COMMENTARY

Rosacea: 5 Things to Know

Graeme M. Lipper, MD

Disclosures

September 19, 2018

3. There Is No One-Size-Fits-All Treatment

As mentioned above, rosacea has several variants, each of which can manifest in the same patient in overlapping fashion or at different times. Rarer pediatric granulomatous and pyodermic (rosacea fulminans) variants also exist.

All patients with rosacea should be educated about gentle skin care and avoidance of triggers, such as intense sun exposure, strongly acidic or basic cleansers, facial cosmetics with fragrance, and dietary triggers (eg, alcohol, spicy foods). Daily sunscreen use and avoidance of such mechanical irritants as facial scrubs should also be encouraged.

Different rosacea components respond best to different treatments. In this context, each patient with rosacea needs his or her own individualized plan.

Papulopustular rosacea. This subtype responds well to topical metronidazole (0.75%, 1%), azelaic acid, and ivermectin. Off-label treatments, such as topical sulfacetamide or dapsone, may be beneficial too, either alone or as part of a combination regimen.[14,15,20,21,22] Vehicle choice is important too, because patients with oily skin may prefer a gel or foam, whereas those with dry skin tend to do best with creams or lotions.

Low-dose doxycycline (40 mg/day) is the only FDA-approved treatment for papulopustular rosacea; however, data support the off-label use of minocycline and azithromycin.[14,15,20,21,22] Some refractory cases of papulopustular rosacea respond well to low-dose oral isotretinoin (off-label), but patients tend to have relapse after drug cessation.[23]

Erythematotelangiectatic rosacea. In contrast, this subtype rosacea responds poorly to topical or oral antibiotics. These patients benefit most from trigger avoidance, gentle skin care, photoprotection, and judicious use of topical vasoconstrictors. To date, two topical alpha-adrenergic receptor agonists are FDA-approved to treat the persistent facial erythema of rosacea: brimonidine tartrate 0.5% gel and oxymetazoline hydrochloride 1% cream. Patients using these topical vasoconstrictors enjoy a transient fading of erythema, but rebound flaring may be problematic for some.[24,25]

Phymatous rosacea. This subtype is the most challenging to treat, and typically requires a combination of topical antimicrobials; low-dose doxycycline; and mechanical, laser, and/or radiofrequency debridement of hypertrophic tissue for optimal management.[26]

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