http://www.cks.nhs.uk/home
http://www.cks.nhs.uk/rosacea
Rosaceahttp://www.cks.nhs.uk/home
http://www.cks.nhs.uk/rosacea
Rosacea
Rosacea is a chronic relapsing disease of the facial skin, characterized by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules and pustules, and eye symptoms (ocular rosacea, usually bilateral, and often described as a foreign-body sensation). Typically, it first presents at the age of 30?50 years in people who are fair-skinned; although it is more common in women, it tends to be more severe in men
Flushing, erythema (without inflammation), telangiectasia, and rhinophyma ? there is no effective treatment for these symptoms in primary care, so management should consist of lifestyle advice (for mild rosacea) or referral. Some drugs can aggravate flushing (e.g. calcium-channel blockers), so avoid these where possible.
Mild or moderate papulopustular rosacea (i.e. limited number of papules and pustules, no plaques) ? treat with a topical drug.
Topical Metronidazole is usually preferred as it is well tolerated. Prescribe the gel (0.75%) or cream (1%) according to the person's preference (the cream may be more suitable for sensitive skin).
Azelaic acid is an alternative to metronidazole that may be more effective, especially in people who do not have sensitive skin. However, it may cause transient stinging.
Moderate or severe papulopustular rosacea (i.e. extensive papules, pustules, or plaques) ? prescribe an oral tetracycline or erythromycin. Tetracycline and oxytetracycline are both licensed for rosacea; they need to be taken twice a day on an empty stomach.
Doxycycline and lymecycline are not licensed for rosacea; they need to be taken once a day (optionally with food).
Erythromycin is an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
Ocular rosacea is the usual cause of posterior blepharitis (Meibomian gland dysfunction), which is discussed fully in the CKS topic on Blepharitis.
The eye is affected in about half of people with rosacea [Berth-Jones, 2004], and requires treatment to relieve symptoms and prevent deterioration.
Evidence for the effectiveness of treatment for blepharitis is, in general, lacking. However, CKS identified one RCT (n = 35) that found that oxytetracycline was associated with more remissions than placebo [Bartholomew et al, 1982].
Self Care Advice
Reassure the person about the benign nature of rosacea and that progression to severe disease, such as rhinophyma, is uncommon (especially in women).
If flushing is problematic, advise the avoidance of trigger factors (where practical). Possible triggers include extremes of weather (in particular heat, and cold winds), sunlight, strenuous exercise, stressful situations, spicy food, alcohol, and hot drinks.
If the skin is dry, advise the use of skin-care products as required (e.g. hypoallergenic and non-comedogenic emollient creams). The use of abrasive products or topical corticosteroids on the face should be avoided (even if they appear to help in the short term).
Advise the person to return if the condition deteriorates despite lifestyle changes or drug treatment.
Arrange to follow up after 12 weeks in people requiring treatment, to assess effectiveness and determine future management.
If treatment has been effective, it may be stopped. However, advise the person that their rosacea may relapse, requiring restarting the same treatment. Options include:
Maintenance treatment. This may be continuous (e.g. a reduced dose of oral treatment for 2?6 months followed by a 'drug holiday') or intermittent (e.g. using a topical treatment on alternate days or twice a week).'Stepping down' from oral to topical treatment. If treatment has not been satisfactory: For people receiving topical treatment, consider switching to a different topical treatment, or prescribing an oral antibiotic. For people receiving an oral antibiotic, consider adding a topical treatment, or seek specialist advice. Switching to an alternative oral antibiotic is unlikely to be of benefit.
CKS recommends people should be followed up after 12 weeks, as this reflects a reasonable individual trial period to assess whether treatment has been effective.
Other topical treatments, such as benzoyl peroxide, topical antibiotics (other than metronidazole), tacrolimus, or retinoids (e.g. tretinoin).
Other oral antibiotics, such as clarithromycin, azithromycin (useful if erythromycin is poorly tolerated), or minocycline.
The combined oral contraceptive pill (if a hormonal cause is suspected in a woman).
Oral isotretinoin or clonidine (for flushing).
Cardiovascular drugs to prevent flushing (e.g. beta-blockers or spironolactone).
Some forms of rosacea are resistant to pharmacological treatment. Referral to secondary care allows for other options to be considered:
Treatment options for telangiectasia and phymatous disease in secondary care include laser treatment and corrective electrosurgery [Pelle et al, 2004; Powell, 2005]. However, these are not generally available on the NHS.
When should I refer a person with rosacea?
Refer routinely to dermatology those people with:
Flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress.
Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
An uncertain diagnosis.
Refer routinely to a plastic surgeon those people with severe phymatous disease (e.g. prominent rhinophyma).
Refer to an ophthalmologist:
Urgently, if keratitis is suspected (eye pain, blurred vision, sensitivity to light). See Referral criteria in the CKS topic on Blepharitis.
Routinely, if ocular symptoms are severe or resistant to maximal treatment in primary care.
Rosacea is a chronic relapsing disease of the facial skin, characterized by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules and pustules, and eye symptoms (ocular rosacea, usually bilateral, and often described as a foreign-body sensation). Typically, it first presents at the age of 30?50 years in people who are fair-skinned; although it is more common in women, it tends to be more severe in men
Flushing, erythema (without inflammation), telangiectasia, and rhinophyma ? there is no effective treatment for these symptoms in primary care, so management should consist of lifestyle advice (for mild rosacea) or referral. Some drugs can aggravate flushing (e.g. calcium-channel blockers), so avoid these where possible.
Mild or moderate papulopustular rosacea (i.e. limited number of papules and pustules, no plaques) ? treat with a topical drug.
Topical Metronidazole is usually preferred as it is well tolerated. Prescribe the gel (0.75%) or cream (1%) according to the person's preference (the cream may be more suitable for sensitive skin).
Azelaic acid is an alternative to metronidazole that may be more effective, especially in people who do not have sensitive skin. However, it may cause transient stinging.
Moderate or severe papulopustular rosacea (i.e. extensive papules, pustules, or plaques) ? prescribe an oral tetracycline or erythromycin. Tetracycline and oxytetracycline are both licensed for rosacea; they need to be taken twice a day on an empty stomach.
Doxycycline and lymecycline are not licensed for rosacea; they need to be taken once a day (optionally with food).
Erythromycin is an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
Ocular rosacea is the usual cause of posterior blepharitis (Meibomian gland dysfunction), which is discussed fully in the CKS topic on Blepharitis.
The eye is affected in about half of people with rosacea [Berth-Jones, 2004], and requires treatment to relieve symptoms and prevent deterioration.
Evidence for the effectiveness of treatment for blepharitis is, in general, lacking. However, CKS identified one RCT (n = 35) that found that oxytetracycline was associated with more remissions than placebo [Bartholomew et al, 1982].
Self Care Advice
Reassure the person about the benign nature of rosacea and that progression to severe disease, such as rhinophyma, is uncommon (especially in women).
If flushing is problematic, advise the avoidance of trigger factors (where practical). Possible triggers include extremes of weather (in particular heat, and cold winds), sunlight, strenuous exercise, stressful situations, spicy food, alcohol, and hot drinks.
If the skin is dry, advise the use of skin-care products as required (e.g. hypoallergenic and non-comedogenic emollient creams). The use of abrasive products or topical corticosteroids on the face should be avoided (even if they appear to help in the short term).
Advise the person to return if the condition deteriorates despite lifestyle changes or drug treatment.
Arrange to follow up after 12 weeks in people requiring treatment, to assess effectiveness and determine future management.
If treatment has been effective, it may be stopped. However, advise the person that their rosacea may relapse, requiring restarting the same treatment. Options include:
Maintenance treatment. This may be continuous (e.g. a reduced dose of oral treatment for 2?6 months followed by a 'drug holiday') or intermittent (e.g. using a topical treatment on alternate days or twice a week).'Stepping down' from oral to topical treatment. If treatment has not been satisfactory: For people receiving topical treatment, consider switching to a different topical treatment, or prescribing an oral antibiotic. For people receiving an oral antibiotic, consider adding a topical treatment, or seek specialist advice. Switching to an alternative oral antibiotic is unlikely to be of benefit.
CKS recommends people should be followed up after 12 weeks, as this reflects a reasonable individual trial period to assess whether treatment has been effective.
Other topical treatments, such as benzoyl peroxide, topical antibiotics (other than metronidazole), tacrolimus, or retinoids (e.g. tretinoin).
Other oral antibiotics, such as clarithromycin, azithromycin (useful if erythromycin is poorly tolerated), or minocycline.
The combined oral contraceptive pill (if a hormonal cause is suspected in a woman).
Oral isotretinoin or clonidine (for flushing).
Cardiovascular drugs to prevent flushing (e.g. beta-blockers or spironolactone).
Some forms of rosacea are resistant to pharmacological treatment. Referral to secondary care allows for other options to be considered:
Treatment options for telangiectasia and phymatous disease in secondary care include laser treatment and corrective electrosurgery [Pelle et al, 2004; Powell, 2005]. However, these are not generally available on the NHS.
When should I refer a person with rosacea?
Refer routinely to dermatology those people with:
Flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress.
Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
An uncertain diagnosis.
Refer routinely to a plastic surgeon those people with severe phymatous disease (e.g. prominent rhinophyma).
Refer to an ophthalmologist:
Urgently, if keratitis is suspected (eye pain, blurred vision, sensitivity to light). See Referral criteria in the CKS topic on Blepharitis.
Routinely, if ocular symptoms are severe or resistant to maximal treatment in primary care.
http://www.cks.nhs.uk/rosacea
Rosaceahttp://www.cks.nhs.uk/home
http://www.cks.nhs.uk/rosacea
Rosacea
Rosacea is a chronic relapsing disease of the facial skin, characterized by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules and pustules, and eye symptoms (ocular rosacea, usually bilateral, and often described as a foreign-body sensation). Typically, it first presents at the age of 30?50 years in people who are fair-skinned; although it is more common in women, it tends to be more severe in men
Flushing, erythema (without inflammation), telangiectasia, and rhinophyma ? there is no effective treatment for these symptoms in primary care, so management should consist of lifestyle advice (for mild rosacea) or referral. Some drugs can aggravate flushing (e.g. calcium-channel blockers), so avoid these where possible.
Mild or moderate papulopustular rosacea (i.e. limited number of papules and pustules, no plaques) ? treat with a topical drug.
Topical Metronidazole is usually preferred as it is well tolerated. Prescribe the gel (0.75%) or cream (1%) according to the person's preference (the cream may be more suitable for sensitive skin).
Azelaic acid is an alternative to metronidazole that may be more effective, especially in people who do not have sensitive skin. However, it may cause transient stinging.
Moderate or severe papulopustular rosacea (i.e. extensive papules, pustules, or plaques) ? prescribe an oral tetracycline or erythromycin. Tetracycline and oxytetracycline are both licensed for rosacea; they need to be taken twice a day on an empty stomach.
Doxycycline and lymecycline are not licensed for rosacea; they need to be taken once a day (optionally with food).
Erythromycin is an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
Ocular rosacea is the usual cause of posterior blepharitis (Meibomian gland dysfunction), which is discussed fully in the CKS topic on Blepharitis.
The eye is affected in about half of people with rosacea [Berth-Jones, 2004], and requires treatment to relieve symptoms and prevent deterioration.
Evidence for the effectiveness of treatment for blepharitis is, in general, lacking. However, CKS identified one RCT (n = 35) that found that oxytetracycline was associated with more remissions than placebo [Bartholomew et al, 1982].
Self Care Advice
Reassure the person about the benign nature of rosacea and that progression to severe disease, such as rhinophyma, is uncommon (especially in women).
If flushing is problematic, advise the avoidance of trigger factors (where practical). Possible triggers include extremes of weather (in particular heat, and cold winds), sunlight, strenuous exercise, stressful situations, spicy food, alcohol, and hot drinks.
If the skin is dry, advise the use of skin-care products as required (e.g. hypoallergenic and non-comedogenic emollient creams). The use of abrasive products or topical corticosteroids on the face should be avoided (even if they appear to help in the short term).
Advise the person to return if the condition deteriorates despite lifestyle changes or drug treatment.
Arrange to follow up after 12 weeks in people requiring treatment, to assess effectiveness and determine future management.
If treatment has been effective, it may be stopped. However, advise the person that their rosacea may relapse, requiring restarting the same treatment. Options include:
Maintenance treatment. This may be continuous (e.g. a reduced dose of oral treatment for 2?6 months followed by a 'drug holiday') or intermittent (e.g. using a topical treatment on alternate days or twice a week).'Stepping down' from oral to topical treatment. If treatment has not been satisfactory: For people receiving topical treatment, consider switching to a different topical treatment, or prescribing an oral antibiotic. For people receiving an oral antibiotic, consider adding a topical treatment, or seek specialist advice. Switching to an alternative oral antibiotic is unlikely to be of benefit.
CKS recommends people should be followed up after 12 weeks, as this reflects a reasonable individual trial period to assess whether treatment has been effective.
Other topical treatments, such as benzoyl peroxide, topical antibiotics (other than metronidazole), tacrolimus, or retinoids (e.g. tretinoin).
Other oral antibiotics, such as clarithromycin, azithromycin (useful if erythromycin is poorly tolerated), or minocycline.
The combined oral contraceptive pill (if a hormonal cause is suspected in a woman).
Oral isotretinoin or clonidine (for flushing).
Cardiovascular drugs to prevent flushing (e.g. beta-blockers or spironolactone).
Some forms of rosacea are resistant to pharmacological treatment. Referral to secondary care allows for other options to be considered:
Treatment options for telangiectasia and phymatous disease in secondary care include laser treatment and corrective electrosurgery [Pelle et al, 2004; Powell, 2005]. However, these are not generally available on the NHS.
When should I refer a person with rosacea?
Refer routinely to dermatology those people with:
Flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress.
Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
An uncertain diagnosis.
Refer routinely to a plastic surgeon those people with severe phymatous disease (e.g. prominent rhinophyma).
Refer to an ophthalmologist:
Urgently, if keratitis is suspected (eye pain, blurred vision, sensitivity to light). See Referral criteria in the CKS topic on Blepharitis.
Routinely, if ocular symptoms are severe or resistant to maximal treatment in primary care.
Rosacea is a chronic relapsing disease of the facial skin, characterized by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules and pustules, and eye symptoms (ocular rosacea, usually bilateral, and often described as a foreign-body sensation). Typically, it first presents at the age of 30?50 years in people who are fair-skinned; although it is more common in women, it tends to be more severe in men
Flushing, erythema (without inflammation), telangiectasia, and rhinophyma ? there is no effective treatment for these symptoms in primary care, so management should consist of lifestyle advice (for mild rosacea) or referral. Some drugs can aggravate flushing (e.g. calcium-channel blockers), so avoid these where possible.
Mild or moderate papulopustular rosacea (i.e. limited number of papules and pustules, no plaques) ? treat with a topical drug.
Topical Metronidazole is usually preferred as it is well tolerated. Prescribe the gel (0.75%) or cream (1%) according to the person's preference (the cream may be more suitable for sensitive skin).
Azelaic acid is an alternative to metronidazole that may be more effective, especially in people who do not have sensitive skin. However, it may cause transient stinging.
Moderate or severe papulopustular rosacea (i.e. extensive papules, pustules, or plaques) ? prescribe an oral tetracycline or erythromycin. Tetracycline and oxytetracycline are both licensed for rosacea; they need to be taken twice a day on an empty stomach.
Doxycycline and lymecycline are not licensed for rosacea; they need to be taken once a day (optionally with food).
Erythromycin is an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
Ocular rosacea is the usual cause of posterior blepharitis (Meibomian gland dysfunction), which is discussed fully in the CKS topic on Blepharitis.
The eye is affected in about half of people with rosacea [Berth-Jones, 2004], and requires treatment to relieve symptoms and prevent deterioration.
Evidence for the effectiveness of treatment for blepharitis is, in general, lacking. However, CKS identified one RCT (n = 35) that found that oxytetracycline was associated with more remissions than placebo [Bartholomew et al, 1982].
Self Care Advice
Reassure the person about the benign nature of rosacea and that progression to severe disease, such as rhinophyma, is uncommon (especially in women).
If flushing is problematic, advise the avoidance of trigger factors (where practical). Possible triggers include extremes of weather (in particular heat, and cold winds), sunlight, strenuous exercise, stressful situations, spicy food, alcohol, and hot drinks.
If the skin is dry, advise the use of skin-care products as required (e.g. hypoallergenic and non-comedogenic emollient creams). The use of abrasive products or topical corticosteroids on the face should be avoided (even if they appear to help in the short term).
Advise the person to return if the condition deteriorates despite lifestyle changes or drug treatment.
Arrange to follow up after 12 weeks in people requiring treatment, to assess effectiveness and determine future management.
If treatment has been effective, it may be stopped. However, advise the person that their rosacea may relapse, requiring restarting the same treatment. Options include:
Maintenance treatment. This may be continuous (e.g. a reduced dose of oral treatment for 2?6 months followed by a 'drug holiday') or intermittent (e.g. using a topical treatment on alternate days or twice a week).'Stepping down' from oral to topical treatment. If treatment has not been satisfactory: For people receiving topical treatment, consider switching to a different topical treatment, or prescribing an oral antibiotic. For people receiving an oral antibiotic, consider adding a topical treatment, or seek specialist advice. Switching to an alternative oral antibiotic is unlikely to be of benefit.
CKS recommends people should be followed up after 12 weeks, as this reflects a reasonable individual trial period to assess whether treatment has been effective.
Other topical treatments, such as benzoyl peroxide, topical antibiotics (other than metronidazole), tacrolimus, or retinoids (e.g. tretinoin).
Other oral antibiotics, such as clarithromycin, azithromycin (useful if erythromycin is poorly tolerated), or minocycline.
The combined oral contraceptive pill (if a hormonal cause is suspected in a woman).
Oral isotretinoin or clonidine (for flushing).
Cardiovascular drugs to prevent flushing (e.g. beta-blockers or spironolactone).
Some forms of rosacea are resistant to pharmacological treatment. Referral to secondary care allows for other options to be considered:
Treatment options for telangiectasia and phymatous disease in secondary care include laser treatment and corrective electrosurgery [Pelle et al, 2004; Powell, 2005]. However, these are not generally available on the NHS.
When should I refer a person with rosacea?
Refer routinely to dermatology those people with:
Flushing, persistent erythema, telangiectasia, or phymatous rosacea that is causing psychological or social distress.
Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
An uncertain diagnosis.
Refer routinely to a plastic surgeon those people with severe phymatous disease (e.g. prominent rhinophyma).
Refer to an ophthalmologist:
Urgently, if keratitis is suspected (eye pain, blurred vision, sensitivity to light). See Referral criteria in the CKS topic on Blepharitis.
Routinely, if ocular symptoms are severe or resistant to maximal treatment in primary care.
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