VOLUME 41 : NUMBER 1 : FEBRUARY 2018 ARTICLE An update on the treatment of rosacea Alexis Lara Rivero Clinical research fellow SUMMARY St George Specialist Centre Sydney Rosacea is a common inflammatory skin disorder that can seriously impair quality of life. Margot Whitfeld Treatment starts with general measures which include gentle skin cleansing, photoprotection and Visiting dermatologist avoidance of exacerbating factors such as changes in temperature, ultraviolet light, stress, alcohol St Vincent’s Hospital Sydney and some foods. Senior lecturer For patients with the erythematotelangiectatic form, specific topical treatments include UNSW Sydney metronidazole, azelaic acid, and brimonidine as monotherapy or in combination. Laser therapies may also be beneficial. Keywords For the papulopustular form, consider a combination of topical therapies and oral antibiotics. flushing, rosacea Antibiotics are primarily used for their anti-inflammatory effects. Aust Prescr 2018;41:20-4 For severe or refractory forms, referral to a dermatologist should be considered. Additional https://doi.org/10.18773/ treatment options may include oral isotretinoin, laser therapies or surgery. austprescr.2018.004 Patients should be checked after the first 6–8 weeks of treatment to assess effectiveness and potential adverse effects. Introduction • papules Rosacea is a common chronic relapsing inflammatory • pustules skin condition which mostly affects the central face, • telangiectases. 1 with women being more affected than men. The In addition, at least one of the secondary features pathophysiology is not completely understood, but of burning or stinging, a dry appearance, plaque dysregulation of the immune system, as well as formation, oedema, central facial location, ocular changes in the nervous and the vascular system have manifestations and phymatous changes are been identified. Microbes that are part of the normal considered enough to make the diagnosis accurately skin flora, and specifically in the pilo-sebaceous in most cases. Rosacea usually follows a pre-rosacea unit – including Demodex mites and Staphylococcus stage that involves flushing only. epidermidis – may also play a role as triggers of rosacea.2,3 Symptoms are initially transient. This is followed by Box Differential diagnoses of rosacea persistent erythema due to repeated vasodilation, Common then telangiectasia and skin inflammation in the form Acne vulgaris of papules, pustules, lymphoedema and fibrosis.2,4 Seborrhoeic dermatitis Rosacea can seriously affect a patient’s quality of life. Tinea faciei This should prompt clinicians to diagnose it early and Periorificial dermatitis start treatment.1 Contact dermatitis (irritant or allergic) Diagnosis Steroid-induced acneiform eruption The diagnosis of rosacea is usually made on history Folliculitis and clinical features. If it is not clear, differential Uncommon diagnoses must be considered and ruled out Lupus erythematosus (see Box).1,5,6 Dermatomyositis Clinical manifestations Drug reaction, e.g. isoniazid The presence of at least one of the following primary Sarcoidosis features indicates rosacea: Demodicosis (mange) flushing (transient redness) • Source: References 1, 4, 6 • non-transient redness 20 Full text free online at nps.org.au/australianprescriber VOLUME 41 : NUMBER 1 : FEBRUARY 2018 ARTICLE Rosacea can be classified into four subtypes: Phymatous rosacea erythematotelangiectatic, papulopustular, phymatous Phymatous rosacea is characterised by thickened skin and ocular.1,5 with enlarged pores and irregular surface nodularities. Erythematotelangiectatic rosacea These changes are most commonly found on the nose (rhinophyma), but can occur on the ears, chin and Erythematotelangiectatic rosacea is characterised forehead. This subtype is more common in men than by flushing and persistent central facial erythema. women (Fig. 4). Redness may also involve the peripheral face, ears, neck and upper chest, but periocular skin is typically Ocular rosacea spared. Telangiectases are also common, but are not Ocular rosacea is characterised by a watery required for the diagnosis (Fig. 1). or bloodshot appearance of the eyes, foreign Papulopustular rosacea body sensation, burning or stinging. Blepharitis, Papulopustular rosacea subtype includes patients conjunctivitis, dryness, itching, light sensitivity, blurred who develop papules or pustules in a central facial vision and telangiectasia of the conjunctiva or eyelids distribution. In severe cases, these episodes of also occur. Chalazia and styes are more common in inflammation can lead to chronic facial oedema ocular rosacea than other forms. Because there is no (Figs 2 and 3). specific test, the diagnosis relies on the physician’s Fig. 1 Erythematotelangiectatic rosacea Fig. 3 Papules and pustules – close-up Fig. 2 Papulopustular rosacea Fig. 4 Rhinophyma MAKE THESE PHOTOS HIGH RES IN THE FINAL PDF Full text free online at nps.org.au/australianprescriber 21 VOLUME 41 : NUMBER 1 : FEBRUARY 2018 ARTICLE An update on the treatment of rosacea clinical judgment. Ocular involvement is estimated Specific treatments to occur in 6–50% of patients with cutaneous Treatment can be optimised according to the rosacea, and can occur with or without a diagnosis of dominant features.9,13 Topical therapies are 7 cutaneous rosacea. recommended for at least six weeks to effectively Additional tests review the response.5,9 Topical corticosteroids should be avoided.14 If the diagnosis cannot be made clinically, other tests may be necessary. These include skin swabs Treatment for flushing and erythema may involve and scrapings for microbiology studies primarily oral drugs with vasoconstriction properties including to exclude staphylococcal infection. An antinuclear adrenergic antagonists including mirtazapine (alpha antibody test can be useful if photosensitivity is blocker), propranolol (beta blocker) or carvedilol 2 prominent. A skin biopsy is useful when other (both alpha and beta blocker). These are used at low diagnoses such as lupus or chronic folliculitis are doses to avoid adverse effects such as hypotension, being considered.1,8 somnolence, fatigue and bronchospasm. They should be prescribed under specialist supervision, and careful Approach to the patient with rosacea monitoring is required. Educating the patient about rosacea as a chronic Clonidine is an oral alpha2 agonist that has been relapsing skin condition which can be controlled used for flushing. However, topical alpha2 agonists but does not have a traditional ‘cure’ is important. are preferred because they target the skin and carry Warning them that flare-ups can occur even when less risk of systemic adverse effects. Brimonidine is treated properly is also useful and plays a key role in a topical alpha2 agonist which can reduce erythema the patient’s expectations and the role of therapy. for up to 12 hours through direct cutaneous General measures vasoconstriction. Brimonidine 0.33% gel is very useful for some people when not used on a daily basis.6,9 The treatment plan will be adapted to the subtype Post-treatment rebound erythema may occur, and in of rosacea and then realistic expectations are set general telangiectases will not clear. and potential adverse effects discussed. This enables the patient to participate in the choice of therapy Erythematotelangiectatic rosacea appropriate for them and consider the balance Topical treatments for this form of rosacea include between the disease and the treatment.9 metronidazole, azelaic acid and brimonidine. They can Skin care be used alone or in combination. Metronidazole works as an anti-inflammatory drug by altering neutrophil Sun avoidance and photoprotection are an chemotaxis and inactivating reactive oxygen species. important part of management.10 Reducing skin Metronidazole 0.75% has been shown to reduce irritability is also key. Skin care should include a erythema, papules and pustules in multiple trials of gentle facial cleanser and a moisturiser or barrier patients with moderate to severe rosacea. It is usually repair product, as this can adjunctively improve well tolerated with minor local adverse effects such as therapeutic outcomes and reduce skin irritation skin irritation.9,15 in patients undergoing medical therapy. Cosmetic products, especially those with a green tinge, Topical azelaic acid is an over-the-counter preparation may help to cover erythema and may improve the which has anti-inflammatory, anti-keratinising and patient’s self-perception.11 antibacterial effects. A 15% gel and 20% lotion are available and can be applied once or twice daily. Avoiding triggers Adverse effects may include skin irritation, but azelaic Avoiding triggers such as extreme temperatures acid is usually well tolerated and can be used for long (hot or cold), ultraviolet radiation exposure, spicy periods of time.8,16 foods, hot or alcoholic beverages, wind, exercise Laser therapy, including vascular lasers or intense and stress, should be recommended to all patients. pulse light, may help to reduce refractory background Hormonal replacement therapy can be used for erythema and clinically significant telangiectases, but 12 menopausal flushing. will not reduce the frequency of flushing episodes. It is important to ask the patient what medicines they Different laser therapies that target the vessels have are taking as some over-the-counter or prescription been used such as 595 nm pulsed dye laser, Nd:YAG and drugs may worsen rosacea or trigger flushing other vascular lasers, or intense pulsed