PCDS rosacea treatment pathway guideline

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What is rosacea?

Rosacea is a chronic disorder of the facial skin characterised by redness, particularly of the convexities—cheeks, chin, and forehead sparing the peri-ocular skin
Flushing is common and tends to be prolonged and can be uncomfortable and embarrassing. This is often triggered by temperature change, exercise, food, emotional stimuli, and alcohol. In time telangiectasia can develop
Some patients develop acne-like papules and pustules, but comedones are absent
Eye symptoms are common including dryness, grittiness, blepharitis, and redness
Rosacea can be seen in all skin types but is more common in fair skin. It affects both sexes and tends to occur in mid-life
A subset of patients develop thickening of the facial tissues, particularly of the nose (rhinophyma) but this is relatively uncommon and very rare in women

Important information about treatments

Treatment is often required because avoiding triggers can be difficult for patients. Use of high factor broad spectrum sunblock (sun protection factor ≥30) is recommended
Light emollients and camouflage skin care products are beneficial. Topical steroids can exacerbate rosacea and should be avoided
Treatment options are directed by the predominant type of rosacea. Flushing and fixed erythema can be helped by topical brimonidine, intense pulsed light (IPL), or pulsed dye laser (PDL). More raised/ inflammatory changes (i.e. papules and pustules) can be treated with topical agents (ivermectin, azelaic acid, or metronidazole gels or creams), or oral antibiotics)
This guidance has been developed to be mindful of the growing concerns about antibiotic resistance. If possible, the use of long-term antibiotics should be avoided
For futher information on treatment options and rosacea subsets, please refer to the PCDS rosacea treatment pathway and treatment options.

Differential diagnosis

Seborrhoeic dermatitis (may co-exist); the patient will usually have history of dandruff, dryness, and scale in the naso-labial folds, medial eyebrow, and ear
Acne vulgaris; when presenting with greasiness, comedones and lack of background erythema
Periorificial dermatitis; typically seen in young women, can be acneiform or eczematous around the mouth and/or eyes
Keratosis pilaris rubra; fixed redness of cheeks since childhood with follicular erythema and scale on upper arms and thighs

Treatment options for rosacea subsets
Product	Flushing and fixed erythema	Inflammatory papules and pustules	Ocular	Protocol and comments^*
Ivermectin cream1%		+++		Well tolerated, once daily, greater efficacy than metronidazole and no concerns with antibiotic resistance
Azelaic acid gel		++		Effective twice daily, may cause irritation and no concerns with antibiotic resistance
Metronidazole gel or cream 0.75%		+		Twice daily, less effective than ivermectin
Brimonidine gel 0.33%	++			Effective and fast-acting vasoconstrictor, patients should be warned about the possibility of rebound flush which can limit usage
Eye lubricants			+++	Lid hygiene and warm eye compresses also important
Doxycycline MR 40 mg		+++		Once daily. Fewer side-effects and equivalent efficacy as full dose (100mg). Sub-microbial dose reduces risk of antibiotic resistance compared with other antibiotics
Doxycycline 100mg and lymecycline 408mg capules		++	++	Less expensive, more side-effects. Well tolerated, once daily
Oxytetracycline 250–500 mg		+	+	Twice daily, avoid taking with meals
Erythromycin/ clarithromycin 250–500 mg		+		Twice daily, useful in pregnancy
Isotretinoin		++		Useful in secondary care for resistant cases
Intense pulsed light (IPL)	+++			Limited NHS availability
Pulsed dye laser (PDL)	++			Limited NHS availability and causes significant bruising
Clonidine 25–50μg	++			Up to three times daily, improves flushing in some patients
Propranolol 10–40 mg	+			Up to three times daily
Carvedilol 3.125–6.25 mg	+			Up to three times a day
+++ = strong recommendation ++ = moderate recommendation + = low recommendation. * These comments are the opinions of the contributors, reviewed by the PCDS Executive Committee and do not consider NHS costs and local prescribing restrictions, if any.

Practical advice and further information resources for doctors and patients

Inflammatory rosacea is highly amenable to treatment and patients should be advised that whilst a chronic condition that cannot be cured, it can be very well controlled. Long-term treatment is generally advisable to minimise the risk of progression of the disease
Patients may initially require a combination of topical and systemic treatment, but ideally managed on topical treatments in the longer term. If significant improvement is not experienced at two months, patients should be encouraged to seek further medical advice
Patients should be reassured that alcohol does not cause rosacea, although it may induce flushing
We would encourage regular reviews to ensure unnecessary use of antibiotics is avoided