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Rosacea

Management of the patient with rosacea

  1. Establish the clinical diagnosis of rosacea (subtype, severity, ocular involvement).
  2. Prescribe treatment (topical, systemic, physical).
  3. Refer patient to an ophthalmologist when needed.
  4. Advise patient to avoid trigger factors, use photoprotection (broad spectrum, both UVA and UVB), select gentle daily skin care. Skin care becomes an important part of their therapy (see handout Skin care for rosacea patients).
  5. Avoid drugs that worsen rosacea. Stop or taper all topical corticosteroids stronger than hydrocortisone 1%. Anticipate a flare when they are discontinued.
  6. Use maintenance therapy.

Subtype Directed Therapy

Topical

Systemic

Physical

Sun protection, specific skin care

Other

Erythemato-telangiectatic

Brimonidine 0.33% gel

-

Pulse-dye laser/KTP laser/ Nd :YAG/ intense pulsed light therapy

+

Avoidance of triggers
Papulo-pustular Metronidazole
Azelaic acid
Sulfacetamide/ sulfur
Low-dose doxycycline
Tetracyclines
Macrolides
Metronidazole
Isotretinoin
Pulse-dye laser/KTP laser/ Nd :YAG/ intense pulsed light therapy

+

Avoidance of triggers
Phymatous

-

Antibiotics
Isotretinoin
Surgery (conventional, laser)

+

Avoidance of triggers
Ocular Corticosteroid eyedrops Tetracyclines Eyelid warm compress

+

Lid hygiene
Artificial tears

Pitfalls

  • Isotretinoin is contraindicated in pregnancy, and tetracycline-class antibiotics are contraindicated after week 14 gestation. Adequately documented contraception, a negative pregnancy test, and extensive counseling are required.
  • Topical corticosteroids can induce rosacea (steroid-induced rosacea).
  • Patients with rosacea have sensitive skin and tolerate topical irritants poorly. Topical retinoids (i.e., tretinoin cream) or high concentrations of benzoyl peroxide are not always recommended (see handout Skin care for rosacea patients).
  • It is recommended that patients are referred to an experienced dermatologist to supervise systemic isotretinoin treatment.
  • Rosacea fulminans (sudden onset of coalescent papules, pustules, nodules) may occur during pregnancy, thyroid diseases, depression, emotional stress, induced by medications. This exacerbation may require use of systemic corticosteroids (prednisone 0.5 to 1 mg/kg/day) and/or isotretinoin.

Need for dermatologic and/or ophthalmologic care

  • As the differential diagnosis and treatment of rosacea is challenging, it is always beneficial to refer the patient to a dermatologist.
  • Severe rosacea cases that require systemic isotretinoin.
  • If a diagnosis of cutaneous rosacea is suspected, an ophthalmologic examination is always beneficial to detect ocular involvement and to prevent complications such as keratitis and corneal ulcers.