Based on CKS 2021, PCDS 2019, Cochrane2015; CD003262, NICE 2016, Drug Safety Update 2016
- Chronic inflammatory skin condition affecting the centro-facial region (i.e. forehead, cheeks, nose, chin).
- Mainly affects those aged 45-60, more common in women and in those with fair skin/blue eyes.
- Aetiology unclear, but genetic factors, vascular and neuronal dysfunction and colonisation with Demodex folliculorum mites may all be factors.
- Relapse rates are high - studies suggest ~20-30% of people can get long-term remission, with the remainder having a variable relapsing/remitting course of disease.
- Diagnostic features (one required for diagnosis):
- Phymatous change - facial skin thickening due to fibrosis/sebaceous gland hyperplasia (commonly the nose = 'rhinophyma').
- Persistent erythema in centro-facial region which intensifies with trigger factors (below).
- Major clinic features (two required for diagnosis):
- Flushing/transient erythema, often with sensation of prickling, tingling or burning/stinging of skin.
- Inflammatory papules and pustules, usually centro-facial region.
- Other features:
- Ocular involvement (common, in as many as 50%, and may be present without other skin features) - lid margin telangiectasia, blepharitis, conjunctivitis, anterior uveitis, keratitis.
- Dry skin or oedema.
- Key differential diagnoses:
- Acne vulgaris - generally younger people, comedones present (absent in rosacea), more widespread.
- Seborrhoeic dermatitis - yellow scaling, affects eyebrows and naso-labial folds (spared in rosacea).
- Lupus 'butterfly' rash - malar distribution, rarely presents with pustules.
- Avoid triggers - Caffeine, alcohol, spicy foods, hot drinks, emotional stress, calcium channel blockers.
- Avoid UV radiation - use high SPF 50 with UVA/UVB cover (e.g. Anthelios®, Sunsense®, Uvistat® - NB expensive, can be prescribed under 'ACBS' rules).
- Regular non-oily emollients.
- Useful information on self-help NHS Choices & British Skin Foundation & BAD, Rosacea
- Facial flushing and moderate to severe erythema:
- Topical brimonidine gel (alpha-adrenergic agonist) can be used on an ‘as required' basis; works within 30 minutes, lasts for up to 12 hours; but may exacerbate rosacea/symptoms in some or lead to rebound symptoms - so use small amounts for 1 week and gradually increase as tolerated; other side effects include alpha adrenergic effects - dizziness, dry mouth, headaches.
- Other options - Propranalol 40mg BD, clonidine 50mcg BD, carvedilol 12.5mg OD.
- Mild to moderate papulopustular rosacea:
- Topical metronidazole 0.75% or azelaic acid 15%, benefits start to appear after 3 to 6 weeks.
- Topical ivermectin cream once-daily for 8-12 weeks - good evidence base, generally well tolerated.
- Moderate to severe papulopustular rosacea (use together with topical treatments):
- Doxycycline (100mg OD or MR 40mg OD - both equally effective, possibly lower side effects with 40mg MR dose but expensive) Oxytetracycline 500mg BD, lymecycline 408mg OD, erythromycin 500mg BD all options - use initially for 8-12 weeks then step down to topical treatment only.
- If very severe, refer for consideration of oral isotretinoin.
- Ocular disease - lid hygiene and artificial tears/lubricants; consider oral tetracyclines; refer if troublesome symptoms to ophthalmology or urgently if anterior uveitis or keratitis suspected.