Rosacea

Overview

This Guidelines summary covers diagnosis, assessment, management, and referral for people with rosacea. For prescribing information, refer to the full Clinical Knowledge Summary (CKS).

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Diagnosis

• The clinical manifestations of rosacea often vary in nature and severity over time, and the diagnosis is usually made on the basis of clinical features alone.
• Make a diagnosis of rosacea if there is at least one ‘diagnostic’ or two ‘major’ clinical features (phenotypes) present.
• Diagnostic clinical features:
  • Phymatous changes—facial skin thickening due to fibrosis and/or sebaceous glandular hyperplasia. Most commonly affects the nose, where it may have a bulbous appearance (so-called rhinophyma). May be clinically inflamed (‘active’) or non-inflamed (‘fibrotic’ or ‘burnt out’).
  • Persistent erythema—persistent centrofacial redness that may periodically intensify in response to various trigger factors. Note: in darker skin phototypes (V and VI), erythema may be difficult to detect visually.
• Major clinical features (which are not individually diagnostic):
  • Flushing/transient erythema—a temporary increase in centrofacial redness, which may include sensations of warmth, heat, burning, and/or pain. Usually lasts for less than five minutes and may spread to the neck and chest. May be the initial presenting feature of rosacea.
  • Inflammatory papules and pustules—red papules and pustules, usually in the centrofacial area. Some may be larger and deeper, and may become nodules.
  • Telangiectasia—visible vessels in the centrofacial region, but not only in the alar area (side of nose).
  • Ocular manifestations.
  • Note: in darker skin phototypes (V and VI), erythema and telangiectasia may be difficult to detect visually.
• Minor clinical features (which may be subjective and are not individually diagnostic):
  • Burning sensation—an uncomfortable or painful feeling of heat, typically in the centrofacial region.
  • Stinging sensation—an uncomfortable or painful sharp, pricking sensation, typically in the centrofacial region.
  • Skin dryness sensation or appearance—skin that feels rough. May be tight, scaly, and/or itchy.
  • Oedema—localised facial swelling that may accompany or follow prolonged erythema or flushing. May be soft or firm (non-pitting), and may be transient or persistent.
• Suspect a diagnosis of ocular rosacea if:
  • There are eye symptoms such as:
    • Eye discomfort, irritation, tearing, foreign body sensation, dryness, itching, photophobia, or blurred vision.
  • There are eye signs of:
    • Lid margin telangiectasia—visible vessels around the eyelid margins. Note: this may be difficult to detect visually in darker skin phototypes (V and VI).
  • There is suspected:
    • Blepharitis or acute lid infection (chalazion or hordeolum).
    • Conjunctivitis—inflammation of the mucous membranes lining the inner surface of the eyelids and bulbar conjunctiva. Typically associated with injection or vascular congestion and conjunctival oedema.
    • Keratitis.
    • Anterior uveitis—inflammation of the iris and/or ciliary body.
  • Note: be aware that eye symptoms or signs may present with or without skin disease.

Assessment of a Person with Suspected Rosacea

• Ask about:
  • Symptoms such as flushing, skin burning, stinging, and dryness, and their onset, duration, and severity.
  • The distribution, extent, and severity of facial skin involvement, including daily fluctuation of features.
  • Symptoms of ocular rosacea, and their onset, duration, and severity.
  • The frequency and duration of relapses.
  • Any psychosocial impact on quality of life, including work, education, social, or leisure activities.
  • Any known trigger factors, including sun exposure, diet, and activities that cause symptoms or relapses.
  • Any known family history.
  • Any previous treatments and symptom response.
• Examine the person:
  • Assess for facial skin involvement, the distribution, extent, and severity of clinical features, including:
    • Phymatous changes (skin thickening, deformation, sites of involvement, inflamed or non-inflamed).
    • Erythema (transient or persistent).
    • Oedema (depth, pitting, distortion).
    • Telangiectasia.
    • Inflammatory papules, pustules, or nodules.
  • Assess for possible clinical features of ocular rosacea.

Management

• Advise that:
  • Rosacea is a chronic condition that may improve with treatment, but intermittent relapses may occur.
  • The aim of treatment should be complete skin clearance, where possible.
• Provide advice on sources of information and support, such as:
  • The British Skin Foundation.
  • The British Association of Dermatologists patient leaflets on Rosacea and Rhinophyma.
  • NHS information leaflet on Rosacea.
  • patient.info leaflet on Rosacea.
• Provide advice on self-management measures:
  • Advise on the importance of avoiding trigger factors wherever possible:
    • Suggest that a diary may be helpful to identify stimuli and triggers that may exacerbate rosacea.
  • Advise on the importance of effective sun protection and to avoid the use of sunbeds:
    • High-factor sunscreen with protection against ultraviolet A and B can be prescribed (these are classified as ‘borderline substances’ and the prescription must be endorsed ‘ACBS’).
    • Ultraviolet protection sunglasses may be helpful for people with features of ocular rosacea.
  • Advise on general skincare measures such as:
    • The use of regular non-oily emollients if the skin is dry. See the CKS topic on Eczema—atopic for detailed prescribing information on emollients.
    • The use of gentle soap-free over-the-counter cleansers.
    • The possible use of yellow- or green-tinted cosmetics to help camouflage skin erythema.
• Offer referral to a skin camouflage service, if appropriate.
• Manage any associated psychosocial comorbidities.
• Prescribe first-line topical and/or oral drug treatments, depending on the clinical phenotype and severity of disease, and the person’s preferences.
  • If there is persistent erythema, consider prescribing topical brimonidine 0.5% gel (a topical alpha-adrenergic agonist) once daily on an ‘as needed’ basis, for temporary relief of symptoms, depending on local prescribing guidelines.
    • Advise that topical brimonidine may reduce erythema within 30 minutes, reaching peak action at 3–6 hours, after which the effect diminishes and erythema returns to baseline.
    • Advise that telangiectasia may be accentuated as general erythema is reduced.
  • If there are mild-to-moderate papules and/or pustules, prescribe topical ivermectin (an antihelmintic and insecticidal preparation) once daily for 8–12 weeks, depending on local prescribing guidelines.
    • Alternative topical preparations are metronidazole 0.75% applied twice daily or azelaic acid 15% applied twice daily, if ivermectin is not available or inappropriate, for example for pregnant or breastfeeding women.
  • If there are moderate-to-severe papules and/or pustules, prescribe a combination of topical ivermectin, depending on local prescribing guidelines, together with oral doxycycline 40 mg once daily as a modified-release preparation for 8–12 weeks.
    • Alternative topical preparations are metronidazole 0.75% applied twice daily or azelaic acid 15% applied twice daily, if ivermectin is not available or inappropriate, for example for pregnant or breastfeeding women.
    • Alternative oral preparations are oxytetracycline 500 mg twice daily or tetracycline 500 mg twice daily, or erythromycin 500 mg twice daily for pregnant or breastfeeding women.
• If there is clinically inflamed phymatous disease, consider prescribing oral doxycycline 40 mg once daily as a modified-release preparation (off-label indication) for 6 weeks.
  • If there is suspected ocular rosacea, manage appropriately and advise on:
    • Lid hygiene measures.
    • The use of artificial tears or ocular lubricants (for mild ocular burning and stinging symptoms and dry eyes).
• Arrange to review the person following first-line treatment(s), to assess the clinical response, need for maintenance therapy, alternative treatment, or referral.
  • For mild-to-moderate papules and/or pustules, if there is a clinical improvement:
    • Continue maintenance treatment with topical preparations as needed, ideally until the skin is clear.
  • For mild-to-moderate papules and/or pustules, if there is little or no improvement, consider prescribing a combination of topical preparation together with oral doxycycline 40 mg once daily as a modified-release preparation for 8–12 weeks.
    • Alternative oral preparations are oxytetracycline or tetracycline 500 mg twice daily, or erythromycin 500 mg twice daily for pregnant or breastfeeding women.
  • For moderate-to-severe papules and/or pustules, if there is a clinical improvement:
    • Continue combination treatment up to 12–16 weeks, then reassess the need for ongoing oral antibiotic treatment and continue topical treatment, depending on clinical judgement.
  • For moderate-to-severe papules and/or pustules if there is little or no improvement, consider arranging referral to dermatology, depending on clinical judgement.
  • For suspected ocular rosacea following 2–4 weeks of self-care treatment:
    • If there is a clinical improvement, continue management as needed.
    • If there is little or no improvement, considering arranging referral to ophthalmology, depending on clinical judgement.

When to Refer a Person With Rosacea

• Consider arranging referral to a dermatologist for possible specialist management if there is:
  • Persistent erythema that has not responded to optimal management in primary care.
  • Persistent inflammatory papules and/or pustules that have not responded to optimal management in primary care.
  • Severe telangiectasia that have not responded to self-management advice, depending on clinical judgement and local referral guidelines.
  • An uncertain diagnosis.
• Consider arranging referral to a local skin camouflage service (which may be available through the local dermatology service).
  • Advise that people may self-refer to the charity Changing Faces, which provides education from skin camouflage practitioners on the use and application of cosmetic camouflage creams and powders. The website changingfaces.org.uk provides patient information on skin camouflage, details of local skin camouflage services, a telephone helpline, and online support forum.
• Consider arranging referral to a plastic surgeon if there is:
  • Prominent non-inflamed phymatous disease.
• Arrange referral to an ophthalmologist, the urgency depending on clinical judgement, if:
  • A serious eye complication, such as keratitis or anterior uveitis, is suspected (for example suggested by sudden pain, red eye, and/or visual disturbance).
  • Other associated ocular symptoms are severe or do not respond to optimal management in primary care.

For prescribing information on topical treatments and oral antibiotics for rosacea, including contraindications, adverse effects, and information on drug interactions, refer to the full CKS.