There are 3 components to rosacea. Redness and blushing, telangiectasias (small surface blood vessels) and pustules similar to those seen in acne are found on the face. Some patients have only one or 2 physical findings. The diagnosis of rosacea cannot be made with certainty unless pustules are present.
There are both topical and oral medications for rosacea. These medications are effective for treating the pustular component. They are marginally effective for controlling her redness and have very little effect on the telangiectasias.
The goal of treatment is to eliminate and prevent pustules. Rosacea can permanently change the skin, especially the nose, if the inflammation is not controlled. Most patients should be given a course of topical treatment first unless they have many pustules. Those patients that do not respond after 8 weeks should be given oral antibiotics. Oral antibiotics are effective for controlling pustules. Some patients will clear after 4-8 weeks of treatment. A trial off oral medication can then be attempted. Some patients will stay clear but others may flare and respond to topical medicine. Others will flare each time oral medication is stopped. These patients require long-term suppression and may need continuous treatment 4 months or years. Doxycycline is usually a safe and well tolerated drug. It can be prescribed for long-term treatment. Minocycline is very effective but not indicated for long-term use. Patients who take minocycline for more than a year may develop blue pigmentation of the skin.
This topical medication has been used for years to treat rosacea. It is well tolerated and effective. Generic forms are available. The 1% formulation is applied once each day. The 0.75% formation is applied twice a day. Patient’s who clear maybe given a trial off medication. Some patients will not experience further activity and stay clear for months or years. Other patients will flare in require intermittent or long-term suppression.
Azelaic acid (Finacea) is another effective first-line treatment. Medication is applied twice each day. It is generally well tolerated. Patient respond after 4-8 weeks of treatment and may be given a trial off medication. Those who flair will require intermittent were long-term treatment.
This combination has been available for years to treat acne and rocacea. Like other topical medications it is most effective for treating the pustular component of rosacea. The medication is available in cream, lotion, and cleansing forms.
Other topical medications
Topical medications such as benzoyl peroxide, erythromycin and clindamycin are used to treat acne. They are less effective for rosacea and are used only as second line drugs.
Doxycycline is standard first line treatment for patient’s who fail topical treatment or for those with very active pustular disease at the first visit. The dosage varies from 50 – 200 mg each day. Many patients will respond to 100 mg given once daily in the morning. Others require 100 mg twice each day. The medication should be taken with water. Esophageal erosions and ulcers occur in patients who attempt to swallow this medication without fluids.
Most patients respond in 2 weeks and may be clear 4-8 weeks after starting this oral medication. The treatment is then discontinued. Those who flair are retreated. Some patients require long-term therapy. Doxycycline seems to be safe even when taken 4 months or years.
A very low dose form of doxycycline called Oracea (40 mg timed release) may be tried. The drug is effective especially for patients who are not overweight. Low-dose therapy prevents the development of resistance bacteria. The incidence of side effects is low.
There are 2 significant side effects to doxycycline treatment. This drug has the ability to cause photosensitivity. The chance of developing a side effect increases with increasing doses. Skin and lips can be intensely red after sun exposure. Patient’s also experience abdominal discomfort. It is best not to take doxycycline at bedtime. This may increase the chance for irritation of the stomach. Patient’s who experience abdominal discomfort may be able to tolerate the drug by taking it with food. This makes the drug slightly less effective.
Minocycline is a very effective oral medication for rosacea. It is probably more effective than doxycycline. Patients who fail doxycycline may be treated with minocycline. The antibiotic is usually prescribed to be taken twice each day. The dosage varies from 50 mg twice each day to 100 mg twice each day. Most patients respond after 2-4 weeks of treatment. Stop treatment after a complete response to give the patient a trial without pills. The above topical medications may be prescribed for maintenance therapy. Those who flair may be retreated with pills.
It is very important to limit the long term use of minocycline. Long-term use can result in the development of blue hyperpigmentation of the skin and nails. This change may be permanent. There are also other rare serious side effects.
Isotretinoin (Accutane) is effective for very active poorly controlled rosacea. There are rare forms of rosacea that are highly inflammatory and these can be controlled with combinations of oral steroids (prednisone) and isotretinoin. Several companies make isotretinoin available in generic form.
Laser therapy and intense pulsed light may be used to treat the small blood vessels that occur as part of this disease. Very small vessels may not respond.
Hot drinks and food may enhance redness and blushing. Avoiding spicy foods may not be effective.
Rosacea is adversely affected by exposure to sunlight. Sunscreens and protective clothing should be used.