Rosacea

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.

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.

Girish S. Munavalli, MD, Mhs, and Robert A. Weiss, MD

Acne is a very prevalent skin disorder, affecting more than 85% of adolescents and often continuing into adulthood. Active acne and its sequelae, especially permanent scarring, may cause longstanding psychological or emotional harm in patients. Novel and promising treatments with laser/light devices (such as blue light, red light, pulsed dye laser, infrared lasers, light-emitting diodes, and pulsed light) have been reported to have varying degrees of efficacy for treatment. The authors compiled a summary of evidence-based literature on laser/light treatment for acne to assist clinicians to more appropriately identify treatment options, should they choose to supplement current medical antiacne therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

Girish S. Munavalli, MD, Mhs, and Robert A. Weiss, MD

Acne is a very prevalent skin disorder, affecting more than 85% of adolescents and often continuing into adulthood. Active acne and its sequelae, especially permanent scarring, may cause longstanding psychological or emotional harm in patients. Novel and promising treatments with laser/light devices (such as blue light, red light, pulsed dye laser, infrared lasers, light-emitting diodes, and pulsed light) have been reported to have varying degrees of efficacy for treatment. The authors compiled a summary of evidence-based literature on laser/light treatment for acne to assist clinicians to more appropriately identify treatment options, should they choose to supplement current medical antiacne therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

Girish S. Munavalli, MD, Mhs, and Robert A. Weiss, MD

Acne is a very prevalent skin disorder, affecting more than 85% of adolescents and often continuing into adulthood. Active acne and its sequelae, especially permanent scarring, may cause longstanding psychological or emotional harm in patients. Novel and promising treatments with laser/light devices (such as blue light, red light, pulsed dye laser, infrared lasers, light-emitting diodes, and pulsed light) have been reported to have varying degrees of efficacy for treatment. The authors compiled a summary of evidence-based literature on laser/light treatment for acne to assist clinicians to more appropriately identify treatment options, should they choose to supplement current medical antiacne therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

Stephan John Kempiak, MD, PhD, and Nathan Uebelhoer, DO

Superficial chemical peels and microdermabrasion are used for many dermatologic conditions. A common condition treated with these modalities is acne vulgaris. In this review, we discuss the theory behind the technique of these procedures and describe the application and complications of each of these procedures in the office setting. The evaluation of patients before proceeding with the procedure and discuss pre- and postpeel regimens used for patients is discussed. We also analyze studies on both of these in-office procedures and comparative studies between the 2 most commonly used superficial chemical peeling agents, glycolic and salicylic acid.

*For a PDF of the full article, click on the link to the left of this introduction.

Stephan John Kempiak, MD, PhD, and Nathan Uebelhoer, DO

Superficial chemical peels and microdermabrasion are used for many dermatologic conditions. A common condition treated with these modalities is acne vulgaris. In this review, we discuss the theory behind the technique of these procedures and describe the application and complications of each of these procedures in the office setting. The evaluation of patients before proceeding with the procedure and discuss pre- and postpeel regimens used for patients is discussed. We also analyze studies on both of these in-office procedures and comparative studies between the 2 most commonly used superficial chemical peeling agents, glycolic and salicylic acid.

*For a PDF of the full article, click on the link to the left of this introduction.

Stephan John Kempiak, MD, PhD, and Nathan Uebelhoer, DO

Superficial chemical peels and microdermabrasion are used for many dermatologic conditions. A common condition treated with these modalities is acne vulgaris. In this review, we discuss the theory behind the technique of these procedures and describe the application and complications of each of these procedures in the office setting. The evaluation of patients before proceeding with the procedure and discuss pre- and postpeel regimens used for patients is discussed. We also analyze studies on both of these in-office procedures and comparative studies between the 2 most commonly used superficial chemical peeling agents, glycolic and salicylic acid.

*For a PDF of the full article, click on the link to the left of this introduction.

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott