Rosacea: Topical Treatments and Oral Medications

What Is Rosacea?

Rosacea is a chronic inflammatory skin condition. It often begins with a tendency to blush or flush more easily than other people.

The first sign may be intermittent redness or blushing. Bumps, tiny pus-filled pimples and enlarged blood vessels can also appear, giving skin a rough, uneven appearance.

There is no known cure, but it can be managed with appropriate treatment and lifestyle changes.

Famous Faces of Rosacea

If you are living with rosacea, you are in good company. Some famous people who have struggled with rosacea include:

• Bill Clinton
• Diana, Princess of Wales
• W.C. Fields (a film star in the 1920s and 1930s)

How Do Dermatologists Diagnose Rosacea?

If your dermatologist suspects you have rosacea, you won’t need medical tests. No medical test can tell whether you have rosacea.

If you have rosacea, your dermatologist can talk with you about treatment options. While treatment cannot cure rosacea, it can help:

• Reduce (or eliminate) signs of rosacea on your skin
• Ease your discomfort
• Prevent rosacea from worsening

How do dermatologists begin with education?

While medication or laser treatment can help reduce or clear signs of rosacea, your everyday habits may cause a new flare-up.

Learning how to do the following can help reduce flare-ups:

1. Find your triggers.

Many things you do can cause rosacea to flare. Dermatologists call these tripwires “triggers.” Common triggers for rosacea include becoming overheated, having cold wind blowing on your face, and eating spicy foods.

• Think sun protection 24/7.

People who have rosacea often find that their skin is quite sensitive to the sun.

• Practice rosacea friendly skin care.

Many skin care products can irritate skin with rosacea. Some skin care habits, such as scrubbing your skin clean, can cause rosacea to flare.

Treatment

After managing these three steps the rest of your treatment plan will be tailored to treating your rosacea. Here’s information from AAD and Medscape how dermatologists treat the different signs of rosacea:

1. How to Treat the Redness

The redness may show up as flushing that lasts a little longer each time. Without treatment for rosacea, this redness can become permanent. Another cause of permanent redness is visible blood vessels on the face.

Dermatologist can create a treatment plan that includes one or more of the following:

• Lasers and Other Light-Based Treatments

For people who have a constantly red face or visible blood vessels, a laser or other light-based treatment can be effective. Some patients see complete clearing of their redness. This clearing can last for years.

• Brimonidine gel and oxymetazoline hydrochloride cream

These prescription medications, topical alpha agonists, can reduce the redness on your face caused by rosacea. They work for up to 12 hours. Once the effects wear off, the redness returns. With daily use, you can have reduced facial redness for up to 12 hours a day.

Both medications have been approved by the U.S. Food and Drug Administration (FDA) to treat the facial redness of rosacea.

How to Treat Acne-Like Breakouts

If your rosacea causes breakouts that look like acne, you have some effective treatment options. Here’s what your rosacea treatment plan from a dermatologist may include:

• Topical Medications You Apply to Your Skin

Azelaic acid: Most patients apply this medication twice a day — in the morning and again in the evening. This product is known as Finacea (15%) in the U.S. Findings from 6 research studies show that between 70% and 80% of patients have had noticeably less rosacea with azelaic acid. Some patients saw complete clearing.

Metronidazole: Available as a gel or cream, this treatment has been used for more than 60 years to treat the acne-like breakouts of rosacea. This product is known as Metrogel (1%) and MetroCream (0.75%) and Noritate (1%) in the U.S.

Research studies show that it can effectively reduce both the redness and the acne-like breakouts.
Some patients are able to stop applying this medication and keep the results they gained by using metronidazole. In one study, only 23% of patients had a rosacea flare-up 6 months after stopping metronidazole.

Erythromycin (E.E.S., Erythrocin, Ery-Tab) tab or 2% topical solution:

The antibiotics are effective against papulopustular rosacea at  lower (sub-antimicrobial) doses, mostly due to their anti-inflammatory properties rather than a direct antimicrobial mechanism. Although bacteria may contribute to this form of rosacea, the evidence is scant.

Clindamycin:

Upon application to skin, drug is converted to active component, which inhibits the microorganism. Effective against mild-to-moderate papulopustular rosacea.

• Oral Medications You Take

Antibiotics: For more than 50 years, dermatologists have prescribed tetracycline, an antibiotic, to their patients with rosacea. It can quickly reduce the acne-like breakouts and redness.  In research studies, most patients have noticeably fewer acne-like breakouts within one month.

Oral tetracyclines are also effective for ocular rosacea, along with lid care and artificial tears.

Other antibiotics, such as minocycline, doxycycline, or erythromycin, can also effectively treat rosacea.

Low-dose doxycycline: Doxycycline is an antibiotic. For the treatment of rosacea however is is used at lower doses, not effective to kill bacteria. This product is known as Oracea (40 mg) in the U.S.

Studies show that low-dose doxycycline can reduce the acne-like breakouts of rosacea and based on these studies, the U.S. Food and Drug Administration (FDA) approved low-dose doxycycline to treat rosacea.

Isotretinoin: Isotretinoin is an oral agent that treats serious dermatologic conditions and it is usually reserved for patients who are intolerant to other therapies. Approved only to treat severe acne, this medication at a lower dose of 10 mg daily may be an option. Due to potentially serious side effects it requires clinical and laboratory monitoring for safety.

It has been shown to reduce the redness and acne-like breakouts. Isotretinoin may also prevent phyma (firm, rounded bumps or thickening of the skin on your face) from worsening.

• Laser or Light Therapy

These can effectively treat the redness and acne-like breakouts.

• How to Treat Thickening Skin

Isotretinoin: See above.

Ablative Lasers or Surgery

The overgrown (hypertrophied) tissue can be reshaped and contoured. Lasers produce less bleeding when compared to traditional surgery. You can be referred to a dermatologist or a plastic surgeon for these therapies.

Other medications

Immunosuppressants

Tacrolimus ointment (Protopic): These agents inhibit immune reactions resulting from diverse stimuli. Tacrolimus ointment reduces itching and inflammation by suppressing the release of cytokines from T cells. It also inhibits transcription of genes encoding IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, it may inhibit the release of preformed mediators from skin mast cells and basophils and may down-regulate the expression of FCeRI on Langerhans cells.

Tacrolimus ointment can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. It is available as ointment in concentrations of 0.03% and 0.1% and is indicated only after other treatment options have failed.

Vasoconstricting agents

Treatment for flushing and redness (erythema) may involve oral drugs with vasoconstriction properties including mirtazapine (alpha blocker), propranolol (beta blocker) or carvedilol (both alpha and beta blocker). They are used at low doses to minimize side effects such as lowering of blood pressure, fatigue and sleepiness. Careful monitoring is required with these therapies.

Outcome for people who have rosacea

There is no cure for rosacea, but you can successfully control it. Making some lifestyle changes and treating rosacea can prevent flare-ups. It can also prevent the rosacea from worsening.

Many people find that by doing these things, living with rosacea becomes a lot easier. They also say they feel and look better.

References

• aad.org
• emedicine.medscape.com/article/1071429-medication
• Jackson JM, Knuckles M, et al. “The role of brimonidine tartrate gel in the treatment of rosacea.” Clin Cosmet Investig Dermatol. 2015 Oct 23;8:529-38
• Angelucci DD. “Rhinophyma progress slowed with swift diagnosis, treatment.” Dermatol Times. June 1, 2011. Last accessed August 2017.
• Pelle MT. “Rosacea.” In: Wolff K, Goldsmith LA, et al. Fitzpatrick’s Dermatology in General Medication (seventh edition). McGraw Hill Medical, New York, 2008:703-9.
• Pelle MT, Crawford GH, et al. “Rosacea: II. Therapy.” J Am Acad Dermatol. 2004;51(4):499-512.
• Tan SR and Tope WD. “Pulsed dye laser treatment of rosacea improves erythema, symptomatology, and quality of life.” J Am Acad Dermatol. 2004;51:592-9.
• Di Nardo A, Holmes AD, et al. “Improved clinical outcome and biomarkers in adults with papulopustular rosacea treated with doxycycline modified-release capsules in a randomized trial.” J Am Acad Dermatol. 2016;74:1086-92.
• Rosamilla LL. “Rosacea treatment schema: An update.” Cutis. 2017;100(1):11-13.
• Two AM, Wu W, et al. “Rosacea Part II. Topical and systemic therapies in the treatment of rosacea.” J Am Acad Dermatol. 2015;72:761-70.

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This article contains medical information provided to help you better understand this medical condition or process and may contain information about medication often used as part of a treatment plan prescribed by a doctor.  It is not intended to be used as either a diagnosis or recommendation for treatment of your medical situation.  If you are unwell, concerned about your physical or mental state, or are experiencing symptoms you should speak with your doctor or primary health care provider. If you are in medical distress, please contact emergency services (such as 911).