Guidelines
Management
Conservative / General Management
- Avoid trigger factors if possible (e.g. smoking, alcohol, spicy food)
- Sun protectionUltraviolet (UV) light is a well-established trigger for rosacea exacerbations with high-factor sunscreen
General skin care measures:
- Regular use of non-oily emollients if skin is dry
- Use gentle soap-free OTC cleansers
- Cosmetics (yellow / green tinted) to camouflage skin erythema
Pharmacological Management
Choice of drugs depends on the clinical phenotype and severity
Persistent Erythema
1st line: topical brimonidineMoA: alpha adrenergic agonist - causes vasoconstriction to reduce erythema 0.5% gel once daily or PRN
- Advise that it only offers temporary relief of symptoms (may reduce erythema within 30 min, reaching peak action at 3-6 hours, but after erythema will return to baseline)
Papules and/or Pustules
Mild to moderate: topical ivermectinAntihelmintic and insecticidal preparation once daily for 8-12 weeks
- Pregnancy: topical metronidazole / azelaic acid
Moderate to severe (or if topical ivermectin not effective alone): topical ivermectinAntihelmintic and insecticidal preparation + oral doxycycline 40mg once daily for 8-12 weeks
- Pregnancy: topical metronidazole / azelaic acid + oral erythromycin
Clinically Inflamed Phymatous Disease
Consider oral doxycycline 40mg once daily for 6 weeks
Specialist Treatment Escalation
The following may be considered:
- Oral isotretinoin
- Severe inflammatory papules and/or pustules, or persistent clinically inflamed phymatous disease
- Electrodessication or laser
- persistent erythema and/or extensive telangiectasia