management

Last edited 05/2020 and last reviewed 07/2023

  • mild to moderate rosacea
    • for people with few papules or pustules and mild to moderate persistent erythema, topical treatment is recommended
      • topical metronidazole is the preferred topical treatment - note that gel preparations that contain alcohol may be more irritating to the skin
        • gel (0.75%) applied twice a day, or cream (1%) applied once a day (4)

      • topical azelaic acid may be considered for people who are intolerant of or not responding to topical metronidazole
        • may cause a mild burning or stinging sensation when initially applied to the skin
        • azelaic acid 15% gel, applied twice a day (4)
        • the 20% cream available in the UK is not licensed for the treatment of rosacea

      • ivermectin 10 mg/g cream
        • mechanism of action is unknown but may be due to a combination of its anti-inflammatory effects and its antiparasitic effects on the Demodex mite, which lives on the skin and may contribute to the symptoms of rosacea (5)
        • studies have shown ivermectin cream to be safe with no serious adverse effects - rate of adverse effects was similar to those of vehicle, metronidazole gel, and azelaic acid
        • will produce clearing or almost clearing of rosacea lesions in 40% to 80% of patients with moderate to severe symptoms after three months of treatment (number needed to treat [NNT] = 4 to 5) (5)

      • some dermatologists also consider the use of other topical antibiotics or topical retinoids - these treatments are not licensed for this condition

  • patients who do not respond to topical treatment and/or have severe rosacea (i.e. extensive papules, pustules, or plaques) (4,6):
    • prescribe an oral tetracycline or erythromycin
    • in an adult:
        • use a tetracycline eg oxytetracycline 500 mg BD, lymecycline 408 mg OD - both on an empty stomach;
          • doxycycline 100 mg once daily (off-label) is an alternative if the person has any degree of renal impairment or prefers once-daily dosing
          • doxycycline modified-release 40 mg once daily in the morning for up to 16 weeks (licensed) is also available for the treatment of papulopustular acne rosacea without ocular involvement. This should be discontinued if no improvement is seen after 6 weeks
          • full doses are given initially but gradually reduced once the condition has been controlled - usually after 1-3 months. Antibiotics should not be stopped suddenly because this may result in rebound rosacea
        • erythromycin 500 mg BD is an alternative - an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
      • initial treatment should be for at least three months (5), although if the patient is responding well the dose may be reduced after one month
      • there is evidence of benefit for the use of low dose isotretinoin (10mg per day) in rosacea (3) - the use of isotretinoin in rosacea can only be initiated by a specialist

Patients with ocular symptoms should be referred to an ophthalmologist:

    • Urgent referral- if keratitis is suspected (eye pain, blurred vision, sensitivity to light)

    • Routine referral- if ocular symptoms are severe or resistant to maximal treatment in primary care

  • Mild eye symptoms are usually treated with a combination of eyelid hygiene measures, ocular lubricants (for dry eye symptoms), and oral tetracyclines (4)

Routine referral to dermatologist is advised for people with:

  • flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress
  • papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
  • an uncertain diagnosis (4)

Routine referral to a plastic surgeon is advised for those people with (4):

  • severe phymatous disease (e.g. prominent rhinophyma)

Flushing / erythema / telangiectasia (6)

  • can sometimes be the predominant symptoms
  • tend not to respond to antibiotics
  • flushing may he helped by a non-selective cardiovascular beta-blocker such as propranolol 40 mg BD, or clonidine 50 micrograms BD
  • persistant erythema / telangiectasia - laser therapy using a pulsed-dye laser can be very effective although improvement is not permanent. Only a few commissioners will provide laser treatment for rosacea on the NHS
  • brimonidine (Mirvaso) topical gel, 0.33% is an alpha adrenergic agonist indicated for the topical treatment of persistent (nontransient) facial erythema of rosacea in adults 18 years of age or older
    • applied thinly once a day, it will benefit some, but not all, patients with persistent erythema.
    • adverse reactions include erythema, flushing, skin burning sensation and contact dermatitis
  • Carvedilol - there is some evidence of efficacy in treatment of rosacea - can take 3-6 months for the optimal response
  • consider camouflage eg green cream, or refer to the British Red Cross, which run free clinics across the UK, normally in association with hospital dermatology departments

Reference:

Related pages:

systemic antibiotics in rosacea