WESTON LIBRARY
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`OCT 1 0 2001
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`Cutaneous
`Med.JCihEf and
`Surgery
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`Editors
`Kenneth A. Arndt, MD
`Philip E. LeBoit, MD
`June K. Robinson, MD
`Bruce U. Wintroub, MD
`
`Publisher
`W. B. Saunders Company
`A Harcourt Health Sciences Company
`
`2
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`

`

`Treatment of Rosacea
`Guy F. Webster, MD, PhD
`
`Rosacea is an inflammatory disease of the face
`and eyes. Treatment is adjusted to the site of the
`disease and its severity.
`Copyright© 2001 by W.B. Saunders Company
`
`A N OBVIOUS but important concept in the
`
`treatment of rosacea is that rosacea is not
`acne. The central lesion of acne, the micro(cid:173)
`comedo, is not part of the pathogenesis of rosacea.
`Moreover, Propionibacterium acnes, the target of
`acne inflammation, does not play a role in the
`rosacea of most patients. Thus, simply using many
`common acne regimens for rosacea is to mistreat
`the disease.
`There are 4 important types of rosacea: vascu(cid:173)
`lar, inflammatory, sebaceous, and ocular, each of
`which has distinct therapeutic regimens.
`
`VASCULAR ROSACEA
`
`The persistent blush of vascular rosacea can be
`the most vexing to treat. Probably mediated by
`neurovascular connections, it is really an exagger(cid:173)
`ation of a normal response. A variant form is ker(cid:173)
`atosis pilaris faceii in which rubor is accompanied
`by follicular plugging. Currently, there are no
`medications that adequately treat vascular rosa(cid:173)
`cea. Avoidance of triggering stimuli such as spicy
`food and alcohol can be of benefit. Cool com(cid:173)
`presses may also be of help.
`Topical steroids, although potent vasoconstric(cid:173)
`tors, are a terrible treatment for rosacea in any of
`its forms. Initially improvement is seen, but atro(cid:173)
`phy and steroid-induced rosacea follows in most
`patients with prolonged use.
`The pulsed dye laser is an excellent tool for
`treating vascular rosacea. Long-lasting improve(cid:173)
`ment typically follows 1 or 2 treatments.
`
`SEBACEOUS HYPERPLASIA
`
`Manifest as either swollen individual glands or
`rhinophyma, sebaceous hyperplasia is often a part
`of rosacea. Its origin is unknown (I suspect neural
`influences, especially on the nose). Treatment is
`primarily surgical. Fifty to 75% trichloracetic acid
`will shrink most sebaceous hyperplasias and the
`pulsed dye laser is helpful for small hyperplastic
`
`glands. C02 laser or hot-loop cautery are fre(cid:173)
`quently used to recontour rhinophyma.
`Although not a labeled indication, isotretinoin
`is useful in early rhinophyma. If treatment is be(cid:173)
`gun before significant fibrosis has formed, isotreti(cid:173)
`noin in modest dosages (eg, 20 mg/day) will
`shrink significant rhinophyma over several
`months of therapy.
`
`INFLAMMATORY ROSACEA
`
`Papules, pustules, and nodules of rosacea are
`the most troublesome to patients, but usually are
`the most responsive to medical therapy. The stim(cid:173)
`ulus for inflammation is unknown, but probably is
`not P acnes because not all antibiotics that lower P
`acnes levels are helpful in rosacea.
`Topical products (Table 1) that are useful in
`inflammatory rosacea include benzoyl peroxide,
`azeleic acid, metronidazole, and sodium sulfacet(cid:173)
`amide. In general, products with low irritancy
`should be used in rosacea because promotion of
`erythema is counterproductive. Thus, lotions and
`creams are preferred over more drying prepara(cid:173)
`tions, and lower concentrations of benzoyl perox(cid:173)
`ide (eg, 3%) are most helpful. Even the best topi(cid:173)
`cal medications do not work quickly; weeks to
`months are required, and patience must be en(cid:173)
`couraged.
`The tetracycline (Table 2) family is the main(cid:173)
`stay of oral rosacea therapy. Tetracyclines dis(cid:173)
`courage neutrophil migration as well as granu(cid:173)
`loma formation, and their activity in rosacea is
`probably more anti-inflammatory than antibac(cid:173)
`terial. Surprisingly, low dosages can be used
`once the disease is under control. The order of
`potency is that tetracycline is less effective than
`doxycycline, which is slightly less than minocy(cid:173)
`cline.
`
`From the Department of Dermatology, Jefferson Medical Col(cid:173)
`lege, Philadelphia, PA.
`Address rep1int requests to Guy F. Webster, MD, PhD, Depart(cid:173)
`ment ofDennatology, 833 Chestnut St, Suite 740,]efferson Med(cid:173)
`ical College, Philadelphia, PA 19107.
`Copylight © 2001 by W.B. Saunders Company
`1085-5629/01/2003-0010$35.0010
`doi:10.1053!sder.2001.27554
`
`Seminars in Cutaneous Medicine and Surgery, Vol20, No 3 (September), 2001: pp 207-208
`
`207
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`208
`
`GUY F. WEBSTER
`
`Despite occasional successes, erythromycin is
`of little use in rosacea. Trimethoprim/sulfame(cid:173)
`thoxazole may be useful in patients who are intol(cid:173)
`erant of members of the tetracycline family but is
`no more effective than minocycline in my experi(cid:173)
`ence.
`Severe inflammatory rosacea that does not re(cid:173)
`spond to antibiotics usually benefits from a course
`of isotretinoin. Although not a labeled indication,
`rosacea responds well to moderate dosages of the
`drug. Typically, 20 to 40 mglday is sufficient to
`control most patients. After 4 to 6 months of ther(cid:173)
`apy, most patients have disease that can be con(cid:173)
`trolled by lesser means.
`
`Table 1. Topical Regimens for Treatment of Rosacea
`
`Metronidazole cream/gel once or twice doily
`Azelaic acid twice doily
`Benzoyl peroxide cream once or twice doily
`Sodium sulfacetamide lotion or wash twice doily
`
`Table 2. Oral Medications for Rosacea
`
`Tetrocycline---250 to 500 mg once or twice doily
`Doxycycline-50 to 1 00 mg once or twice doily
`Minocycline---50, 75, or 100 mg once or twice doily
`Trimethoprim/sullomethoxozole DS----{)nce or twice doily
`lsotretinoin-20 to 40 mg once doily
`
`OCULAR ROSACEA
`
`The biggest challenge in treating the ocular
`manifestations of rosacea is their recognition. Pa(cid:173)
`tients presenting to a dermatologist rarely voice
`complaints about their eyes· and we rarely elicit
`them. Ocular rosacea patients may complain of
`dry eyes, irritable or allergic eyes, ocular sebor(cid:173)
`rheic dermatitis, or give a history of frequent
`styes.
`Lubrication of the ocular rosacea never hurts,
`but oral therapy with one of the tetracyclines is
`usually best. I prefer doxycycline or minocycline
`in initial dosages of 100 mg bid with a gradual
`tapering to the least effective dosage over several
`months.
`
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