Rosacea Treatments

Rosacea is a chronic skin disease, which means there’s no curative treatment. 
As rosacea can manifest with many different symptoms these are the targets of various treatment modalities.

In 2017 the Global Rosacea Consensus Panel agreed on the latest treatment recommendations for rosacea. Their overall points were:

GENERAL STRATEGIES 
1) Skincare is fundamental (more on that in my post on How To Manage Rosacea)
2) Treatment should be based on the phenotype (= symptoms the patient presents)
3) If several symptoms appear in a patient, which is often the case, they can be treated simultaneously with different agents/modalities. 

Topical and oral (systemic) treatment modalities for mild, moderate and severe rosacea

REDNESS & TELANGIECTASIAS
Unfortunately there’s no high-quality evidence for flushing treatments, which emphasizes the complexity of the disease. Transient redness (=comes and goes) can be treated with cream and pills that constrict the vessels in the skin. Persistent redness and telangiectasias (chronic dilated vessels) can both be treated with IPL (intense pulsed light) and PDL (pulsed-dye laser) and the latter with electrodesiccation and other laser options.

PAPULES & PUSTULES
These symptoms are (according to severity) treated with 1) Creams with anti-inflammatory properties that also kill the mites 2) Oral antibiotics in submicrobial doses used for their anti-inflammatory properties
3) Oral vitamin A which has anti-angiogenic effects (improving redness and flushing), alters skin microbiome and changes composition of sebum/skin fatty acids (ref. 3).

For treatment of ocular rosacea (rosacea involving the eye) see table below.

Topical and oral (systemic) treatment options for mild, moderate and severe ocular rosacea.


Which treatment(s) have you tried?

REFERENCES: 
1) Schaller et al. “Rosacea treatment update: recommendations from the
global ROSacea COnsensus (ROSCO) panel” Br J Dermatol 2017; 176:465–471 
DOI 10.1111/bjd.15173

2) Valentín, Sheila et al. “Safety and efficacy of doxycycline in the treatment of rosacea” Clinical, cosmetic and investigational dermatology vol. 2 129-40. 12 Aug. 2009 PMCID: PMC3047926

3) M. Rademaker “Very low-dose isotretinoin in mild to moderate papulopustular rosacea; a retrospective review of 52 patients.” Australas J Dermatol. 2018 Feb;59(1):26-30. doi: 10.1111/ajd.12522.

Rosacea Classifications

The continuum of rosacea symptoms across all four subtypes

Traditionally rosacea has been divided into 4 subtypes (listed below) but over the past 15 years significant new knowledge of the causes of rosacea, disease development and mechanisms have emerged.
Thus, the global ROSacea COnsensus (ROSCO) panel concluded in their 2017 recommandations that classification of rosacea should be based on phenotype (= the present symptoms in the patient).

Subtype 1) Erythematotelangiectatic rosacea (ETR)
Subtype 2) Papulopustular rosacea (PPR)
Subtype 3) Phymatous rosacea 
Subtype 4) Ocular rosacea

Some patients present only predominantly one or two features (e.g. redness, flushing and occasional papules) and others are affected by all the symptoms across the four subtypes during their life, but common for everyone with rosacea is the chronic central redness of the face.

DIAGNOSTIC FEATURES
To set the diagnosis either of two has to be present 
1) “Persistent centrofacial erythema associated with periodic intensification by potential trigger factors” (e.i. flushing)
2) “Phymatous changes” (skin thickening of the nose) 
Based on this new insight rosacea should be considered a spectrum of symptoms that can be present in varying degree in each individual, rather than classified as 4 fixed subtypes.

What symptoms are you mostly affected by?

REFERENCES:
1) Gallo RL, Granstein RD, Kang S et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018; 78:148–55.

2) Tan, J & Almeida, L.M.C. & Bewley, Anthony & Cribier, B & Dlova, N.C. & Gallo, Rich & Kautz, G & Mannis, M & Oon, Hazel & Rajagopalan, Murlidhar & Steinhoff, Martin & Thiboutot, D & Troielli, P & Webster, G & Wu, Y & van Zuuren, Esther & Schaller, M. (2016). Updating the diagnosis, classification and assessment of rosacea: Recommendations from the global ROSacea COnsensus (ROSCO) panel. The British journal of dermatology. 176. 
DOI: 10.1111/bjd.15122 

Rosacea

Rosacea is a common chronic inflammatory skin condition affecting the face primarily cheeks, nose, chin, central forehead and includes eye symptoms. It’s believed to be highly under-diagnosed, as mild to moderate cases can go on untreated without consulting a doctor.

SYMPTOMS 
It’s characterized by redness, flushing, inflammatory papules and pustules, telangiectasia (dilated blood vessels) and phymatous changes (thickening of the nose). Read more about subtypes here.

The clinical features of rosacea subtypes

SENSITIVE SKIN
People with rosacea often have inherently compromised skin barrier with increased transepidermal water loss and decreased epidermal hydration leading to dryness and sensitive skin. 


IN NUMBERS
5.46% of adults are estimated to suffer from rosacea. Women & men are affected equally (contrary to previous knowledge). Typical onset age 30 to 65. Fair skinned people and familial disposition are more likely to get rosacea.

CAUSES
The exact pathogenesis of rosacea is still unclear, however we know:
Microorganisms, like the skin mite Demodex folliculorum and staphylococcus epidermidis, may contribute to development of rosacea by stimulating the innate immune system driving the inflammatory response causing the papules and pustules.
Neurogenic dysregulation of the vessels in the skin may contribute to rosacea symptoms such as flushing and burning.
Genetic heredity also plays a role.

Triggers initiating a cascade of inflammation in rosacea skin around the hair follicle
The inflammation around a hair follicle creating the papules and pustules

REFERENCES: 
Gether. L et al. Incidence and Prevalence of Rosacea: a systematic review and meta-analysis. Br. J. Dermatol 2018 DOI: 10.1111/bjd.16481

Two AM et al: Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors. J Am Acad Dermatol. 72(5):749-58 DOI: 10.1016/j.jaad.2014.08.028

Gallo RL, Granstein RD, Kang S et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018; 78:148–55.

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