Rosacea - Antibiotic Prescribing

Comments from Expert Advisory Committee

Key factors in history

  • Centrofacial erythema
  • Pustules / papules centrofacially
  • Episodic facial flushing
  • Affected skin can feel dry and irritated
  • Can affect ADLs and quality of life
  • Erythema and flushing exacerbated by emotional stress, extremes in temperature, exercise, hot caffeinated drinks, alcohol, direct sunlight
  • Can also experience red sore gritty eyelid margins and may have history of styes / blepharitis
  • Be aware of medications that can cause vasodilatation / flushing
    • All vasodilators 
    • All calcium-channel blockers
    • Opiates such as morphine
    • Nicotinic acid
    • Bromocriptine (Parkinson’s disease)

Exam

  • Erythema on cheeks, chin and forehead sparing the periocular and periorbital skin
  • Telangiectasia present on nose / cheeks (can be present without other features of rosacea)
  • Dome shaped papules and some pustules on nose and cheeks
  • No open or closed comedones seen on exam
  • Rhinophyma
    • Marked thickening of nasal skin
    • Build-up of boggy lumpy tissue
    • Prominent blood vessels (telangiectasia and venulectasia) and prominent pores (sebaceous hyperplasia)
    • Nose enlarged as a result

Eye Exam

  • Blepharitis
  • Lid margin telangiectasia and papules
  • Conjunctival injection
Papulopustular Rosacea

Image-1-Papulo-pustular-rosacea

Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

Rhinophyma

Refer to plastic surgeons or dermatology for discussion regarding shave excision or CO2 laser ablation.

Image-2-rhinopyma

Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

Telangiectasia

image-3-Telangiectasia

Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

Telangiectasia with early rhinophyma

Refer to plastic surgeons or dermatology for discussion regarding shave excision or CO2 laser ablation.

Image-4-Telangiectasia-with-early-rhinopyhma

Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

Clinical Diagnosis (i.e. no test required)

  • Either one diagnostic feature or two major clinical features:
  • Diagnostic Features
    • Phymatous change (most commonly affects nose)
    • Persistent erythema (centrofacial distribution which worsens in response to triggers)
  • Major Clinical Features
    • Flushing/transient erythema
    • Inflammatory papules and pustules
    • Telangiectasia (centrofacial area, not just alar area)
    • Ocular involvement

General Advice with Rosacea

  • Idiopathic cause of rosacea
  • Advise that anything that will make the face hot / flush will make rosacea worse
  • Keep a diary to identify triggers (emotional stress, extremes in temperatures, exercise, hot caffeinated drinks, alcohol, direct sunlight, mustard, pepper, vinegar, pickles or spicy foods)
  • Explain that it is known as the ‘curse of the Celts’ as it is more prevalent in those with fair skin, blue eyes and of Celtic origins

General Treatment of Rosacea

  • SPF 50 cream to be used all year round
  • Daily water-based creams and soap free pH balanced cleansers with lukewarm water
  • Gentle skin cleanser
  • Make up that contains a green / yellow pigment in the form of a primer can help camouflage erythema
  • Cosmetics (i.e. colour-correcting cream) containing a UV filter
  • Topical treatments can be irritants especially at the start of treatment. To reduce this, apply every second day. Some patients may initially need to apply for one hour and then wash off, eventually building up tolerance over time to a once daily application
  • Avoid topical steroids which are known to exacerbate rosacea

Management Overview

  • Rosacea frequently presents with more than one phenotype so approach to treatment is guided by what clinical features are present:

1) Papules, pustules and nodules
2) Flushing / erythema / telangiectasia
3) Rhinophyma
4) Ocular symptoms 

Combination therapy may be necessary to achieve satisfactory control of disease.

Treatment of Moderate papules / pustules

Treatment of Moderate papules / pustules

Drug Dose Duration +/- Notes
1st choice options

Ivermectin 10mg/g cream (Soolantra®)
OR
Azelaic acid 15% gel(Skinoren®)

Apply thinly every 24 hours at night

Apply every 12 hours

3 months & review. If effective consider ongoing treatment.

Up to 4 weeks for improvement. If effective consider ongoing treatment.

Apply a pea sized amount on affected areas of face (forehead/chin/nose/cheek).

2nd choice options
Metronidazole 0.75% cream or gel (Rozex®) Apply thinly every 12 hours 3 months & review. If effective consider ongoing treatment.  

Treatment of Severe papules / pustules

Seek specialist advice in pregnancy and breastfeeding.

Treatment of Severe papules / pustules

Seek specialist advice in pregnancy and breastfeeding.

Drug Dose Duration +/- Notes
1st choice options

Ivermectin 10mg/g cream (Soolantra®)
PLUS
Doxycyline modified release

Apply thinly every 24 hours at night

40mg every 24 hours

3 months & review


3 months

Doxycyline & Lymecycline not suitable for children <12yrs old or pregnancy and can cause photosensitivity.

Alternative to Doxycycline (either can be used first line)
Lymecycline 408mg every 24 hours 3 months
Please note: anti-inflammatory effects may not be seen until 3 months. Review at 4 months (after stopping antibiotic for 1 month). Any small residual papules are superficial and tend to respond to topical ivermectin. In severe cases patients may need 3 months of oral doxycycline or lymecycline per year (but not more frequently). If greater than 2 recurrences or if a non-responder then refer to Consultant Dermatologist.

Temporary treatment of redness

Drug Dose Duration +/- Notes
1st choice options
Brimonidine 3mg/g gel (Mirvaso®) Apply thinly when required (maximum every 24 hours) Until erythema subsides or as required.

Apply thinly and uniformly on the affected skin once daily when required.

Peak effect 3-6 hours in up to 30% of patients.

Effects wear off at 8-10 hours.

Used on days when redness is an issue (e.g. attending a wedding).

Advise patients to patch test on area of planned application a week beforehand.

Can cause paradoxical/exaggerated erythema at 3-6 hours.

Treatment of Ocular Rosacea

  • Consider early specialist referral in ocular rosacea.
  • Clean eyelids daily using compresses to remove concretions/crusting using either cotton wool soaked in cooled boiled water or a capful of an emollient wash in a basin of water. Soak a piece of gauze from the basin and lie it across lashes for 5 minutes.
  • Lubricating eye drops for dry gritty eyes applied liberally three times daily.
  • Lubricating ointment may be used at night if needed.
  • Return to see GP if any eye pain.

Treatment of Rhinophyma

  • Refer to plastic surgeons or dermatology for discussion regarding shave excision or CO2 laser ablation.

Patient Information


Safe Prescribing (visit the safe prescribing page)

  • Doses are oral and for adults unless otherwise stated
  • Safety in Pregnancy and Lactation
  • Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed December 2021