KISS: Rosacea

Based on CKS 2021,  PCDS 2019,  Cochrane2015; CD003262,  NICE 2016,  Drug Safety Update 2016

Background:

• 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 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.