National Rosacea Society Expert Committee on the Classification and Staging of Rosacea

Management of Rosacea by Subtype

The management of rosacea should be tailored to address the individual signs and symptoms of each patient and often may be keyed to subtypes and levels of severity while noting that patients often experience more than one subtype concurrently.¹ Using the standard grading system, primary features of each subtype are graded as mild, moderate, or severe (grades 1–3, respectively), and most secondary signs and symptoms are graded as simply present or absent (Tables 1–4, PLEASE REFER TO THE PDF TO VIEW THE TABLES). All patients should be advised of proper skin care procedures, including the use of sunscreen as well as avoidance of environmental and lifestyle factors that may affect their individual cases.

Subtype 1: Erythematotelangiectatic Rosacea

Erythematotelangiectatic rosacea is primarily characterized by flushing and persistent erythema of the central face. The appearance of telangiectases is common but not essential to the diagnosis, while burning and stinging sensations, edema, and roughness or scaling are common secondary features. Patients with this subtype often have a history of flushing alone.

Because this subtype of rosacea may be difficult to treat, identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation of the skin may be especially important.¹

Although no drugs to reduce flushing have been approved by the US Food and Drug Administration (FDA), off-label use of certain medications may potentially have a moderating effect for grades 2 and 3 flushing. It should be noted, however, that there are no broad-spectrumantiflushing medications, and those specific to the cause of the flushing should be chosen.

Flushing is a phenomenon of vasodilation that can be considered an abnormality of cutaneous vascular smooth muscle control. Vascular smooth muscle is controlled by circulating vasoactive agents or by autonomic nerves.

Circulating vasoactive agents are associated with dry flushing and may be exogenous (eg, alcohol, calcium channel-blocking agents, and nicotinic acid [niacin]) or endogenous (eg, histamine and prostaglandins). Management options to mediate flushing caused by endogenous agents may include aspirin, indomethacin, or other nonsteroidal anti-inflammatory drugs that also may reduce erythema. Antihistamines may be prescribed to reduce flushing related to histamines produced endogenously or exogenously by certain foods.²

When vasodilation is controlled by autonomic nerves, it is accompanied by sweating.² This flushing usually results from heat in the ambient surroundings or from exercise or hot drinks, for example. In this case, flushing may be reduced by cooling the neck and face with a cold wet towel or a fan. Ice chips held in the mouth and ingestion of ice water may be effective.² Flushing also may be diminished, of course, by avoidance of other potential environmental and lifestyle factors.¹

In severe cases, the alpha 2 agonist clonidine or a beta-blocker such as nadolol may sometimes reduce neurally mediated flushing.² For women with menopausal flushing, hormone replacement therapy prescribed by a gynecologist or primary care physician could be considered but should be used with caution.

Flushing also may have emotional origins for some patients, and these individuals may additionally benefit from psychological counseling or biofeedback.

Telangiectases and background erythema are commonly treated with laser therapy,^3-8 including long-pulsed dye, potassium-titanyl-phosphate, and diode lasers, which have been associated with little or no purpura.⁴ They also may be reduced by intense pulsed light therapy,^7,9 and electrocautery is an additional option for telangiectasia. Although published clinical data are limited, lasers and intense pulsed light also may be used to reduce flushing.⁶

The appearance of flushing, erythema, and telangiectases also may be concealed with cosmetics.¹ In addition, burning, stinging, roughness, and/or scaling may be minimized by selecting appropriate over-the-counter products, including nonirritating cosmetics, nonsoap cleansers, moisturizers, and appropriate cleansing techniques. Sunblocks or sunscreens may be particularly important.

Subtype 2: Papulopustular Rosacea

This subtype is characterized by persistent central facial erythema with transient central facial papules or pustules, or both (Figure, PLEASE REFER TO THE PDF TO VIEW THE FiGURE). In these patients, topical therapies and oral antibiotics are prescribed, though the modes of action have not been definitively established.

Topical therapies FDA approved for the treatment of rosacea including metronidazole and azelaic acid as well as topical sodium sulfacetamide–sulfur may be used alone or in conjunction with oral therapy administered initially or at any point during treatment. A controlled-release formulation of oral doxycycline is FDA approved for rosacea with low plasma levels that do not exert antimicrobial effects while retaining anti-inflammatory activity.¹⁰ Topical therapy and/or a controlled-release oral therapy for rosacea may be used for grades 1 and 2 disease. For grade 3, an oral antibiotic may be used initially with a topical therapy to bring the disorder under immediate control. Once remission has been achieved, it often may be maintained on a long-term basis with a topical or controlled-release agent alone for an indefinite period.¹¹

In some cases, oral drug therapy for grades 2 and 3and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followed by 0.5 g/d for 2 to 3 weeks.¹² Some physicians may prescribe higher doses, longer courses, or other tetracyclines such as doxycycline or minocycline.

In refractory cases, off label oral trimethoprim-sulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

Additional off-label alternatives for refractory rosacea may include other antibacterial agents, mild topical retinoids, or adapalene.^13,14 It also has been suggested in isolated reports that drugs eradicating Demodex folliculorum may play a role in treating certain cases of papulopustular rosacea, including topical permethrin; systemic ivermectin; and topical crotamiton, sulfur, and lindane.¹⁵ Use on the face for patients with rosacea is off label, and if prescribed, patients should be cautioned about the irritation potential of these agents.

While there was historical speculation on the treatment of Helicobacter pylori to manage rosacea, studies found no substantial difference in the abatement of rosacea following H pylori treatment compared with patients in placebo control groups.^16,17

In certain exceptional cases, short-term use of a low-strength topical steroid may be considered for rapid resolution of inflammation. However, long-term use of these agents often produces rosacealike manifestations, commonly called steroid-induced rosacea, and therefore should be avoided. Topical calcineurin inhibitors such as tacrolimus and pimecrolimus also may be of value in treating erythema from active inflammation,¹² though they have been reported to induce a rosacealike eruption.^18-21 Topical retinoids have been recommended by some to repair the dermis by decreasing abnormal elastin, increasing collagen, increasing glycosaminoglycan, and decreasing telangiectases.²²

Possible burning and stinging sensations may be dealt with as described for erythematotelangiectatic rosacea.

Subtype 3: Phymatous Rosacea

In addition to a primary feature of rosacea (flushing, erythema, telangiectases, papules or pustules), phymatous rosacea may include skin thickening, irregular surface nodularities, and patulous follicles. Enlargement commonly occurs on the nose (rhinophyma), though other affected locations may include the chin, forehead, cheeks, and ears.

Management options for grade 1 phymatous rosacea, with patulous follicles but no contour changes, include topical and systemic antibiotics if inflammatory lesions are present. Isotretinoin has been demonstrated to decrease nasal volume in rhinophyma, especially in younger patients with less advanced disease, though volume may increase again after therapy is stopped.^22,23 During isotretinoin therapy, numerous large sebaceous glands were reported to be diminished in size and number.²² There also is evidence that topical retinoids may decrease fibrosis, elastosis, and sebaceous gland hypertrophy.^24-26

Grades 2—change in contour without a nodular component—and 3—change in contour with a nodular component—phymatous rosacea may require surgical therapy, such as cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting, and dermabrasion. CO₂ or erbium:YAG lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose. Fractional resurfacing can be of value in mild cases.

Subtype 4: Ocular Rosacea

The common presentations of ocular rosacea are a watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity, and blurred vision. A history of styes (chalazion, hordeolum) is a strong indication, as well as dry eye, recurrent conjunctivitis, or blepharitis. Telangiectases of the eyelid margins or lid and periocular erythema also may be present.

The meibomian glands typically are obstructed and often may be blocked. The formation of collarettes, narrow rims of loosened keratin around the base of the eyelashes, is common. A gritty granular symptom indicates damage to the ocular surface. Undiagnosed ocular rosacea may present with recurring inflammation such as episcleritis, iritis,
and keratitis.

Ocular rosacea may appear in advance of the cutaneous form, and more than 60% of patients with cutaneous rosacea also may have ocular involvement. Treatment of cutaneous rosacea alone may be inadequate in lessening the risk for vision loss resulting from ocular rosacea, and referral to an ophthalmologist may be needed.

Treatment of grades 1 and 2 ocular rosacea may initially include artificial tears, and on a long-term basis, the patient should apply a warm compress and cleanse the eyelashes twice daily with baby shampoo on a wet washcloth rubbed onto the upper and lower eyelashes of the closed eyes. Antibiotic ointment may be appropriate to decrease the presence of Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus, and to soften any collarettes, allowing easy removal by the patient during eyelash hygiene. An oral tetracycline such as low-dose doxycycline may be necessary, and for grade 3 ocular rosacea, a topical steroid, cyclosporine ophthalmic emulsion, or alternative oral medications may be prescribed by the ophthalmologist. Any corneal ulceration requires immediate attention by an ophthalmologist, as it may involve loss of visual acuity.

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively known and the etiology and pathogenesis of rosacea are more completely understood. Meanwhile, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments—The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD, Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.

Management of Rosacea by Subtype

The management of rosacea should be tailored to address the individual signs and symptoms of each patient and often may be keyed to subtypes and levels of severity while noting that patients often experience more than one subtype concurrently.¹ Using the standard grading system, primary features of each subtype are graded as mild, moderate, or severe (grades 1–3, respectively), and most secondary signs and symptoms are graded as simply present or absent (Tables 1–4, PLEASE REFER TO THE PDF TO VIEW THE TABLES). All patients should be advised of proper skin care procedures, including the use of sunscreen as well as avoidance of environmental and lifestyle factors that may affect their individual cases.

Subtype 1: Erythematotelangiectatic Rosacea

Erythematotelangiectatic rosacea is primarily characterized by flushing and persistent erythema of the central face. The appearance of telangiectases is common but not essential to the diagnosis, while burning and stinging sensations, edema, and roughness or scaling are common secondary features. Patients with this subtype often have a history of flushing alone.

Because this subtype of rosacea may be difficult to treat, identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation of the skin may be especially important.¹

Although no drugs to reduce flushing have been approved by the US Food and Drug Administration (FDA), off-label use of certain medications may potentially have a moderating effect for grades 2 and 3 flushing. It should be noted, however, that there are no broad-spectrumantiflushing medications, and those specific to the cause of the flushing should be chosen.

Flushing is a phenomenon of vasodilation that can be considered an abnormality of cutaneous vascular smooth muscle control. Vascular smooth muscle is controlled by circulating vasoactive agents or by autonomic nerves.

Circulating vasoactive agents are associated with dry flushing and may be exogenous (eg, alcohol, calcium channel-blocking agents, and nicotinic acid [niacin]) or endogenous (eg, histamine and prostaglandins). Management options to mediate flushing caused by endogenous agents may include aspirin, indomethacin, or other nonsteroidal anti-inflammatory drugs that also may reduce erythema. Antihistamines may be prescribed to reduce flushing related to histamines produced endogenously or exogenously by certain foods.²

When vasodilation is controlled by autonomic nerves, it is accompanied by sweating.² This flushing usually results from heat in the ambient surroundings or from exercise or hot drinks, for example. In this case, flushing may be reduced by cooling the neck and face with a cold wet towel or a fan. Ice chips held in the mouth and ingestion of ice water may be effective.² Flushing also may be diminished, of course, by avoidance of other potential environmental and lifestyle factors.¹

In severe cases, the alpha 2 agonist clonidine or a beta-blocker such as nadolol may sometimes reduce neurally mediated flushing.² For women with menopausal flushing, hormone replacement therapy prescribed by a gynecologist or primary care physician could be considered but should be used with caution.

Flushing also may have emotional origins for some patients, and these individuals may additionally benefit from psychological counseling or biofeedback.

Telangiectases and background erythema are commonly treated with laser therapy,^3-8 including long-pulsed dye, potassium-titanyl-phosphate, and diode lasers, which have been associated with little or no purpura.⁴ They also may be reduced by intense pulsed light therapy,^7,9 and electrocautery is an additional option for telangiectasia. Although published clinical data are limited, lasers and intense pulsed light also may be used to reduce flushing.⁶

The appearance of flushing, erythema, and telangiectases also may be concealed with cosmetics.¹ In addition, burning, stinging, roughness, and/or scaling may be minimized by selecting appropriate over-the-counter products, including nonirritating cosmetics, nonsoap cleansers, moisturizers, and appropriate cleansing techniques. Sunblocks or sunscreens may be particularly important.

Subtype 2: Papulopustular Rosacea

This subtype is characterized by persistent central facial erythema with transient central facial papules or pustules, or both (Figure, PLEASE REFER TO THE PDF TO VIEW THE FiGURE). In these patients, topical therapies and oral antibiotics are prescribed, though the modes of action have not been definitively established.

Topical therapies FDA approved for the treatment of rosacea including metronidazole and azelaic acid as well as topical sodium sulfacetamide–sulfur may be used alone or in conjunction with oral therapy administered initially or at any point during treatment. A controlled-release formulation of oral doxycycline is FDA approved for rosacea with low plasma levels that do not exert antimicrobial effects while retaining anti-inflammatory activity.¹⁰ Topical therapy and/or a controlled-release oral therapy for rosacea may be used for grades 1 and 2 disease. For grade 3, an oral antibiotic may be used initially with a topical therapy to bring the disorder under immediate control. Once remission has been achieved, it often may be maintained on a long-term basis with a topical or controlled-release agent alone for an indefinite period.¹¹

In some cases, oral drug therapy for grades 2 and 3and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followed by 0.5 g/d for 2 to 3 weeks.¹² Some physicians may prescribe higher doses, longer courses, or other tetracyclines such as doxycycline or minocycline.

In refractory cases, off label oral trimethoprim-sulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

Additional off-label alternatives for refractory rosacea may include other antibacterial agents, mild topical retinoids, or adapalene.^13,14 It also has been suggested in isolated reports that drugs eradicating Demodex folliculorum may play a role in treating certain cases of papulopustular rosacea, including topical permethrin; systemic ivermectin; and topical crotamiton, sulfur, and lindane.¹⁵ Use on the face for patients with rosacea is off label, and if prescribed, patients should be cautioned about the irritation potential of these agents.

While there was historical speculation on the treatment of Helicobacter pylori to manage rosacea, studies found no substantial difference in the abatement of rosacea following H pylori treatment compared with patients in placebo control groups.^16,17

In certain exceptional cases, short-term use of a low-strength topical steroid may be considered for rapid resolution of inflammation. However, long-term use of these agents often produces rosacealike manifestations, commonly called steroid-induced rosacea, and therefore should be avoided. Topical calcineurin inhibitors such as tacrolimus and pimecrolimus also may be of value in treating erythema from active inflammation,¹² though they have been reported to induce a rosacealike eruption.^18-21 Topical retinoids have been recommended by some to repair the dermis by decreasing abnormal elastin, increasing collagen, increasing glycosaminoglycan, and decreasing telangiectases.²²

Possible burning and stinging sensations may be dealt with as described for erythematotelangiectatic rosacea.

Subtype 3: Phymatous Rosacea

In addition to a primary feature of rosacea (flushing, erythema, telangiectases, papules or pustules), phymatous rosacea may include skin thickening, irregular surface nodularities, and patulous follicles. Enlargement commonly occurs on the nose (rhinophyma), though other affected locations may include the chin, forehead, cheeks, and ears.

Management options for grade 1 phymatous rosacea, with patulous follicles but no contour changes, include topical and systemic antibiotics if inflammatory lesions are present. Isotretinoin has been demonstrated to decrease nasal volume in rhinophyma, especially in younger patients with less advanced disease, though volume may increase again after therapy is stopped.^22,23 During isotretinoin therapy, numerous large sebaceous glands were reported to be diminished in size and number.²² There also is evidence that topical retinoids may decrease fibrosis, elastosis, and sebaceous gland hypertrophy.^24-26

Grades 2—change in contour without a nodular component—and 3—change in contour with a nodular component—phymatous rosacea may require surgical therapy, such as cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting, and dermabrasion. CO₂ or erbium:YAG lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose. Fractional resurfacing can be of value in mild cases.

Subtype 4: Ocular Rosacea

The common presentations of ocular rosacea are a watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity, and blurred vision. A history of styes (chalazion, hordeolum) is a strong indication, as well as dry eye, recurrent conjunctivitis, or blepharitis. Telangiectases of the eyelid margins or lid and periocular erythema also may be present.

The meibomian glands typically are obstructed and often may be blocked. The formation of collarettes, narrow rims of loosened keratin around the base of the eyelashes, is common. A gritty granular symptom indicates damage to the ocular surface. Undiagnosed ocular rosacea may present with recurring inflammation such as episcleritis, iritis,
and keratitis.

Ocular rosacea may appear in advance of the cutaneous form, and more than 60% of patients with cutaneous rosacea also may have ocular involvement. Treatment of cutaneous rosacea alone may be inadequate in lessening the risk for vision loss resulting from ocular rosacea, and referral to an ophthalmologist may be needed.

Treatment of grades 1 and 2 ocular rosacea may initially include artificial tears, and on a long-term basis, the patient should apply a warm compress and cleanse the eyelashes twice daily with baby shampoo on a wet washcloth rubbed onto the upper and lower eyelashes of the closed eyes. Antibiotic ointment may be appropriate to decrease the presence of Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus, and to soften any collarettes, allowing easy removal by the patient during eyelash hygiene. An oral tetracycline such as low-dose doxycycline may be necessary, and for grade 3 ocular rosacea, a topical steroid, cyclosporine ophthalmic emulsion, or alternative oral medications may be prescribed by the ophthalmologist. Any corneal ulceration requires immediate attention by an ophthalmologist, as it may involve loss of visual acuity.

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively known and the etiology and pathogenesis of rosacea are more completely understood. Meanwhile, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments—The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD, Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.

Management of Rosacea by Subtype

The management of rosacea should be tailored to address the individual signs and symptoms of each patient and often may be keyed to subtypes and levels of severity while noting that patients often experience more than one subtype concurrently.¹ Using the standard grading system, primary features of each subtype are graded as mild, moderate, or severe (grades 1–3, respectively), and most secondary signs and symptoms are graded as simply present or absent (Tables 1–4, PLEASE REFER TO THE PDF TO VIEW THE TABLES). All patients should be advised of proper skin care procedures, including the use of sunscreen as well as avoidance of environmental and lifestyle factors that may affect their individual cases.

Subtype 1: Erythematotelangiectatic Rosacea

Erythematotelangiectatic rosacea is primarily characterized by flushing and persistent erythema of the central face. The appearance of telangiectases is common but not essential to the diagnosis, while burning and stinging sensations, edema, and roughness or scaling are common secondary features. Patients with this subtype often have a history of flushing alone.

Because this subtype of rosacea may be difficult to treat, identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation of the skin may be especially important.¹

Although no drugs to reduce flushing have been approved by the US Food and Drug Administration (FDA), off-label use of certain medications may potentially have a moderating effect for grades 2 and 3 flushing. It should be noted, however, that there are no broad-spectrumantiflushing medications, and those specific to the cause of the flushing should be chosen.

Flushing is a phenomenon of vasodilation that can be considered an abnormality of cutaneous vascular smooth muscle control. Vascular smooth muscle is controlled by circulating vasoactive agents or by autonomic nerves.

Circulating vasoactive agents are associated with dry flushing and may be exogenous (eg, alcohol, calcium channel-blocking agents, and nicotinic acid [niacin]) or endogenous (eg, histamine and prostaglandins). Management options to mediate flushing caused by endogenous agents may include aspirin, indomethacin, or other nonsteroidal anti-inflammatory drugs that also may reduce erythema. Antihistamines may be prescribed to reduce flushing related to histamines produced endogenously or exogenously by certain foods.²

When vasodilation is controlled by autonomic nerves, it is accompanied by sweating.² This flushing usually results from heat in the ambient surroundings or from exercise or hot drinks, for example. In this case, flushing may be reduced by cooling the neck and face with a cold wet towel or a fan. Ice chips held in the mouth and ingestion of ice water may be effective.² Flushing also may be diminished, of course, by avoidance of other potential environmental and lifestyle factors.¹

In severe cases, the alpha 2 agonist clonidine or a beta-blocker such as nadolol may sometimes reduce neurally mediated flushing.² For women with menopausal flushing, hormone replacement therapy prescribed by a gynecologist or primary care physician could be considered but should be used with caution.

Flushing also may have emotional origins for some patients, and these individuals may additionally benefit from psychological counseling or biofeedback.

Telangiectases and background erythema are commonly treated with laser therapy,^3-8 including long-pulsed dye, potassium-titanyl-phosphate, and diode lasers, which have been associated with little or no purpura.⁴ They also may be reduced by intense pulsed light therapy,^7,9 and electrocautery is an additional option for telangiectasia. Although published clinical data are limited, lasers and intense pulsed light also may be used to reduce flushing.⁶

The appearance of flushing, erythema, and telangiectases also may be concealed with cosmetics.¹ In addition, burning, stinging, roughness, and/or scaling may be minimized by selecting appropriate over-the-counter products, including nonirritating cosmetics, nonsoap cleansers, moisturizers, and appropriate cleansing techniques. Sunblocks or sunscreens may be particularly important.

Subtype 2: Papulopustular Rosacea

This subtype is characterized by persistent central facial erythema with transient central facial papules or pustules, or both (Figure, PLEASE REFER TO THE PDF TO VIEW THE FiGURE). In these patients, topical therapies and oral antibiotics are prescribed, though the modes of action have not been definitively established.

Topical therapies FDA approved for the treatment of rosacea including metronidazole and azelaic acid as well as topical sodium sulfacetamide–sulfur may be used alone or in conjunction with oral therapy administered initially or at any point during treatment. A controlled-release formulation of oral doxycycline is FDA approved for rosacea with low plasma levels that do not exert antimicrobial effects while retaining anti-inflammatory activity.¹⁰ Topical therapy and/or a controlled-release oral therapy for rosacea may be used for grades 1 and 2 disease. For grade 3, an oral antibiotic may be used initially with a topical therapy to bring the disorder under immediate control. Once remission has been achieved, it often may be maintained on a long-term basis with a topical or controlled-release agent alone for an indefinite period.¹¹

In some cases, oral drug therapy for grades 2 and 3and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followed by 0.5 g/d for 2 to 3 weeks.¹² Some physicians may prescribe higher doses, longer courses, or other tetracyclines such as doxycycline or minocycline.

In refractory cases, off label oral trimethoprim-sulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

Additional off-label alternatives for refractory rosacea may include other antibacterial agents, mild topical retinoids, or adapalene.^13,14 It also has been suggested in isolated reports that drugs eradicating Demodex folliculorum may play a role in treating certain cases of papulopustular rosacea, including topical permethrin; systemic ivermectin; and topical crotamiton, sulfur, and lindane.¹⁵ Use on the face for patients with rosacea is off label, and if prescribed, patients should be cautioned about the irritation potential of these agents.

While there was historical speculation on the treatment of Helicobacter pylori to manage rosacea, studies found no substantial difference in the abatement of rosacea following H pylori treatment compared with patients in placebo control groups.^16,17

In certain exceptional cases, short-term use of a low-strength topical steroid may be considered for rapid resolution of inflammation. However, long-term use of these agents often produces rosacealike manifestations, commonly called steroid-induced rosacea, and therefore should be avoided. Topical calcineurin inhibitors such as tacrolimus and pimecrolimus also may be of value in treating erythema from active inflammation,¹² though they have been reported to induce a rosacealike eruption.^18-21 Topical retinoids have been recommended by some to repair the dermis by decreasing abnormal elastin, increasing collagen, increasing glycosaminoglycan, and decreasing telangiectases.²²

Possible burning and stinging sensations may be dealt with as described for erythematotelangiectatic rosacea.

Subtype 3: Phymatous Rosacea

In addition to a primary feature of rosacea (flushing, erythema, telangiectases, papules or pustules), phymatous rosacea may include skin thickening, irregular surface nodularities, and patulous follicles. Enlargement commonly occurs on the nose (rhinophyma), though other affected locations may include the chin, forehead, cheeks, and ears.

Management options for grade 1 phymatous rosacea, with patulous follicles but no contour changes, include topical and systemic antibiotics if inflammatory lesions are present. Isotretinoin has been demonstrated to decrease nasal volume in rhinophyma, especially in younger patients with less advanced disease, though volume may increase again after therapy is stopped.^22,23 During isotretinoin therapy, numerous large sebaceous glands were reported to be diminished in size and number.²² There also is evidence that topical retinoids may decrease fibrosis, elastosis, and sebaceous gland hypertrophy.^24-26

Grades 2—change in contour without a nodular component—and 3—change in contour with a nodular component—phymatous rosacea may require surgical therapy, such as cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting, and dermabrasion. CO₂ or erbium:YAG lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose. Fractional resurfacing can be of value in mild cases.

Subtype 4: Ocular Rosacea

The common presentations of ocular rosacea are a watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity, and blurred vision. A history of styes (chalazion, hordeolum) is a strong indication, as well as dry eye, recurrent conjunctivitis, or blepharitis. Telangiectases of the eyelid margins or lid and periocular erythema also may be present.

The meibomian glands typically are obstructed and often may be blocked. The formation of collarettes, narrow rims of loosened keratin around the base of the eyelashes, is common. A gritty granular symptom indicates damage to the ocular surface. Undiagnosed ocular rosacea may present with recurring inflammation such as episcleritis, iritis,
and keratitis.

Ocular rosacea may appear in advance of the cutaneous form, and more than 60% of patients with cutaneous rosacea also may have ocular involvement. Treatment of cutaneous rosacea alone may be inadequate in lessening the risk for vision loss resulting from ocular rosacea, and referral to an ophthalmologist may be needed.

Treatment of grades 1 and 2 ocular rosacea may initially include artificial tears, and on a long-term basis, the patient should apply a warm compress and cleanse the eyelashes twice daily with baby shampoo on a wet washcloth rubbed onto the upper and lower eyelashes of the closed eyes. Antibiotic ointment may be appropriate to decrease the presence of Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus, and to soften any collarettes, allowing easy removal by the patient during eyelash hygiene. An oral tetracycline such as low-dose doxycycline may be necessary, and for grade 3 ocular rosacea, a topical steroid, cyclosporine ophthalmic emulsion, or alternative oral medications may be prescribed by the ophthalmologist. Any corneal ulceration requires immediate attention by an ophthalmologist, as it may involve loss of visual acuity.

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively known and the etiology and pathogenesis of rosacea are more completely understood. Meanwhile, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments—The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD, Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.

Rosacea is well established as a chronic typology or syndrome, primarily affecting the convexities of the central face (ie, cheeks, nose, chin, forehead) and often affecting the eyes. In 2002, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes.¹ In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.²

Developed and reviewed by 21 experts worldwide, these standard systems are essential to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. Because present scientific knowledge of the etiology of rosacea is limited, these systems are considered provisional and are based on morphologic characteristics alone to avoid assumptions about pathogenesis and progression. They are intended to facilitate communication and ultimately the development of a research-based understanding of the disorder.

As a final step, the committee has developed standard management options based on these standard criteria to assist in providing optimal patient care. Because it is fundamental in the management of rosacea to consider the broad spectrum of potential therapies, the consensus committee and review panel have been expanded to include leading experts in dermatology, laser therapy, skin care, and ophthalmology. As with the standard classification and grading systems, the standard management options are considered provisional and may be expanded and updated as scientific knowledge increases and additional therapies become available.

Although rosacea encompasses various combinations of signs and symptoms, in most cases, some rather than all of these features appear in any given patient and often are characterized by remissions and exacerbations. Therefore, it is important to define the roles of respective treatment modalities as well as lifestyle management and skin care within the context of specific potential manifestations. In this way, an optimal management approach may be tailored for each individual patient.^3,4

The standard management options are intended to serve as a menu of options rather than a treatment protocol. Although there is no cure for rosacea, its various signs and symptoms may be reduced or controlled with a range of therapeutic modalities, even though their actions may not be fully defined by clinical data.⁵ It should be noted that clinical trials are rarely a reflection of clinical practice because they are typically intended to discern only the contribution of a specific treatment.⁶ In practice, clinicians rarely rely on a single mode of care alone, and in the case of rosacea, factors such as proper skin care and avoidance of exacerbating factors may substantially improve results. Thus, patients often may experience better outcomes than might be suggested by clinical studies designed to isolate the effect of a single therapy.

Part 1 of this 2-part series will review the patient evaluation process and respective modalities of care.

Medical History

In addition to clinical observation of potential primary and secondary features of rosacea (Table 1, PLEASE REFER TO THE PDF TO VIEW THE TABLE), a medical history is needed to identify features that may not be visually evident or present at the time of the patient visit, to rule out alternative diagnoses, and to help identify potential environmental and lifestyle triggers. There is no laboratory test for rosacea and a biopsy is warranted only to rule out alternative diagnoses.

It may be difficult to clinically distinguish between the effects of chronic actinic damage on sun-sensitive skin (heliodermatitis) and subtype 1 (erythematotelangiectactic) rosacea. In some individuals, there may be overlapping features. A medical history may be especially useful in differentiating between erythematotelangiectactic rosacea and isolated photodamage. For example, any patient whose occupation or lifestyle has involved extensive sun exposure may experience chronic actinic damage, whereas patients with a history of flushing alone may be more likely to have rosacea. In addition, in the case of rosacea, erythema and telangiectasia tend to present with a central facial distribution.⁷ Other differential diagnoses include seborrheic dermatitis, lupus erythematosus, polycythemia vera, and carcinoid syndrome, with flushing mimicking rosacea.

A medical history also may be relevant for treatment purposes in distinguishing between dry flushing, which often is caused by exogenous or endogenous vasoactive agents, and wet flushing, which is accompanied by sweating that is regulated by the autonomic nervous system. Flushing can be further divided according to causes such as physical exertion, heat, or emotional reaction.⁸

Importantly, a medical history can uncover ocular involvement that may not be currently present or readily apparent from clinical observation as well as identify physical discomfort such as burning or stinging that may substantially affect quality of life for many patients.

Because rosacea affects facial appearance, its presence also may have considerable impact on an individual patient’s psychologic well-being and ability to interact socially or professionally. An assessment can help guide the physician toward providing an appropriate level of care.

Drug Therapy

The papules and pustules of rosacea, as well as nodules, plaques, or perilesional erythema, can be effectively treated in most patients with drugs that have been extensively studied in clinical trials and approved by the US Food and Drug Administration for rosacea, such as topical metronidazole, topical azelaic acid, and oral controlled-release doxycycline 40 mg, all approved for the treatment of inflammatory lesions of rosacea. In addition, the efficacy of topical sodium
sulfacetamide–sulfur is supported by many years of clinical experience in treating rosacea, though it was allowed to be marketed for rosacea prior to more stringent modern requirements for clinical studies and US Food and Drug Administration review. Options for the use of approved medications as well as off-label use of other medications such as oral tetracycline are reviewed in detail in part 2 of this series.⁹

Several oral antibiotics commonly are prescribed on an off-label basis for subtype 4 (ocular) rosacea. Moreover, when appropriate, the off-label use of other medical therapies may be administered to treat flushing and background erythema, which will be discussed in detail in part 2 of this series.⁹ The committee encourages further drug research aimed to improve the treatment of background erythema, which represents a great unmet clinical need in rosacea therapy.¹⁰

In all cases, physicians should review the package insert for prescribing information. This document is not intended to suggest the monitoring and actual dosing practices for drugs.

Laser and Light Therapy

The efficacy of laser therapy for the treatment of telangiectasia has been well established in clinical practice,^11-16 and limited studies also have suggested that it may reduce erythema and flushing.^11,15,17 Most lasers used to treat vascular components of rosacea have wavelengths in the 500 to 600 nm range and are known as nonablative (they do not destroy tissue). Recent developments using long-pulsed pulsed dye lasers,¹³ a technique of stacking pulses,¹⁸ or 532-nm potassium-titanyl-phosphate lasers19 may produce excellent improvement in erythema and telangiectasia without purpura.¹³

Polychromatic light-emitting devices such as intense pulsed light devices (515–1200 nm) also have been found to be effective in reducing erythema and telangiectasia.^15,20

Ablative lasers, such as the 2.94-nm erbium:YAG or 10,600-nm CO2 lasers, destroy tissue and may be used to treat subtype 3 (phymatous) rosacea.^3,12,21

Lifestyle Management

Signs and symptoms of rosacea often appear to be triggered by environmental or lifestyle factors, most related to flushing. Some of the most common rosacea triggers include sun exposure, emotional stress, hot or cold weather, wind, heavy exercise, alcohol consumption, hot baths, spicy foods, humidity, indoor heat, certain skin care products, heated beverages, certain cosmetics, medications, medical conditions, and certain foods (Table 2, PLEASE REFER TO THE PDF TO VIEW THE TABLE).²² However, triggers that may affect one patient may not affect another, and avoidance of every potential factor may be unnecessary as well as impractical.

An appropriate management strategy identifies and avoids only those lifestyle factors that trigger or exacerbate rosacea symptoms in each individual patient. To help identify a patient’s individual rosacea triggers, the patient can record daily contact with the most common rosacea triggers and other possible factors and then match them to flare-ups of signs and symptoms. In unscientific surveys of patients with rosacea who identified and avoided their personal rosacea triggers, more than 90% reported that their condition had improved in varying degrees.²³

Adjunctive Care

Skin Care Products

Because patients with rosacea often have skin that is sensitive and easily irritated, causing redness, inflammation, and stinging, skin care is an important component of rosacea management.^21,24 The goal of everyday skin care for patients with rosacea is to maintain the integrity of the skin barrier while avoiding agents that cause inflammation or flushing.

Complicating skin care is the typical heightened neurosensory response in many patients with rosacea who may experience stinging and burning from minor irritants more frequently than the general population. Patients may therefore be advised to select cleansers and moisturizers that do not irritate their skin.

Sunscreens or sunblocks effective against the full spectrum of UVA and UVB radiation can be especially important for patients with rosacea whose facial skin may be particularly susceptible to actinic damage and consequent rosacea flare-ups. A sun protection factor of 15 or higher is recommended, and physical blocks utilizing zinc or titanium dioxide may be effective if chemical sunscreens cause irritation.

A useful rule of thumb may be to select products for patients with rosacea that contain no sensory provoking ingredients, no volatile substances, no minor irritants or allergens, minimal botanical agents, and no unnecessary ingredients.

Cleansing Regimen

Patients should be informed that compliance with instructions on facial cleansing and topical medication application may be critical to avoiding irritation, burning, and stinging. They may be advised to wash the face gently with a nonirritating cleanser, avoiding the use of abrasive materials such as washcloths and loofahs. They also may be advised to blot, not rub, the face dry with a soft towel and wait up to 30 minutes for the face to completely dry before applying topical medication or other products, as stinging most often occurs when the skin is wet.^6,8

After this routine is established and the face is not irritated, the patient can reduce the amount of time waiting to dry by 5 minutes every day to determine the shortest waiting time necessary for the individual patient.

Cosmetics

Cosmetics, especially those with a green or yellow tint, may be effective in reducing the appearance of redness. However, as with skin cleansers and moisturizers, care should be taken to minimize irritation.

Patients should be advised to avoid any products that cause burning, stinging, itching, or other discomfort. They also may be advised that waterproof cosmetics may be difficult to remove, requiring the use of harsh agents that may induce irritation.

New cosmetics should be regularly purchased to minimize microbial contamination and degradation. Brushes are preferred over sponges to avoid abrasion and because brushes can be easily cleaned to decrease bacterial contamination.²⁴

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively established. Until the etiology and pathogenesis are more completely understood, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments

The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD,  Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.

Rosacea is well established as a chronic typology or syndrome, primarily affecting the convexities of the central face (ie, cheeks, nose, chin, forehead) and often affecting the eyes. In 2002, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes.¹ In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.²

Developed and reviewed by 21 experts worldwide, these standard systems are essential to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. Because present scientific knowledge of the etiology of rosacea is limited, these systems are considered provisional and are based on morphologic characteristics alone to avoid assumptions about pathogenesis and progression. They are intended to facilitate communication and ultimately the development of a research-based understanding of the disorder.

As a final step, the committee has developed standard management options based on these standard criteria to assist in providing optimal patient care. Because it is fundamental in the management of rosacea to consider the broad spectrum of potential therapies, the consensus committee and review panel have been expanded to include leading experts in dermatology, laser therapy, skin care, and ophthalmology. As with the standard classification and grading systems, the standard management options are considered provisional and may be expanded and updated as scientific knowledge increases and additional therapies become available.

Although rosacea encompasses various combinations of signs and symptoms, in most cases, some rather than all of these features appear in any given patient and often are characterized by remissions and exacerbations. Therefore, it is important to define the roles of respective treatment modalities as well as lifestyle management and skin care within the context of specific potential manifestations. In this way, an optimal management approach may be tailored for each individual patient.^3,4

The standard management options are intended to serve as a menu of options rather than a treatment protocol. Although there is no cure for rosacea, its various signs and symptoms may be reduced or controlled with a range of therapeutic modalities, even though their actions may not be fully defined by clinical data.⁵ It should be noted that clinical trials are rarely a reflection of clinical practice because they are typically intended to discern only the contribution of a specific treatment.⁶ In practice, clinicians rarely rely on a single mode of care alone, and in the case of rosacea, factors such as proper skin care and avoidance of exacerbating factors may substantially improve results. Thus, patients often may experience better outcomes than might be suggested by clinical studies designed to isolate the effect of a single therapy.

Part 1 of this 2-part series will review the patient evaluation process and respective modalities of care.

Medical History

In addition to clinical observation of potential primary and secondary features of rosacea (Table 1, PLEASE REFER TO THE PDF TO VIEW THE TABLE), a medical history is needed to identify features that may not be visually evident or present at the time of the patient visit, to rule out alternative diagnoses, and to help identify potential environmental and lifestyle triggers. There is no laboratory test for rosacea and a biopsy is warranted only to rule out alternative diagnoses.

It may be difficult to clinically distinguish between the effects of chronic actinic damage on sun-sensitive skin (heliodermatitis) and subtype 1 (erythematotelangiectactic) rosacea. In some individuals, there may be overlapping features. A medical history may be especially useful in differentiating between erythematotelangiectactic rosacea and isolated photodamage. For example, any patient whose occupation or lifestyle has involved extensive sun exposure may experience chronic actinic damage, whereas patients with a history of flushing alone may be more likely to have rosacea. In addition, in the case of rosacea, erythema and telangiectasia tend to present with a central facial distribution.⁷ Other differential diagnoses include seborrheic dermatitis, lupus erythematosus, polycythemia vera, and carcinoid syndrome, with flushing mimicking rosacea.

A medical history also may be relevant for treatment purposes in distinguishing between dry flushing, which often is caused by exogenous or endogenous vasoactive agents, and wet flushing, which is accompanied by sweating that is regulated by the autonomic nervous system. Flushing can be further divided according to causes such as physical exertion, heat, or emotional reaction.⁸

Importantly, a medical history can uncover ocular involvement that may not be currently present or readily apparent from clinical observation as well as identify physical discomfort such as burning or stinging that may substantially affect quality of life for many patients.

Because rosacea affects facial appearance, its presence also may have considerable impact on an individual patient’s psychologic well-being and ability to interact socially or professionally. An assessment can help guide the physician toward providing an appropriate level of care.

Drug Therapy

The papules and pustules of rosacea, as well as nodules, plaques, or perilesional erythema, can be effectively treated in most patients with drugs that have been extensively studied in clinical trials and approved by the US Food and Drug Administration for rosacea, such as topical metronidazole, topical azelaic acid, and oral controlled-release doxycycline 40 mg, all approved for the treatment of inflammatory lesions of rosacea. In addition, the efficacy of topical sodium
sulfacetamide–sulfur is supported by many years of clinical experience in treating rosacea, though it was allowed to be marketed for rosacea prior to more stringent modern requirements for clinical studies and US Food and Drug Administration review. Options for the use of approved medications as well as off-label use of other medications such as oral tetracycline are reviewed in detail in part 2 of this series.⁹

Several oral antibiotics commonly are prescribed on an off-label basis for subtype 4 (ocular) rosacea. Moreover, when appropriate, the off-label use of other medical therapies may be administered to treat flushing and background erythema, which will be discussed in detail in part 2 of this series.⁹ The committee encourages further drug research aimed to improve the treatment of background erythema, which represents a great unmet clinical need in rosacea therapy.¹⁰

In all cases, physicians should review the package insert for prescribing information. This document is not intended to suggest the monitoring and actual dosing practices for drugs.

Laser and Light Therapy

The efficacy of laser therapy for the treatment of telangiectasia has been well established in clinical practice,^11-16 and limited studies also have suggested that it may reduce erythema and flushing.^11,15,17 Most lasers used to treat vascular components of rosacea have wavelengths in the 500 to 600 nm range and are known as nonablative (they do not destroy tissue). Recent developments using long-pulsed pulsed dye lasers,¹³ a technique of stacking pulses,¹⁸ or 532-nm potassium-titanyl-phosphate lasers19 may produce excellent improvement in erythema and telangiectasia without purpura.¹³

Polychromatic light-emitting devices such as intense pulsed light devices (515–1200 nm) also have been found to be effective in reducing erythema and telangiectasia.^15,20

Ablative lasers, such as the 2.94-nm erbium:YAG or 10,600-nm CO2 lasers, destroy tissue and may be used to treat subtype 3 (phymatous) rosacea.^3,12,21

Lifestyle Management

Signs and symptoms of rosacea often appear to be triggered by environmental or lifestyle factors, most related to flushing. Some of the most common rosacea triggers include sun exposure, emotional stress, hot or cold weather, wind, heavy exercise, alcohol consumption, hot baths, spicy foods, humidity, indoor heat, certain skin care products, heated beverages, certain cosmetics, medications, medical conditions, and certain foods (Table 2, PLEASE REFER TO THE PDF TO VIEW THE TABLE).²² However, triggers that may affect one patient may not affect another, and avoidance of every potential factor may be unnecessary as well as impractical.

An appropriate management strategy identifies and avoids only those lifestyle factors that trigger or exacerbate rosacea symptoms in each individual patient. To help identify a patient’s individual rosacea triggers, the patient can record daily contact with the most common rosacea triggers and other possible factors and then match them to flare-ups of signs and symptoms. In unscientific surveys of patients with rosacea who identified and avoided their personal rosacea triggers, more than 90% reported that their condition had improved in varying degrees.²³

Adjunctive Care

Skin Care Products

Because patients with rosacea often have skin that is sensitive and easily irritated, causing redness, inflammation, and stinging, skin care is an important component of rosacea management.^21,24 The goal of everyday skin care for patients with rosacea is to maintain the integrity of the skin barrier while avoiding agents that cause inflammation or flushing.

Complicating skin care is the typical heightened neurosensory response in many patients with rosacea who may experience stinging and burning from minor irritants more frequently than the general population. Patients may therefore be advised to select cleansers and moisturizers that do not irritate their skin.

Sunscreens or sunblocks effective against the full spectrum of UVA and UVB radiation can be especially important for patients with rosacea whose facial skin may be particularly susceptible to actinic damage and consequent rosacea flare-ups. A sun protection factor of 15 or higher is recommended, and physical blocks utilizing zinc or titanium dioxide may be effective if chemical sunscreens cause irritation.

A useful rule of thumb may be to select products for patients with rosacea that contain no sensory provoking ingredients, no volatile substances, no minor irritants or allergens, minimal botanical agents, and no unnecessary ingredients.

Cleansing Regimen

Patients should be informed that compliance with instructions on facial cleansing and topical medication application may be critical to avoiding irritation, burning, and stinging. They may be advised to wash the face gently with a nonirritating cleanser, avoiding the use of abrasive materials such as washcloths and loofahs. They also may be advised to blot, not rub, the face dry with a soft towel and wait up to 30 minutes for the face to completely dry before applying topical medication or other products, as stinging most often occurs when the skin is wet.^6,8

After this routine is established and the face is not irritated, the patient can reduce the amount of time waiting to dry by 5 minutes every day to determine the shortest waiting time necessary for the individual patient.

Cosmetics

Cosmetics, especially those with a green or yellow tint, may be effective in reducing the appearance of redness. However, as with skin cleansers and moisturizers, care should be taken to minimize irritation.

Patients should be advised to avoid any products that cause burning, stinging, itching, or other discomfort. They also may be advised that waterproof cosmetics may be difficult to remove, requiring the use of harsh agents that may induce irritation.

New cosmetics should be regularly purchased to minimize microbial contamination and degradation. Brushes are preferred over sponges to avoid abrasion and because brushes can be easily cleaned to decrease bacterial contamination.²⁴

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively established. Until the etiology and pathogenesis are more completely understood, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments

The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD,  Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.

Rosacea is well established as a chronic typology or syndrome, primarily affecting the convexities of the central face (ie, cheeks, nose, chin, forehead) and often affecting the eyes. In 2002, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes.¹ In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.²

Developed and reviewed by 21 experts worldwide, these standard systems are essential to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. Because present scientific knowledge of the etiology of rosacea is limited, these systems are considered provisional and are based on morphologic characteristics alone to avoid assumptions about pathogenesis and progression. They are intended to facilitate communication and ultimately the development of a research-based understanding of the disorder.

As a final step, the committee has developed standard management options based on these standard criteria to assist in providing optimal patient care. Because it is fundamental in the management of rosacea to consider the broad spectrum of potential therapies, the consensus committee and review panel have been expanded to include leading experts in dermatology, laser therapy, skin care, and ophthalmology. As with the standard classification and grading systems, the standard management options are considered provisional and may be expanded and updated as scientific knowledge increases and additional therapies become available.

Although rosacea encompasses various combinations of signs and symptoms, in most cases, some rather than all of these features appear in any given patient and often are characterized by remissions and exacerbations. Therefore, it is important to define the roles of respective treatment modalities as well as lifestyle management and skin care within the context of specific potential manifestations. In this way, an optimal management approach may be tailored for each individual patient.^3,4

The standard management options are intended to serve as a menu of options rather than a treatment protocol. Although there is no cure for rosacea, its various signs and symptoms may be reduced or controlled with a range of therapeutic modalities, even though their actions may not be fully defined by clinical data.⁵ It should be noted that clinical trials are rarely a reflection of clinical practice because they are typically intended to discern only the contribution of a specific treatment.⁶ In practice, clinicians rarely rely on a single mode of care alone, and in the case of rosacea, factors such as proper skin care and avoidance of exacerbating factors may substantially improve results. Thus, patients often may experience better outcomes than might be suggested by clinical studies designed to isolate the effect of a single therapy.

Part 1 of this 2-part series will review the patient evaluation process and respective modalities of care.

Medical History

In addition to clinical observation of potential primary and secondary features of rosacea (Table 1, PLEASE REFER TO THE PDF TO VIEW THE TABLE), a medical history is needed to identify features that may not be visually evident or present at the time of the patient visit, to rule out alternative diagnoses, and to help identify potential environmental and lifestyle triggers. There is no laboratory test for rosacea and a biopsy is warranted only to rule out alternative diagnoses.

It may be difficult to clinically distinguish between the effects of chronic actinic damage on sun-sensitive skin (heliodermatitis) and subtype 1 (erythematotelangiectactic) rosacea. In some individuals, there may be overlapping features. A medical history may be especially useful in differentiating between erythematotelangiectactic rosacea and isolated photodamage. For example, any patient whose occupation or lifestyle has involved extensive sun exposure may experience chronic actinic damage, whereas patients with a history of flushing alone may be more likely to have rosacea. In addition, in the case of rosacea, erythema and telangiectasia tend to present with a central facial distribution.⁷ Other differential diagnoses include seborrheic dermatitis, lupus erythematosus, polycythemia vera, and carcinoid syndrome, with flushing mimicking rosacea.

A medical history also may be relevant for treatment purposes in distinguishing between dry flushing, which often is caused by exogenous or endogenous vasoactive agents, and wet flushing, which is accompanied by sweating that is regulated by the autonomic nervous system. Flushing can be further divided according to causes such as physical exertion, heat, or emotional reaction.⁸

Importantly, a medical history can uncover ocular involvement that may not be currently present or readily apparent from clinical observation as well as identify physical discomfort such as burning or stinging that may substantially affect quality of life for many patients.

Because rosacea affects facial appearance, its presence also may have considerable impact on an individual patient’s psychologic well-being and ability to interact socially or professionally. An assessment can help guide the physician toward providing an appropriate level of care.

Drug Therapy

The papules and pustules of rosacea, as well as nodules, plaques, or perilesional erythema, can be effectively treated in most patients with drugs that have been extensively studied in clinical trials and approved by the US Food and Drug Administration for rosacea, such as topical metronidazole, topical azelaic acid, and oral controlled-release doxycycline 40 mg, all approved for the treatment of inflammatory lesions of rosacea. In addition, the efficacy of topical sodium
sulfacetamide–sulfur is supported by many years of clinical experience in treating rosacea, though it was allowed to be marketed for rosacea prior to more stringent modern requirements for clinical studies and US Food and Drug Administration review. Options for the use of approved medications as well as off-label use of other medications such as oral tetracycline are reviewed in detail in part 2 of this series.⁹

Several oral antibiotics commonly are prescribed on an off-label basis for subtype 4 (ocular) rosacea. Moreover, when appropriate, the off-label use of other medical therapies may be administered to treat flushing and background erythema, which will be discussed in detail in part 2 of this series.⁹ The committee encourages further drug research aimed to improve the treatment of background erythema, which represents a great unmet clinical need in rosacea therapy.¹⁰

In all cases, physicians should review the package insert for prescribing information. This document is not intended to suggest the monitoring and actual dosing practices for drugs.

Laser and Light Therapy

The efficacy of laser therapy for the treatment of telangiectasia has been well established in clinical practice,^11-16 and limited studies also have suggested that it may reduce erythema and flushing.^11,15,17 Most lasers used to treat vascular components of rosacea have wavelengths in the 500 to 600 nm range and are known as nonablative (they do not destroy tissue). Recent developments using long-pulsed pulsed dye lasers,¹³ a technique of stacking pulses,¹⁸ or 532-nm potassium-titanyl-phosphate lasers19 may produce excellent improvement in erythema and telangiectasia without purpura.¹³

Polychromatic light-emitting devices such as intense pulsed light devices (515–1200 nm) also have been found to be effective in reducing erythema and telangiectasia.^15,20

Ablative lasers, such as the 2.94-nm erbium:YAG or 10,600-nm CO2 lasers, destroy tissue and may be used to treat subtype 3 (phymatous) rosacea.^3,12,21

Lifestyle Management

Signs and symptoms of rosacea often appear to be triggered by environmental or lifestyle factors, most related to flushing. Some of the most common rosacea triggers include sun exposure, emotional stress, hot or cold weather, wind, heavy exercise, alcohol consumption, hot baths, spicy foods, humidity, indoor heat, certain skin care products, heated beverages, certain cosmetics, medications, medical conditions, and certain foods (Table 2, PLEASE REFER TO THE PDF TO VIEW THE TABLE).²² However, triggers that may affect one patient may not affect another, and avoidance of every potential factor may be unnecessary as well as impractical.

An appropriate management strategy identifies and avoids only those lifestyle factors that trigger or exacerbate rosacea symptoms in each individual patient. To help identify a patient’s individual rosacea triggers, the patient can record daily contact with the most common rosacea triggers and other possible factors and then match them to flare-ups of signs and symptoms. In unscientific surveys of patients with rosacea who identified and avoided their personal rosacea triggers, more than 90% reported that their condition had improved in varying degrees.²³

Adjunctive Care

Skin Care Products

Because patients with rosacea often have skin that is sensitive and easily irritated, causing redness, inflammation, and stinging, skin care is an important component of rosacea management.^21,24 The goal of everyday skin care for patients with rosacea is to maintain the integrity of the skin barrier while avoiding agents that cause inflammation or flushing.

Complicating skin care is the typical heightened neurosensory response in many patients with rosacea who may experience stinging and burning from minor irritants more frequently than the general population. Patients may therefore be advised to select cleansers and moisturizers that do not irritate their skin.

Sunscreens or sunblocks effective against the full spectrum of UVA and UVB radiation can be especially important for patients with rosacea whose facial skin may be particularly susceptible to actinic damage and consequent rosacea flare-ups. A sun protection factor of 15 or higher is recommended, and physical blocks utilizing zinc or titanium dioxide may be effective if chemical sunscreens cause irritation.

A useful rule of thumb may be to select products for patients with rosacea that contain no sensory provoking ingredients, no volatile substances, no minor irritants or allergens, minimal botanical agents, and no unnecessary ingredients.

Cleansing Regimen

Patients should be informed that compliance with instructions on facial cleansing and topical medication application may be critical to avoiding irritation, burning, and stinging. They may be advised to wash the face gently with a nonirritating cleanser, avoiding the use of abrasive materials such as washcloths and loofahs. They also may be advised to blot, not rub, the face dry with a soft towel and wait up to 30 minutes for the face to completely dry before applying topical medication or other products, as stinging most often occurs when the skin is wet.^6,8

After this routine is established and the face is not irritated, the patient can reduce the amount of time waiting to dry by 5 minutes every day to determine the shortest waiting time necessary for the individual patient.

Cosmetics

Cosmetics, especially those with a green or yellow tint, may be effective in reducing the appearance of redness. However, as with skin cleansers and moisturizers, care should be taken to minimize irritation.

Patients should be advised to avoid any products that cause burning, stinging, itching, or other discomfort. They also may be advised that waterproof cosmetics may be difficult to remove, requiring the use of harsh agents that may induce irritation.

New cosmetics should be regularly purchased to minimize microbial contamination and degradation. Brushes are preferred over sponges to avoid abrasion and because brushes can be easily cleaned to decrease bacterial contamination.²⁴

Conclusion

Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as their mechanisms of action are more definitively established. Until the etiology and pathogenesis are more completely understood, however, the classification of rosacea by its morphologic features and grading by severity may serve as an appropriate guide for its effective management.

As with the standard classification and grading systems, the options described here are provisional and subject to modification with the development of new therapies, increase in scientific knowledge, and testing of their relevance and applicability by investigators and clinicians. Also, as with any consensus document, these options do not necessarily reflect the views of any single individual and not all comments were incorporated.

Acknowledgments

The committee thanks the following individuals who reviewed and contributed to this document: Joel Bamford, MD, Duluth, Minnesota; Mats Berg, MD, Uppsala, Sweden; James Del Rosso, DO, Las Vegas, Nevada; Roy Geronemus, MD, New York, New York; David Goldberg, MD, JD, Hackensack, New Jersey; Richard Granstein, MD, New York, New York; William James, MD, Philadelphia, Pennsylvania; Albert Kligman, MD, PhD, Philadelphia, Pennsylvania; Mark Mannis, MD, Davis, California; Ronald Marks, MD, Cardiff, United Kingdom; Michelle Pelle, MD, San Diego, California; Noah Scheinfeld, MD, JD, New York, New York; Bryan Sires, MD, PhD,  Kirkland, Washington; Helen Torok, MD, Medina, Ohio; John Wolf, MD, Houston, Texas; and Mina Yaar, MD, Boston, Massachusetts.