Topical Treatments for Papulopustular Rosacea
Mild to moderate Papulopustular Rosacea will respond well to topical therapy. There is a wide range of topical measures used to treat Papulopustular Rosacea. The most frequently used are the various preparations of metronidazole (creams, gels and lotions which may be available in different strengths) and azelaic acid gel. Azelaic acid gel (15%) and the metronidazole preparations are effective treatments when applied twice daily to the skin. Both of these preparations should be applied to the area of skin affected and not solely to inflammatory lesions. An occasional patient will experience an initial burning sensation with azelaic acid, but this usually settles with continued use. When the rosacea clears, treatment should be continued to maintain remission. If the skin remains in remission over several months, the patient can gradually discontinue treatment, initially applying the preparation once daily for two weeks and then on alternate days for two weeks before stopping.
If a flare occurs, the patient should reintroduce therapy at the original frequency themselves. In this way, the individual can take over the management of their skin condition with occasional supervision by the physician. Metronidazole 0.75% cream preparation is particularly well tolerated by patients with sensitive skin. In comparative studies it would appear that there is little difference in the efficacy of these products (azelaic acid and metronidazole) and that both are well tolerated. They are particularly effective in clearing the inflammatory lesions of Papulopustular Rosacea. The erythema may respond better to the azelaic acid preparation, but can be expected to diminish progressively (over several months) following sucessful with either treatment. Topical metronidazole products should not be prescribed to pregnant or lactating females. Experience with the use of azelaic acid by pregnant mothers is too limited to permit assessment of the safety of its used during pregnancy.
what is Rosacea
Rosacea is a common chronic inflammatory disorder of the hair follicles, sebaceous glands and vasculature of the face. The role of Demodex mite in the pathogenesis of Rosacea is controversial.
Rosacea sufferers have recurrent flushing, exacerbated by heat (shower, hot drinks), spicy foods, sunlight, cold, alcohol, and stress. They have sensitive skin, and may complain of dry and gritty eyes.
The peak incidence of Rosacea is 30—50 yr; Females being more affected than Males.
Rosacea sufferers may develop erythema, telangiectases, papules, and pustules of central face; there are no comedones in contrast to acne. Sebaceous hyperplasia, seborrheic dermatitis and facial lymphedema are also more common.
There are 4 Major Subtypes of Rosacea:
Erythematotelangiectatic, papulopustular, ocular, and phymatous.
Chronic inflammation may progress to rhinophyma (enlarged nose; in males). Ocular involvement is also common (e.g., gritty, conjunctival injection, styes, photophobia).
Investigations include clinical diagnosis; uncommonly, skin biopsy is indicated to rule out lupus or sarcoidosis.
Similar conditions that needs to be differentiated from Rosacea are: Acne, lupus erythematosus, perioral dermatitis, sarcoidosis, seborrheic dermatitis.
Treatment of Rosacea is based on severity and subtype.
Lifestyle modification:
Avoid triggers; sun protection and avoidance; facial massage for lymphedema.
Topical antibiotics:
Metronidazole 0.75% gel or 1% cream bid.
Sodium sulfacetamide lotion 10% bid.
Oral antibiotics (moderate to severe cases with inflammatory papulopustular component):
Tetracycline 500 mg po bid
Minocycline 100 mg po od—bid.
Doxycycline 20 mg po bid (subantimicrobial dose therapy) or 100 mg po qd–bid.
Isotretinoin (low dose); less commonly, topical retinoids may be used.
Laser therapy (e.g., PDL, IPL) for telangiectases and ablative laser (e.g., CO2) for rhinophyma.
Camouflage makeup (e.g., Dermablend, Covermark) for erythema.
Ophthalmologist to assess for ocular Rosacea (blepharitis, conjunctivitis, episcleritis).
