Acne rosacea (Rosacea)

Introduction
Rosacea is a chronic inflammatory skin condition primarily affecting the central face. It presents with persistent erythema, flushing, telangiectasia, papules, pustules, and in advanced cases, phymatous changes such as rhinophyma. Unlike acne vulgaris, comedones are absent. Management is tailored to clinical subtype (erythematotelangiectatic, papulopustular, phymatous, or ocular) and focuses on symptom control, reduction of flare-ups, and prevention of disease progression.

1. Topical Therapies

• Metronidazole (0.75%–1%): First-line for papulopustular rosacea; applied once or twice daily.

• Azelaic acid (15% gel or foam): Reduces inflammatory lesions and erythema.

• Ivermectin (1% cream): Effective for inflammatory papules and pustules, targeting Demodex mites and inflammation.

• Brimonidine (0.33% gel) or oxymetazoline (1% cream): Alpha-adrenergic agonists that reduce persistent facial erythema via vasoconstriction.

2. Systemic Antibiotics

• Doxycycline (40 mg modified-release once daily or 100 mg/day): Anti-inflammatory dosing preferred over antimicrobial dosing to reduce resistance risk.

• Minocycline: Alternative to doxycycline.

• Erythromycin or azithromycin: Used in patients intolerant to tetracyclines (e.g., pregnancy, children).

3. Other Systemic Therapies

• Isotretinoin: Low-dose oral isotretinoin for refractory or severe papulopustular or phymatous rosacea.

• Beta-blockers (propranolol, carvedilol) or clonidine: Occasionally used off-label to reduce severe flushing.

4. Ocular Rosacea Management

• Eyelid hygiene with warm compresses and lid scrubs.

• Artificial tears for dryness.

• Oral doxycycline or azithromycin in persistent cases.

• Ophthalmology referral for keratitis, blepharitis, or severe ocular involvement.

5. Procedural and Device-Based Treatments

• Laser therapy (pulsed dye laser, intense pulsed light): Effective for telangiectasia and persistent erythema.

• Surgical intervention: May be required for severe rhinophyma.

6. Lifestyle and Preventive Measures

• Identification and avoidance of triggers: alcohol, spicy foods, hot beverages, extremes of temperature, emotional stress, and UV exposure.

• Daily use of broad-spectrum sunscreen (SPF 30 or higher).

• Non-comedogenic, fragrance-free skincare products.

• Stress management and adequate skin hydration.

7. Multidisciplinary Care

• Dermatologist involvement for diagnosis and treatment escalation.

• Ophthalmologist input for ocular rosacea.

• Psychological support for patients experiencing social or emotional distress due to facial appearance.