Education Center

Treatment of Acne Rosacea Reviewed

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

September 11, 2009 — Treatment options for acne rosacea seen in the family practice setting are reviewed in an article published in the September 1 issue of American Family Physician.

“Rosacea is a common skin condition with characteristic symptoms and signs, including symmetric flushing, stinging sensation, inflammatory lesions (papules and pustules), and telangiectasias on the face,” write Constance Goldgar, MS, PA-C; David J. Keahey, MSPH, PA-C; and John Houchins, MD, from the University of Utah Physician Assistant Program in Salt Lake City. “Phymatous changes include thickened skin and large pores. Clinical findings represent a spectrum of disease with one or several predominating characteristics, including a pattern of exacerbations and relative inactivity.”

Rosacea is a chronic, and sometimes progressive, dermatosis, typically presenting with central facial erythema involving the nose, forehead, chin, and perioral areas. However, it may also cause inflammation of the eyes and eyelids. Regardless of location, rosacea adversely affects quality of life.

Estimated US prevalence of rosacea is 14 million. Although it occurs more commonly in women and in whites, it can affect other ethnic groups. Typical age of onset is in the 30s.

The differential diagnosis of facial rosacea includes acne vulgaris, systemic lupus erythematosus, polymyositis, sarcoidosis, photodermatitis, drug eruptions (especially from iodides and bromides), skin granulomas, and perioral dermatitis. For ocular rosacea, the differential diagnosis may include staphylococcal and seborrheic blepharokeratoconjunctivitis, and sebaceous gland carcinoma.

Identifying the specific subtype of rosacea allows tailoring treatment to the individual patient, which is most likely to result in effective control. According to the National Rosacea Society, there are 4 subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular, but these are further classified by severity based on the number of papules/pustules and plaques.

In addition to rosacea classification, other factors determining optimal choice of pharmacotherapy include rosacea severity and response to previous treatment regimens. The quality of studies evaluating rosacea treatments is generally poor, according to a 2005 Cochrane review.

The initial treatment strategy for rosacea, especially for the erythematotelangiectatic and papulopustular subtypes, is to avoid known triggers or exacerbating factors whenever possible.

For patients with mild rosacea, topical metronidazole, sulfacetamide/sulfur, and azelaic acid are usually effective and carry less risk for adverse events, drug interactions, and antibiotic resistance vs systemic treatments.

The first-line choice for moderate papulopustular rosacea is combination therapy with oral tetracyclines and topical agents. Treatment with metronidazole or other topical agent may help patients maintain remission.

Treatment with long-term oral antibiotics and metronidazole gel may be necessary for patients with ocular involvement. For patients who have ocular rosacea with ophthalmic complications, severe or recalcitrant rosacea, or phymatous changes, referral to a subspecialist is required.

Specific clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

Rosacea classification, severity, and response to previous therapeutic regimens should determine choice of pharmacologic treatment (level of evidence, C).
To reduce rosacea flares, the following measures may be helpful:

Using emollient, noncomedogenic moisturizers and mild, fragrance-free, soap-free cleansers with nonalkaline or neutral pH;
Protecting against sun exposure with use of broad-spectrum sunscreen containing zinc oxide or titanium dioxide, and wide-brimmed hats; and
Avoiding astringents and other skin care products containing alcohol, menthol, eucalyptus oil, clove oil, peppermint, witch hazel, or sodium lauryl sulfate (level of evidence, C).

For background erythema and telangiectasia, dermatologic laser therapy may be considered (level of evidence, C).
For mild rosacea, initial pharmacotherapy should include appropriate topical regimens, such as antibiotics, immunomodulators, or retinoids. First-line topical regimens, such as metronidazole, azelaic acid, or sulfacetamide/sulfur, should be applied to affected areas once or twice daily (level of evidence, A).
For moderate to severe rosacea, first-line pharmacotherapy should include orally administered drugs or combined topical and oral therapy. Tetracycline, doxycycline, and minocycline are among the first-line oral medications. Clinicians should consider subantimicrobial dosing (level of evidence, B).
Once-daily doxycycline administered at a subantimicrobial dose may reduce inflammatory lesions when given alone or in combination with metronidazole therapy (level of evidence, B).
Eyelid hygiene with hot compresses, eyelid cleansing, and other appropriate measures, as well as topical agents, should be used to treat mild ocular rosacea (level of evidence, C).
Oral drug therapy with agents from the tetracycline class should be used to treat moderate ocular rosacea (level of evidence, C).

“Evidence for using oral antibiotics to treat rosacea is limited and is often based on clinical experience or older, low-quality studies instead of on well-designed RCTs [randomized controlled trials,” the review authors write. “Initial therapy for moderate to severe rosacea should include oral treatment or a combination of topical and oral treatments. Because rosacea is a chronic disease, the long-term use of antibiotics can lead to adverse effects….One potential management strategy is to taper the dosage of oral antibiotics after six to 12 weeks of successful treatment, transitioning to topical agents only.”

Am Fam Physician. 2009;80:461-468.

Courtesy of Medscape.com (http://cme.medscape.com/)

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