions

Caution in older patients

Small studies

$$$ ($$$$$) for 250 mg

$$$ ($$$$$) for 500 mg

Isotretinoin

0.3 mg per kg per day or 10 to 20 mg per day initially for 4 to 6 months, followed by microdose therapy (0.03 to 0.17 mg per kg per day)

Teratogenicity, hyperlipidemia, hepatotoxicity, depression, dry skin, photosensitivity, impaired night vision

Patients must enroll in National iPledge Program; physicians require special training to prescribe

Refractory papulopustular and phymatous subtypes

RCTs (few)

$$$$ to $$$$$, depending on which generic is used and the dosage


note: Therapies are listed in order of preference.

GI = gastrointestinal; NA = not available; RCTs = randomized controlled trials.

*—Estimated retail price for one month's treatment based on information obtained at http://www.goodrx.com (accessed April 3, 2015). Discounts are available for multiple retailers. Generic price listed first; brand price listed in parentheses. Cost: $ = less than $50; $$ = $50 to $100; $$$ = $100 to $250; $$$$ = $250 to $500; $$$$$ = more than $500.

†—Only U.S. Food and Drug Administration–approved systemic therapy for the treatment of rosacea.

Information from: Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies. Cutis. 2014;93(1):18–28.

Ampicillin, erythromycin, and clarithromycin (Biaxin), although effective against papulopustular rosacea in a few studies, are not oral agents of choice because of drug interactions, gastrointestinal intolerance, and concerns about promoting antibiotic resistance. Azithromycin (Zithromax) has greater tolerability, but use has been supported only by case reports and small studies.19,26

Oral metronidazole (Flagyl) has demonstrated similar effectiveness when compared with tetracyclines in four studies,18 but the risk of a disulfiram (Antabuse)-like reaction with alcohol (i.e., nausea, vomiting, diaphoresis, flushing of the skin, tachycardia, shortness of breath, headache, confusion, dizziness), and the rare risk of neuropathy and seizures, relegates its use to patients experiencing treatment failures or intolerance of other agents.19,26

Oral isotretinoin may have a role in the management of refractory papulopustular and phymatous rosacea.19,28 One study found low-dose isotretinoin to be more effective than doxycycline in physician- and patient-assessed outcomes.18

For patients with moderate to severe papulopustular rosacea or those experiencing an inadequate response to topical therapy, limited studies support combination therapy (usually oral subantimicrobial-dose doxycycline and topical metronidazole or azelaic acid).18,26,29

Therapy for Phymatous Rosacea

Phymatous rosacea (Figure 3) can be disfiguring and difficult to treat. Best results are achieved when treatment is instituted early. Oral isotretinoin may be effective in reducing nasal volume in early disease (Table 5); however, recurrence is likely after discontinuation, and mucinous and fibrotic changes are unresponsive.26,28 Surgical techniques including laser- or light-based therapies (pulsed dye laser, intense pulsed light, carbon dioxide laser), electrosurgery, dermabrasion, tangential excision, electroscalpel, loop cautery, and scissor sculpting are effective in correcting or minimizing phymatous changes and may be life-changing.25,26

View/Print Figure

Figure 3.

Phymatous changes on tip of nose, inflammatory lesions (papules and pustules) visible laterally, and telangiectasia.


Figure 3.

Phymatous changes on tip of nose, inflammatory lesions (papules and pustules) visible laterally, and telangiectasia.

Therapy for Ocular Rosacea

More than 50% of patients with cutaneous rosacea have ocular symptoms that may include tearing, foreign body sensation, itching, photophobia, and blurred vision. Ophthalmology consultation is recommended because complications (e.g., corneal ulcerations, scleritis, episcleritis, iritis, persistent hordeola and chalazia) may occur.30 Blepharitis, recurrent hordeola, chalazia, and telangiectasias can affect the lid margin (Figure 4). Mild symptoms can be managed with artificial tears, warm compresses, and cleansing the eyelashes with baby shampoo.30 Long-term consumption of omega-3 fatty acids may improve meibomian-gland dysfunction.31 Topical ophthalmic cyclosporine drops (Restasis) demonstrate statistically significant improvement in common signs and symptoms compared with artificial tears.19 Topical metronidazole and erythromycin may be useful for eyelid symptoms. Patients may be treated with systemic therapy using tetracyclines or azithromycin.

View/Print Figure

Figure 4.

Ocular rosacea. (top) Telangiectasia of the upper lid. (middle) Lower-lid granuloma secondary to meibomian gland dysfunction; inflammation and scarring; mild conjunctivitis is also present. (bottom) Scarring of the lower lid margin secondary to recurrent bouts of inflammation.


Figure 4.

Ocular rosacea. (top) Telangiectasia of the upper lid. (middle) Lower-lid granuloma secondary to meibomian gland dysfunction; inflammation and scarring; mild conjunctivitis is also present. (bottom) Scarring of the lower lid margin secondary to recurrent bouts of inflammation.

Data Sources: We searched the Cochrane Database of Systematic Reviews, PubMed, Medline, and Essential Evidence Plus using keywords rosacea, rosacea and pathophysiology, rosacea and treatment outcome, rosacea and evidence-based medicine, rosacea and drug therapy, and rosacea and dermatological agents. The search included reviews, meta-analyses, randomized controlled trials, consensus guidelines, and clinical trials. Search dates: June 2014 and April 30, 2015.

editor's note: Additional photos of various subtypes of acne rosacea are available at http://www.aafp.org/afp/2009/0901/p461.html.

The Authors

show all author info

LINDA K. OGE', MD, is an assistant clinical professor and chief of family medicine at Louisiana State University Family Medicine Residency at University Hospital and Clinics in Lafayette....

HERBERT L. MUNCIE, MD, is a professor of family medicine and director of predoctoral education at Louisiana State University School of Medicine in New Orleans.

AMANDA R. PHILLIPS-SAVOY, MD, MPH, is an assistant clinical professor in the Department of Family Medicine at Louisiana State University Family Medicine Residency at University Hospital and Clinics.

Author disclosure: No relevant financial affiliations.

Address correspondence to Linda K. Oge', MD, LSU Health UHC, 2390 West Congress St., Lafayette, LA 70506 (e-mail: loge@lsuhsc.edu). Reprints are not available from the authors.

REFERENCES

show all references

1. Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician. 2002;66(3):435–440....

2. Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005;352(8):793–803.

3. Gupta MA, Gupta AK, Chen SJ, Johnson AM. Comorbidity of rosacea and depression: an analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey—Outpatient Department data collected by the U.S. National Center for Health Statistics from 1995 to 2002. Br J Dermatol. 2005;153(6):1176–1181.

4. Kligman AM. A personal critique on the state of knowledge of rosacea. Dermatology. 2004;208(3):191–197.

5. Spoendlin J, Voegel JJ, Jick SS, Meier CR. A study on the epidemiology of rosacea in the U.K. Br J Dermatol. 2012;167(3):598–605.

6. Elewski BE, Draelos Z, Dréno B, Jansen T, Layton A, Picardo M. Rosacea—global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group. J Eur Acad Dermatol Venereol. 2011;25(2):188–200.

7. Tan J, Berg M. Rosacea: current state of epidemiology. J Am Acad Dermatol. 2013;69(6 suppl 1):S27–S35.

8. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):584–587.

9. Tan J, Blume-Peytavi U, Ortonne JP, et al. An observational cross-sectional survey of rosacea: clinical associations and progression between subtypes. Br J Dermatol. 2013;169(3):555–562.

10. Steinhoff M, Schauber J, Leyden JJ. New insights into rosacea pathophysiology: a review of recent findings. J Am Acad Dermatol. 2013;69(6 suppl 1):S15–S26.

11. Cohen AF, Tiemstra JD. Diagnosis and treatment of rosacea. J Am Board Fam Pract. 2002;15(3):214–217.

12. Kligman AM. An experimental critique on the state of knowledge of rosacea. J Cosmet Dermatol. 2006;5(1):77–80.

13. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 1: a status report on the disease state, general measures, and adjunctive skin care. Cutis. 2013;92(5):234–240.

14. Odom R, Dahl M, Dover J, et al.; National Rosacea Society Expert Committee on the Classification and Staging of Roasacea. Standard management options for rosacea, part 1: overview and broad spectrum of care. Cutis. 2009;84(1):43–47.

15. Del Rosso JQ. The role of skin care and maintaining proper barrier function in the managment of rosacea. Cosmet Dermatol. 2007;20(8):485–490.

16. Levin J, Miller R. A guide to the ingredients and potential benefits of over-the-counter cleansers and moisturizers for rosacea patients. J Clin Aesthet Dermatol. 2011;4(8):31–49.

17. Del Rosso JQ, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 2: a status report on topical agents. Cutis. 2013;92(6):277–284.

18. van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Inverventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262.

19. van Zuuren EJ, Kramer S, Carter B, Graber MA, Fedorowicz Z. Interventions for rosacea. Cochrane Database Syst Rev. 2011;(3):CD003262.

20. Thiboutot DM, Fleischer AB Jr, Del Rosso JQ, Graupe K. Azelaic acid 15% gel once daily versus twice daily in papulopustular rosacea. J Drugs Dermatol. 2008;7(6):541–546.

21. Fowler J, et al.; Brimonidine Phase II Study Group. Once-daily topical brimonidine tartrate gel 0.5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies. Br J Dermatol. 2012;166(3):633–641.

22. Shanler SD, Ondo AL. Successful treatment of the erythema and flushing of rosacea using a topically applied selective alpha1-adrenergic receptor agonist, oxymetazoline. Arch Dermatol. 2007;143(11):1369–1371.

23. Layton A, Thiboutot D. Emerging therapies in rosacea. J Am Acad Dermatol. 2013;69(6 suppl 1):S57–S65.

24. Chang AL, Alora-Palli M, Lima XT, et al. A randomized, double-blind, placebo-controlled, pilot study to assess efficacy and safety of clindamycin 1.2% and tretinoin 0.025% combination gel for the treatment of acne rosacea over 12 weeks. J Drugs Dermatol. 2012;11(3):333–339.

25. Tanghetti E, Del Rosso JQ, Thiboutot D, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. 2014;93(2):71–76.

26. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies. Cutis. 2014;93(1):18–28.

27. Del Rosso JQ, Webster GF, Jackson M, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56(5):791–802.

28. Park H, Del Rosso JQ. Use of oral isotretinoin in the management of rosacea. J Clin Aesthet Dermatol. 2011;4(9):54–61.

29. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 5: a guide on the management of rosacea. Cutis. 2014;93(3):134–138.

30. Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed. J Am Acad Dermatol. 2013;69(6 suppl 1):S36–S41.

31. Oltz M, Check J. Rosacea and its ocular manifestations. Optometry. 2011;82(2):92–103.


 

Copyright © 2015 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article