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Rosacea

Rosacea

Rosacea is a chronic, relapsing disorder with intermittent or persistent facial flushing, telangiectasia, papules and pustules, in the absence of comedones. The rash usually involves forehead, cheeks & chin, sparing the peri-orbital & peri-oral areas. Not all signs may be present in the same patient.
It is more common in fair skinned people and peak incidence is 40-50 years.

Rosacea can also cause ocular symptoms in > 50% of patients and can cause dry gritty eyes, conjunctivitis, blepharitis, episcleritis & chalazion. Keratitis may be a more serious complication.

Rhinophyma

Rosacea nose

Rosacea nose

Less commonly, rosacea can develop Rhinophyma where the shape and size of the nose changes

All images on this page are sourced from DermNet | Dermatology Resource (dermnetnz.org)

R.C 24-05-24

Referral Guidelines

  • Severe unresponsive disease for consideration of isotretinoin
  • Refer to Plastic Surgery for consideration of laser or surgical therapy:
    • Rhinophyma
    • Severe Telangiectaisa
  • Refer to Ophthalmology for associated keratitis.

Management

General Advice

  • Give patient information sheet
  • Advise about oil-free products
  • Advise on UV protection
  • Cosmetic camouflage may be helpful for flushing, erythema and telanglectasia which will not respond to topical or oral antibiotics
  • Avoid exacerbating factors: spicy foods, alcohol, hot drinks, caffeine, temperature changes, sun exposure
  • Avoid topical steroids where possible

Topical Therapy

For mild to moderate rosacea.

  • Use topical agents for 2-3 months then intermittently as required
  • Metronidazole gel or cream od
  • Azelaic acid 15% gel or 20% cream od
  • Ivermectin cream 10mg/g od
  • Brimonidine 0.33% gel for temporary improvement of erythema as required od

Systemic therapy

For mild to moderate rosacea.

  • 2-3 months courses required intermittently
  • Lymecycline 408mg od
  • Doxycycline 100mg od
  • Erythromycin 500mg bd

Therapeutic Tips

  • If no improvement after 3 months switch to alternative antibiotic
  • Intermittent or continuous antibiotics may be required if recurrent flares and there is scope to use low dose antibiotics in the longer term once symptoms have settled (e.g. doxycycline 50-100mg daily)

Management of Ocular Symptoms

  • Lid hygiene – clean the eyelids using cotton wool soaked in cooled, boiled water
  • Artificial tears – should be applied liberally throughout the day. If necessary a lubricating ointment, sometimes containing an antibiotic preparation may be used at night
  • Systemic tetracyclines are the most effective treatment for ocular rosacea. Erythromycin can be taken orally for patients intolerant of tetracyclines
  • Retinoids should be avoided in patients with significant ocular problems as they can worsen symptoms and lead to a severe keratitis
  • Troublesome ocular symptoms that persist despite of treatment should be referred to an ophthalmologist. Patients with potentially more serious symptoms such as keratitis should be referred for urgent specialist assessment.