Rosacea is a chronic skin condition, it is a rash involving the central face that most often affects people who have fair skin, blue eyes and Celtic origins and aged 30 to 60.

It has different variants which sometimes can be similar to acne, however, the cause for rosacea is different.

Like acne, there are risk factors for this skin condition including:
-Genetic
-Sun damage (ultra-violet damage).
-Abnormal or exaggerated immune response in skin appears to be important.
-Matrix (fluids and materials between cells in the skin) enzyme such as collagenase and elastase have important roles in rosacea.
-Hair follicle mites are sometimes observed within rosacea papules but their role is unclear.
-Rosacea can be aggravated by facial creams or oils, and especially by topical steroids.

Features of Rosacea
Red spots (papules) and sometimes pustules. They are dome-shaped rather than pointed and unlike acne, there are no blackheads, whiteheads or nodules.
Rosacea may also result in just red areas (erythematotelangiectatic rosacea), scaling (rosacea dermatitis) and swelling (phymatous rosacea).

Treatment for Rosacea

General measures

  • Where possible, reduce factors causing facial flushing.
  • Avoid oil-based facial creams. Use water-based make-up.
  • Never apply a topical steroid to the rosacea as although short-term improvement may be observed (vasoconstriction and anti-inflammatory effect), it makes the rosacea more severe over the next weeks (possibly by increased production of nitric oxide).
  • Protect yourself from the sun. Use light oil-free facial sunscreens.
  • Keep your face cool to reduce flushing: minimise your exposure to hot or spicy foods, alcohol, hot showers and baths and warm rooms.
  • Some people find they can reduce facial redness for short periods by holding an ice block in their mouth, between the gum and cheek

Oral antibiotics for rosacea

Tetracycline antibiotics including doxycycline and minocycline are commonly used to treat rosacea

  • They reduce the redness, papules, pustules and eye symptoms.
  • The antibiotics are usually prescribed for 6–12 weeks, with the duration and dose depending on the severity of the rosacea.
  • Further courses are often needed from time to time, as antibiotics don’t cure the disorder.

Sometimes other oral antibiotics such as cotrimoxazole or metronidazole are prescribed for resistant cases.

Anti-inflammatory effects of antibiotics are under investigation.

  • They have been shown to inhibit matrix enzymes function and in turn, reduce cathelicidins and inflammation.
  • The effective dose of tetracyclines in rosacea is lower than that required to kill bacteria, so they are not working through their antimicrobial function.

Disadvantages of longterm antibiotics include the development of bacterial resistance, so low doses that do not have antimicrobial effects are preferable  (eg, 40–50 mg doxycycline daily).

Topical treatment of rosacea

  • Metronidazole cream or gel can be used intermittently or long-term on its own for mild inflammatory rosacea and in combination with oral antibiotics for more severe cases.
  • Azelaic acid cream or lotion is also effective for mild inflammatory rosacea, applied twice daily to affected areas.
  • Brimonidine gel, an alpha-2 adrenergic agonist, and oxymetazoline hydrochloride cream, an alpha1A adrenoceptor agonist, reduce facial redness temporarily. 
  • Ivermectin cream can be used in the treatment of papulopustular rosacea. It controls demodex mites and is anti-inflammatory.

Isotretinoin

When antibiotics are ineffective or poorly tolerated, oral isotretinoin may be very effective. Although isotretinoin is often curative for acne, it may be needed in low dose long-term for rosacea, sometimes for years. It has important side effects and is not suitable for everyone.

Medications to reduce flushing

Nutraceuticals targeting flushing, facial redness and inflammation may be beneficial.

Certain medications such as clonidine (an alpha2-receptor agonist) and carvedilol (a non-selective beta blocker with some alpha-blocking activity) may reduce the vascular dilatation (widening of blood vessels) that results in flushing. They are generally well tolerated. Side effects may include low blood pressure, gastrointestinal symptoms, dry eyes, blurred vision and low heart rate.

Anti-inflammatory agents used for rosacea

Oral non-steroidal anti-inflammatory agents such as diclofenac may reduce the discomfort and redness of the affected skin. Although these are uncommon, serious potential adverse effects to these agents include peptic ulceration, renal toxicity and hypersensitivity reactions.

Calcineurin inhibitors such as tacrolimus ointment and pimecrolimus cream are reported to help some patients with rosacea.

Vascular laser

Persistent telangiectasia can be successfully improved with vascular laser or intense pulsed light treatment. Where these are unavailable, cautery, diathermy (electrosurgery) or sclerotherapy (strong saline injections) may be helpful. Papulopustular rosacea may also improve with laser treatment or radiofrequency.

Surgery for rhinophyma

Rhinophyma can be treated successfully by a dermatologic or plastic surgeon by reshaping the nose surgically or with carbon dioxide laser.

References:

  1. https://www.dermnetnz.org/
  2. Clinical Dermatology by Thomas Habif
  3. https://www.betterhealth.vic.gov.au/