Rosacea Management

Introduction to Rosacea

Rosacea is a chronic inflammatory skin condition characterized by persistent facial erythema, flushing, inflammatory papules/pustules, telangiectasia, phymatous changes, and ocular manifestations, typically affecting middle-aged individuals with a higher prevalence in women, suggesting a possible hormonal component 1, 2
Demodex mite overgrowth is associated with rosacea 1, 3

Rosacea is associated with other conditions, including ocular manifestations that affect approximately 75% of rosacea patients, and can be challenging to diagnose in patients with darker skin tones due to difficulty visualizing telangiectasia or facial flushing 1, 4
A phenotype-based approach to diagnosis and management is recommended, identifying predominant phenotypes such as persistent erythema, flushing, inflammatory lesions, telangiectasia, phymatous changes, and ocular manifestations, as stated by the Global Rosacea Consensus (ROSCO) panel 5

A comprehensive approach including medication, skincare, and environmental trigger avoidance is essential for rosacea management, with the American Academy of Ophthalmology recommending topical azelaic acid, topical ivermectin, or brimonidine as effective treatments, and the American Academy of Dermatology suggesting beta-blockers (such as propranolol) for managing facial flushing 1, 3, 6
Topical metronidazole (0.75% or 1%) can reduce inflammatory lesions by 48-65% in rosacea patients, and oral doxycycline has anti-inflammatory properties and can be used for refractory cases of rosacea 3
Avoidance of triggers, mild cleansing agents and moisturizing regimens, and photoprotection with wide-brimmed hats and broad-spectrum sunscreens are recommended for the management of rosacea, according to the American Academy of Dermatology 7

Long-term corticosteroid use should be avoided as it can worsen rosacea, and tetracyclines should not be used in children under 8 years of age or pregnant women, as recommended by the Ophthalmology guidelines 1, 3
Oral azithromycin carries a small but absolute increase in cardiovascular death risk, particularly in patients with high baseline cardiovascular risk, and medications such as vasodilating drugs, antidepressants, and systemic retinoids can cause facial flushing 3, 8
Aspirin 30 minutes before niacin dose can help reduce flushing in patients taking niacin, as recommended by the American College of Cardiology 6

Assessing the severity of each rosacea feature is crucial in determining the severity of each phenotype and prioritizing treatment targets, as recommended by the Global Rosacea Consensus (ROSCO) panel and the British Journal of Dermatology guidelines 5
Facial flushing can be caused by numerous conditions, including rosacea, medication reactions, emotional responses, and certain systemic diseases, and food reactions, including scombroid fish poisoning, can also cause facial flushing, as reported by the American Academy of Allergy, Asthma, and Immunology 7
Anaphylaxis, a life-threatening reaction, can present with flushing, urticaria, angioedema, and respiratory/cardiovascular symptoms, according to the American Academy of Allergy, Asthma, and Immunology 7