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

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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

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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])

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Refractory

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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)

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