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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.
    • Telangiectasiae.
  •  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 FoundationBAD, 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.
Published on 19th May 2021

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