1 Background Information / Important Principles

Important Principles:

  • Patients should be advised to avoid direct sunlight and wear a high factor sun block daily.
  • If triggers can be identified, they should be avoided.
  • Consider referral for cosmetic camouflage
  • Psychological support may be considered for both emotional triggers and consequences of rosacea - consider signposting to IAPT
  • Intermittent therapy can be considered for those with very occasional flare-ups, but maintenance therapy may reduce the frequency of inflammatory flares.
  • Patients with rosacea often have sensitive skin. Advise washing with a cream instead of soap and to avoid irritant cosmetics.

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2 Information Resources for Patients and Carers

Patient Information Leaflets:
British Association of Dermatologists Patient Information Leaflets:

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3 Development and Updates to this Pathway

Developed October 2016, updated August 2020

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4 Training and Further Resources

Additional Resources:
British Association of Dermatologists
Primary Care Dermatology Society
Derm Net NZ: The Dermatology Resource

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5 Patient Presents with Rosacea

Clinical Features:

  • Flushing, often made worse by alcohol, spicy foods, hot drinks, temperature changes or emotion
  • Erythema with peri-ocular sparing
  • Inflammatory lesions
  • Erythematous papules
  • Pustules
  • No comedones (these are a sign of acne vulgaris)
  • Rhinophyma
  • Ocular rosacea: posteria blepharitis (Meibomian gland dysfunction) 50% of patients
  • Pyoderma faciale: painful large erythematous nodules, pustules and erosions. May scar.
  • If scaling in seborrhoic areas, consider concomitant seborrhoic dermatosis

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6 Treatment

  • Erythemato-telangiectatic
    • Intermittent erythema and fixed erythema without visible blood vessels,             if no contraindications consider systemic treatment with
  • If no response, inflammation controlled (see below) and DLQI >10, consider referral for vascular laser treatment

  • Papulo-pustular
    • Topical treatment
      • First Line – Ivermectin 1% cream od (well tolerated, good evidence for efficacy, no risk of antimicrobial resistance but more expensive than other topicals)
      • Second Line –Azelaic acid 15% gel od – bd (initial skin irritation is common)
      • Third Line – Metronidazole 0.75% gel / 0.75% cream od – bd  (theoretical risk of antimicrobial resistance)

  • if no improvement after 6 weeks, consider adding oral Doxycycline 40mg         MR or 50mg a day (anti-inflammatory, but not anti-biotic and not leading to         bacterial resistance)

  • if no improvement after 6 weeks, increase to 100mg a day

  • if patient pregnant or breast-feeding, consider Erythromycin 500mg bd

  • once control achieved, stop oral medication and continue topical treatment.

  • repeat courses of oral treatment as required.

  • If no improvement after 6 weeks, consider referral to community  dermatology for low dose oral isotretinoin 0.25mg/kg/day. Prolonged course may be required.

  • Phymatous
    • if inflammatory component, treat as papulo-pustular
    • if insufficient response and DLQI>10, referral to laser for consideration of initial pulsed dye laser followed by ablative laser treatment.

  • Ocular
    • modify / stop medication that could trigger dryness
    • use OTC ocular lubricant / liposomal sprays (preservative free)
    • use warm compresses with proprietary lid warming devices
    • massage ocular lid
    • maintain lid hygiene, e.g. OTC lid wipes
    • if symptoms persist and affect quality of life, refer to ophthalmology

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7 Criteria for Referral

Criteria for referral to Community Dermatology services:

  • Doubt over diagnosis
  • Optimisation of combination treatment in non-responders
  • For oral isotretinoin treatment

Criteria for referral to Secondary care:

  • Severe disease, development of pyoderma faciale
  • Erythema, telangiectasia, rhinophyma for consideration of laser treatment

Criteria for referral to Ophthalmology:

  • Ocular rosacea with keratitis or uveitis or unresponsive to treatment