Current Treatment

Treatment Challenges

Long-Term Treatment for a Chronic Condition

The initial therapeutic step is education and reassurance, including advice on the recognition and avoidance of exacerbating factors. Treatment may include a combination of topicals, oral therapy, laser or light therapies, and surgery, depending on patient history and presentation (see Figure 1).

Figure 1

Subtype Symptoms and signs Treatment Challenges

Subtype I — Erythematotelangiectatic Rosacea

Approximately 83% of rosacea patients experience erythematotelangiectatic rosacea, also referred to as vascular rosacea.		 Prolonged flushing and erythema of the central face; may present with telangiectasias First-line treatment is generally a topical agent. Laser and phototherapy have also shown promise in patients with this subtype. Current topical and systemic therapies have little-to-no effect on erythema and telangiectasias. Long-pulsed dye lasers and intense pulsed light (IPL) are currently the treatments of choice—although multiple courses may be required for a cosmetically satisfactory result.

Subtype II — Papulopustular Rosacea

Approximately 63% of rosacea patients experience papulopustular rosacea.		 Central facial erythema combined with papules and/or pustules. Often responds well to both topical and oral agents. In conventional practice, topical agents are preferred over systemic antibiotic agents when practicable due to concerns over safety, tolerability, and antimicrobial resistance; systemic antibiotics are more often prescribed for short-term use.

Subtype III — Phymatous Rosacea

About 15% of rosacea patients suffer from phymatous rosacea.		 Thickened skin, nodularities, follicle enlargement; may present with telangiectasis Generally requires surgical or laser ablation in combination with oral antibiotics, although isotretinoin may shrink the volume of rhinophymata Therapies are invasive and may not fully restore appearance.

Subtype IV — Ocular Involvement

At least 20% of rosacea patients have ocular involvement.		 Foreign body sensation, burning or stinging, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera or other parts of the eye, or periorbital edema; if allowed to progress, can (rarely) result in corneal complications and vision impairment Oral therapy with agents in the tetracycline class Due to safety, tolerability, and resistance issues, systemic antibiotics are generally prescribed for short-term use.

Challenges of Topical Therapies

Topical agents are generally considered benign and safe for long-term use, however they do present some drawbacks:

  • They are not capable of treating all subtypes or severity levels of rosacea, and are considered most effective in mild-to-moderate cases
  • Their effect is temporary (25% of patients relapse 1 month after discontinuation and 66% of patients relapse 6 months after discontinuation)
  • They may cause skin irritation
  • Patients with moderate to severe disease typically require additional agents
  • They are not effective for ocular rosacea

Challenges of Systemic Antibiotic Therapies

Oral antibiotics, particularly the tetracyclines, have been mainstays of rosacea therapy for over 50 years. However, they are associated with well-known side effects:

  • Serious
    • Teratogenic effects
    • Tooth discoloration and alteration of bone growth if used by patients 12 years of age
  • Common
    • Photosensitivity
    • Gastrointestinal distress
  • Uncommon and minocycline-specific
    • Vertigo
    • Hyperpigmentation
    • Lupus-like syndrome/autoimmune hepatitis
  • Changes in bacterial microflora
    • Gram-negative folliculitis
    • Vaginal candidiasis
  • Antibiotic resistance
    • Can reduce future treatment options
    • Can induce cross-resistance
    • Can be transferred from commensal to pathogenic microorganisms

Advances in Therapy

An optimized oral therapy for rosacea could theoretically permit many of the current treatment challenges to be minimized or avoided.

Role of Inflammation