Rosacea and Its Topical Management

M. Gooderham, MSc, MD, FRCPC


Skin Therapy Letter. 2009;14(2) 

In This Article

Abstract and Introduction


Many options exist for the treatment of rosacea, including topical and systemic therapies, laser and light-based therapies, and surgical procedures. A classification system for rosacea identifies 4 subtypes (i.e., erythematotelangiectatic, papulopustular, phymatous, and ocular), which may help guide therapeutic decision-making. The goals of therapy include reduction of papules, pustules, erythema, physical discomfort, and an improvement in quality of life. Standard topical treatment agents include metronidazole, azelaic acid, and sodium sulfacetamide-sulfur. Second line therapies include benzoyl peroxide, clindamycin, calcineurin inhibitors, and permethrin.


Rosacea is a chronic relapsing skin disorder characterized by facial flushing, persistent erythema, telangiectasia, and inflammatory papules and pustules affecting the central face. The National Rosacea Society has described a classification system based on 4 main subtypes: erythematotelangiectatic, papulopustular, phymatous, ocular, and one variant, i.e., granulomatous.[1] Rosacea can contribute to lower self-esteem and have significant psychosocial implications, e.g., stress at work and social isolation.[2] This can have a significant impact on quality of life and should be taken into consideration when treating these patients.

Treatment starts with making a proper diagnosis, including identification of subtype. Following this, conservative measures, such as trigger avoidance, proper skin care, camouflaging cosmetics, and photoprotection should be discussed in detail. Topical pharmacotherapeutic options include: azelaic acid (Finacea® Gel, Intendis/Bayer), clindamycin, clindamycin 1%-benzoyl peroxide 5% gel (BenzaClin®, sanofi-aventis; Duac®, Stiefel), erythromycin, metronidazole (MetroCream®, MetroLotion®, MetroGel®, Rozex® Gel, Galderma; Noritate®, Dermik), or sodium sulfacetamide 10% + sulfur 5% (Plexion®, Medicis; Rosac ® Cream, Stiefel; Rosula® Lotion, Doak Dermatologics; Sulfacet-R®, Novacet® Lotion, Perrigo). For patients with moderate-to-severe papulopustular rosacea or those with ocular involvement, systemic therapy is often prescribed and options include doxycycline, erythromycin, metronidazole, minocycline, tetracycline, or in severe cases, low dose isotretinoin. The telangiectatic component does not respond to either oral or topical therapy, and is best treated with laser and light-based therapies. Surgical intervention may be required for the phymatous subtype. Therapeutic choices will depend on patient expectations, tolerance, previous therapies used, rosacea subtype, and severity. This article will focus on topical therapies for rosacea.


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