Update on the management of rosacea

Abstract

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Keywords: guidelines; management; rhinophyma; rosacea; vascular laser.

Figure 1

Erythematotelangiectatic rosacea. Note: Central facial erythema (most prominently on the cheeks) with telangiectasias.

Figure 2

Papulopustular rosacea. Note: Multiple papules and pustules on the central face, lacking comedones and sparing the perioral area.

Figure 3

Phymatous rosacea. Note: Thickened, glandular skin of the nose, creating a cosmetic deformity.

Figure 4

Ocular rosacea. Note: Erythematous conjunctiva with increased watery discharge in the setting of acutely flared granulomatous rosacea.

Figure 5

Before (A) and after (B) injectable botulinum toxin (Botox^®, 10 U, 0.05 mL aliquots every 1–2 cm) intradermally into each cheek in combination with pulsed dye laser (10 mm, 10 msec, 7 J/cm). Note: Clinical results and symptomatic relief were seen rapidly after the treatments.

Figure 6

Before (A) and after (B) oxymetazoline (Afrin^®) combined with a topical moisturizing cream (CeraVe^®) applied twice daily. Significant improvement in facial erythema was seen after only one day of application.

Figure 7

(A) Severe perioral dermatitis (a version of acne-rosacea). (B) Dramatic improvement after initiation of oral isotretinoin. Note: Full clearance with no recurrence was seen after 20 weeks of therapy.

Figure 8

Before (A) and immediately after (B) continuous wave fully ablative carbon dioxide laser treatment, and 2 weeks following (C) treatment for metaphyma (enlargement of sebaceous glands on the forehead). Notes: Dramatic improvement without any sequelae is seen in the areas of concern for this patient. Similar results are seen with rhinophyma using comparable methods.