Rosacea: Update on Management and Emerging Therapies

Robyn S. Fallen MD; Melinda Gooderham MD, MSc, FRCPC


Skin Therapy Letter. 2012;17(10) 

In This Article

Abstract and Introduction


Rosacea is a common chronic skin disorder that has significant impact on the self-esteem and quality of life of affected individuals. Currently understood as an inflammatory condition that occurs in the context of an altered innate immune response, the available topical and systemic therapies function as immunomodulators to restore cutaneous homeostasis. The goals of therapy include reduction of papules, pustules, erythema and physical discomfort with improvement in quality of life. Standard topical treatments include metronidazole and azelaic acid, although many other agents and regimens have been presented. Subantimicrobial/antiinflammatory dose oral doxycycline was US FDA approved in 2006 for the management of rosacea, but Health Canada clearance was only recently granted for this indication. Furthermore, renewed research interest has led to the development of other emerging therapies including topical ivermectin, brimonidine and oxymetazoline that hold promise for patients suffering from this condition.


Rosacea is a chronic skin disorder characterized by facial erythema, telangiectasia, inflammatory papules and pustules with intermittent episodes of exacerbation and remission. There are four generally accepted clinical subtypes, which have been described by the National Rosacea Society: erythematotelangiectatic, papulopustular, phymatous, and ocular.[1] Two variants, granulomatous and neurogenic, have also been presented.[1,2]

Affecting approximately 10% of the general population, rosacea is more prevalent in women, although impacted men often have more disfiguring skin changes.[3] Patients often present between 30 and 50 years of age, but manifestations can occur throughout the life course.[4]

Given that up to a third of patients have a family history of rosacea and the increased prevalence among individuals of Northern European descent, an underlying genetic predisposition may help explain these patterns.[3] While the etiology of rosacea remains unclear and despite clinical heterogeneity, basic science has developed a possible unified understanding of the condition as an inflammatory disorder in the context of an altered innate immune response.[5] It is proposed that environmental changes, which may include UV light exposure, hormone balances, and microbe challenges (by pathogens such as Demodex folliculorum), are sensed by pattern recognition receptors of the immune system. Subsequent signaling-induced effector molecules such as reactive oxygen species, cytokines, cathelicidin and chemokines may then modify dermal structure through vascular changes, collagen degeneration, lymphohistiocytic infiltration and neutrophil recruitment, which may perpetuate this response.[6,7] Given this model, it is clear why most current therapies attempt to modulate various points of this inflammatory cascade.

Furthermore, although the intricacies of the relationship between psychological factors and rosacea remains to be elucidated, 75% of affected patients report low self-esteem, with a significant odds ratio of 4.81 for a diagnosed depressive disorder in this population compared to the general population.[8] The use of validated assessment tools has demonstrated the impact of rosacea on quality of life, and, importantly, the improvement in these psychological indices that can occur with treatment.[9]

Once rosacea is diagnosed, patients should be reassured of the benign, but chronic, nature of the condition. Counseling should be directed toward the identification and avoidance of triggers, diligent photoprotection, concealing cosmetics and proper skin care.[3,10] It is also prudent to review medications to identify, and discontinue if possible, those that may exacerbate flushing such as beta blockers.[3]