Systemic Rosacea Treatment

Systemic Rosacea Treatment
ANTIBIOTICS
The most agreeable feature of Acne Rosacea is that it generally responds well to oral antibiotics. Tetracycline-HCl, oxytetracycline, doxycycline, and minocycline are usually quite effective in controlling papulopustular Acne Rosacea and even reducing erythema. It is important to start with full doses, for example, 1.0 to 1.5 g tetracycline-HCl or oxytetracycline per day. Likewise 50 mg of minocycline (our own choice) or doxycycline twice daily can be given. If tetracyclines are ineffective or not tolerated, erythromycin or other macrolides such as clarithromycin 34 or azithromycin 35 may be used. As soon as full control of papulopustules is achieved, usually after 2 to 3 weeks, maintenance doses of 250 to 500 mg tetracycline-HCl or oxytetracycline, or 50 mg minocycline or doxycycline per day or every other day are generally sufficient. Acne Rosacea sufferers often know how to titrate disease activity and vary dosage accordingly. Some get by with 250 mg tetracycline-HCl every other day. The sufferer's input should be encouraged and antibiotic usage should be carefully monitored. The disease has exacerbations and remissions and topical drugs may be sufficient during inactive periods. Some sufferers seem to become “addicted” to oral antibiotics and find ways to get them without prescription. Tetracycline therapy is mandatory for ophthalmic Acne Rosacea.
ISOTRETINOIN
This drug is exceptionally effective, although accompanied by far greater risks than tetracyclines. Before using it, one has to consider indications, contraindications, and all risks. Isotretinoin may be appropriate for all forms of severe or therapy-resistant Acne Rosacea, especially the variants which are unresponsive to antibiotics, such as lupoid Acne Rosacea, stage III Acne Rosacea, Acne Rosacea conglobata, gram-negative Acne Rosacea, and Acne Rosacea fulminans. It is particularly helpful in sufferers who have oily, wide-pored skin and multiple, often many dozens of sebaceous gland hyperplasias. Furthermore, all forms of phymas are worthwhile indications. The dose required for the control of severe Acne Rosacea varies. Tailored doses are recommended. The standard dose of isotretinoin is lower than in acne, namely 0.2 to 0.5 mg/kg body weight per day. Side effects on the eyes make this low dose unbearable for some sufferers. Ophthalmic Acne Rosacea may get worse, complaints of dry eyes can increase, and so can blepharitis. This may lead to the inability to use contact lenses. The standard dose is only used in Acne Rosacea fulminans, or preoperatively for a couple of months to shrink rhinophyma before surgical reduction of the bulbous nose. More recent studies demonstrate the efficacy of low-dose isotretinoin in the treatment of Acne Rosacea. In this schedule, initially 10 mg or 20 mg daily (not adjusted to body weight) are used. This dose is helpful in many forms of the disease, especially stage III Acne Rosacea, lupoid Acne Rosacea, and persistent edema in Acne Rosacea. After 1 to 2 months, this is further reduced to 10 mg every other day or even to two or three of seven days per week. Side effects on the eyes are minimal. Duration of therapy is longer as with the standard dose, for about 6 months. The cumulative dose, however, is very low. The usual precautions apply as in the therapy of acne. Isotretinoin is a teratogen and is contraindicated for women of childbearing age unless the sufferer meets all the requirements printed in detail in the package insert. Laboratory monitoring includes liver transaminases, bilirubin, cholesterol, and triglycerides before therapy and at monthly or bimonthly intervals thereafter.
METRONIDAZOLE
This is a synthetic nitroimidazole-derivative antibacterial and antiprotozoal agent for the treatment of infections caused by Trichomonas vaginalis, Entamoeba histolytica, and several anaerobic organisms. The usual dose is 500 mg twice daily for 6 days. Oral metronidazole is generally effective in all types of Acne Rosacea, including stage II and III. However, it may require 20 to 60 days to achieve control with a daily dose of 500 mg. The use of oral metronidazole is limited by concerns over adverse systemic effects and toxicity with long-term therapy, and it is not approved for Acne Rosacea treatment. Consequently, oral metronidazole is a second-line drug that may be tried when other methods are not working. It is very helpful for the treatment of Demodex folliculitis, even its worst form, such as Demodex-associated abscesses and furunculoid nodules. The dose is 750 to 1500 mg daily in divided doses for 10 to 14 days.