Other topical therapies used to treat rosacea

In mild to moderate papulopustulr rosacea, 10% sodium sulfacetamide and 5% sulfur cream or lotion are effective topical therapies of papulopustular rosacea and can be used to treat concomitant seborrheic dermatitis. It should be avoided in patients with sensitivity to sulfur or sulphonamides. Tinted and sunscreen containing preparations of these products are available, which appeal to some patients.
The choice among these topical agents can be difficult. There is individual variations in patients tolerance and response to treatment (what works for one patient may not always suit another). Most patients usually start with a metronidazole cream or azelaic acid gel applied twice daily.
Occasionally the response will be disappointing and this requires the physician to switch from one topical therapy to another to achieve optimal results. Patients are
adviced that initial prescription is likely to be successful, but that a follow-up
visit is required after three weeks to ensure that they have had a good response.
It is advisable that the physician becomes familiar with the tolerability of two or three topical agents on dry, normal, sensitive and oily skin as well as in patients with various skin types. With experience the clinician will be able to select the appopriate treatment to suit an individual patient.
Other topical therapy used to treat papulopustular rosacea includes, erythromycin 2% solution applied twice daily. This may be slightly drying and irritant and is probably not as effective as the other topical treatments but has the advantage that it can be used safely in the pregnant patient. Tretinoin 0.025% cream or lotion or 0.01% gel applied at night has the theoretical advantage of treating both the actinic damage as well as the rosacea, but is poorly tolerated by rosacea patients with dry sensitive skin and should be avoided in pregnancy. Isotretinoin 0.05% and erythromycin 2% alcohol gel applied as a thin film twice daily may also be effective, but again irritancy may reduce its acceptability to patients and it does not appear to have any advantage over the better tolerated metronidazole and azelaic acid products. Other topical therapies that have been reported to be effective in treating individual or small groups of patients with papulopustular rosacea include various sulfur containing products (often in combination with salicylic acid or precipitated sulfur with 0.75% hydrocortisone lotion), benzoyl peroxide gel (which is quite drying and poorly tolerated on the rosacea patient’s skin) sometimes used in combination with clindamycin 1% or erythromycin, and topical antimite preparations (Permethrin 1% or ivermectin 1.87% creams). There is insufficient
evidence to recommend these medications and the clinician is best advised to adhere to the FDA apapulopustular rosaceaoved and appropriately tested products. Only in the exceptional case will it be necessary to resort to any of these latter agents. Topical calcineurin antagonists such as tacrolimus and pimecrolimus initially showed promise in the treatment of papulopustular rosacea,but they may induce a rosaceiform eruption and so their use for these patients should probably be avoided. The method of application of topical therapies and how they should be used in relation to cosmetic and sun-block creams should be explained to the patient.

Local Treatments for Rosacea

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.

The Best Treatment for Acne Rosacea Can Be A Personal Dilemma

The Best Treatment for Acne Rosacea Can Be A Personal Dilemma

Trying to determine which of the many rosacea products is the best rosacea treatment can be confusing, to say the least. The reason being is that it is generally different for each person due to the variability of the symptoms from individual to individual. Acne rosacea can prove very difficult to treat, however with a proper treatment plan, the condition can be controlled. Though self treatment is not uncommon we generally suggest that you schedule an appointment with a dermatologist to help in developing a rosacea treatment based on your particular set of symptoms.

Rosacea Is Socially Disruptive

Based on surveys conducted with acne rosacea sufferers with more severe symptoms, about 70% of those surveyed claimed that the skin disease had negatively affected their professional and occupational relationships. Also of interest was the fact that 30% stated they had called into work sick to avoid the embarrassment of their rosacea symptoms. It is obvious that this skin affliction not only affects the personal lives of many its sufferers, but also impacts workplace productivity.

Finding the Best Rosacea Treatments

The good news is that you do have options in the treatment of your acne rosacea. The pharmaceutical approach to rosacea control is available through your dermatologist and local pharmacy. The bad news is that this kind of treatment can be irritating at times, especially for those acne rosacea sufferers who are sensitive to antibiotics.

An alternative rosacea treatment to the pharmaceutical approach is available and may better suit your skin condition and particular symptoms. Using a rosacea best treatment alternative is a personal choice that most rosacea patients have pondered. If a natural rosacea treatment sounds preferable to you, there are some very effective new herbal rosacea remedies that can actually relieve your rosacea symptoms. Their secret is a precise combination of herbal ingredients and pure, natural ingredients.

Simply stated, the best rosacea treatment will depend on your particular symptoms and those factors that aggravate your skin condition. Once these conditions become obvious to you, a simple modification to your lifestyle or environment can have a dramatic effect on the frequency and severity of your rosacea flareups. Combine these modifications with a regular skin care program of natural cleansers and moisturizers, and you will have done everything possible to manage your skin condition.

Hope for rosacea: Cytokinin treatment offers patients a new therapeutic option

Hope for rosacea: Cytokinin treatment offers patients a new therapeutic option
By Ilya Petrou, M.D
National report — Several treatment approaches are used for the treatment of rosacea, however no current therapy is considered a panacea for all the symptoms associated with this condition. A recent trial with Pyratine-XR proves to be very effective in treating many of the associated symptoms seen in rosacea, and offers patients a new therapeutic option for this cosmetic thorn.

Pyratine-6 (0.1 percent furfuryl tetrahydropyranyladenine) and pyratine-XR (0.125 percent furfuryl tetrahydropyranyladenine) are second-generation compounds associated with a molecule called kinetin, which have been shown to have a significant therapeutic effect in rosacea. These cytokinin compounds are antioxidants, which positively impact many aspects of skin aging by increasing mitochondrial activity, helping actin and fibroblast function as well as helping in the removal of cellular debris. In the wake of initial therapeutic clinical trial success with pyratine-6 lotion for the treatment of rosacea, Senetek recently completed a clinical study with pyratine-XR lotion in rosacea patients.

In the 48-week study conducted at the University of California, Irvine, 18 patients with mild-to-moderate rosacea received a twice a day treatment with Pyratine-XR lotion. The investigators evaluated inflammatory papule and pustule lesion count, severity of facial erythema and telangiectasias, and participants self-assessed their signs and symptoms of rosacea as well as skin tolerance to the treatment.

Results showed that at 48 weeks, 80 percent of the patients showed an overall clinical improvement including reduction of facial erythema and inflammatory lesions. There was a 90 percent improvement of inflammatory lesions, a 45 percent improvement of erythema and a 28 percent improvement of telangiectasias. In addition, a significant improvement of the skin barrier function from week four through the end of the study was seen, as measured by a decrease in water loss from the skin.

Pyratine-6 was initially studied for photodamage and results showed that in addition to improving fine lines and wrinkles, it also dramatically helped improve erythema. Pyratine-XR is a reformulation of the original compound that appears to be extremely effective in treating the clinical symptoms seen in rosacea, including erythema, inflammatory lesions as well as spider veins.

"Pyratine-XR appears not only to be effective in treating rosacea, but may also be effective for other dermatoses where erythema plays a major role in the symptomatology such as facial redness, inflammatory lesions, telangiectasias, eczema and atopic dermatitis," says Mark Nestor M.D., Ph.D., voluntary associate professor, department of dermatology and cutaneous surgery, University of Miami Miller School of Medicine, Miami.

The three clinical presentations of rosacea include papulopustular, telangiectatic and sebaceous (rhinophyma) type rosacea and all three variants have been amenable to some degree with different treatment approaches. Current treatments for papulopustular type rosacea include oral and topical antibiotics as well as topical metronidazole and azeleic acid, whereas telangiectatic rosacea responds best to laser or IPL therapies. Because rosacea is a chronic condition, therapeutic regimens used are geared for the long-term. According to Dr. Nestor, long-term tolerability and the development of antibiotic resistance, which can be associated with oral and topical antibiotic regimens, are a non-issue with the cytokinin therapy, and is considered one of the major advantages of this novel therapeutic approach.

"The currently used pharmaceutical therapies do not effectively address the erythema associated with rosacea and none of them treat the telangiectasias. Therefore, it is refreshing to have a compound now that can compliment laser or IPL therapy, does not have any side effects and makes the skin look better and at the same time not only decreases the erythema, but also the suppresses exacerbations of rosacea," Dr. Nestor tells Dermatology Times.

Patients in the trial tolerated Pyratine-XR very well and the cosmetic acceptability was very high. The regimen is twice a day with the lotion until improvements are seen which can be as soon as two weeks of therapy. According to Dr. Nestor, any kind of topical therapy, ultimately, has the potential to cause some degree of irritation, but in the trial patients, there was no difference seen here between Pyratine-XR and the vehicle. Pyratine-XR can be used either alone or as an adjunct in patients with rosacea.

"This gives us another option to help us treat our rosacea patients. In addition, Pyratine-XR lotion also seems to improve other aspects of aging skin such as fine lines, roughness and hyperpigmentations," Dr. Nestor says. DT

Disclosure: Dr. Nestor reoports no relevant financial interests.

Pathogenesis of rosacea: Breakthroughs hold promise for therapeutic developments

Pathogenesis of rosacea: Breakthroughs hold promise for therapeutic developments
By Cheryl Guttman

San Diego — Understanding the pathogenesis of rosacea has been advanced by recent research and is expected to provide an important foundation for developing novel, rational approaches to therapy in the future, says Richard L. Gallo, M.D., Ph.D., professor and chief, division of dermatology, University of California, San Diego.

Dr. Gallo discusses findings from a series of research studies that show there is a dysfunction in antimicrobial peptide production and processing in rosacea and that it can arise via multiple pathways.

"This information indicates no one gene or stimulus can explain rosacea in all patients, and therefore, it is consistent with our longstanding frustration in trying to identify a solitary etiologic trigger,

" Dr. Gallo says.

Skin’s immune system

"Now, understanding of these antimicrobial peptides as a critical element of rosacea should offer us new targets of therapy," Dr. Gallo tells Dermatology Times.

Dr. Gallo and colleagues approached their investigations of rosacea pathogenesis from a biochemical and genetic standpoint, considering the key elements of the biology of the disease and their understanding of the functioning of the innate immune system of the skin.

Based on this knowledge, they hypothesized that rosacea reflects an abnormality in the reaction of the early response system to the variety of elements that have been identified as rosacea triggers.

More specifically, they hypothesized that elements of the antimicrobial peptide system and enzymes controlling that system may represent a "choke point" in the communication between the multiple different disease stimuli and the various clinical subtypes of rosacea.

Immunohistochemistry

A series of studies were designed to construct proof for this hypothesis. The first investigated levels of cathelicidin antimicrobial peptides in facial skin and showed significantly higher expression in patients with rosacea compared with unaffected controls as measured by immunohistochemistry, Enzyme-Linked ImmunoSorbent Assay (ELISA) and gene expression. Evaluation with mass spectroscopy showed the size of the cathelicidin peptides was also abnormal in the skin of all rosacea patients compared with controls, indicating a difference in proteolytic processing.

"The differences between rosacea patients and our control samples — uninvolved edges of basal cell carcinoma excisions — were dramatic, and the findings were somewhat surprising to us.

"However, it was the difference in peptide size that really led us to believe we had come upon something important," Dr. Gallo says.

Consistent with that belief, the researchers also found that all rosacea patients had abnormally increased activity of the serine protease enzymes responsible for cathelicidin peptide processing.

In previous research, Dr. Gallo and colleagues had already identified the genes for individual cathelicidin-processing enzymes. Based on that information, they evaluated the expression of the gene for stratum corneum tryptic enzyme (SCTE, kallikrein 5) in facial skin of rosacea patients and found it was also elevated and specifically in areas where the processed cathelicidin peptides were found.

Further experiments aimed to establish significance for the laboratory findings by demonstrating a cause and effect relationship. Applying Koch’s postulates, these experiments investigated the hypothesis that if the unique peptides found only in rosacea skin were important in disease pathogenesis, they could induce findings consistent with the clinical presentation of rosacea.

Cathelicidin peptides

A first in vitro experiment showed that production of pro-inflammatory cytokines by cultured keratinocytes was significantly greater when the skin cells were co-incubated with processed cathelicidin peptides found in rosacea skin compared with peptides from normal skin.

"Although supportive, this finding was not overly convincing. The results of a second experiment blew us away," Dr. Gallo says.

The latter research involved a murine model and evaluated the responses to dorsal skin injections of physiologically relevant concentrations of peptides from normal and rosacea skin.

After just two days of twice daily treatment, the animals injected with the rosacea-related peptides developed a phenotype that reproduced rosacea with the presence of inflammation, a vascular response, and ectasia.Adding strength to the cause and effect relationship was the observation of a dose-related response.

The research has now entered a new phase where studies are evaluating potential correlations between the proposed pathogenic pathway and both gene abnormalities and effective treatments.

These are our last questions, but really represent the beginning of our research project, not the end," Dr. Gallo says.

Available evidence is still limited, but so far, it is entirely consistent with the existing hypothesis. One line of support is derived from an "experiment of nature," which is the finding that a polymorphism of the vitamin D receptor gene leading to excessive production of processed cathelicidin peptides is associated with rosacea fulminans.

Isotretinoin

In addition, it is also known that isotretinoin, which has been found to have beneficial effects in rosacea, influences genes involved in the cathelicidin and SCTE expression system.

Findings from a study examining serine protease levels in facial skin of rosacea patients after they start, stop, and restart minocycline therapy are preliminary but so far are providing a dramatic demonstration of how tetracyclines can affect this innate immune response pathway.

Dr. Gallo says that marked decreases in SCTE levels have been observed after the initiation of minocycline therapy and occur in parallel with improvement in clinical disease activity.

Subsequent minocycline withdrawal and re-initiation corresponded to increases and decreases, respectively, in enzyme activity.

"The effects of minocycline withdrawal and rechallenge on SCTE show the initially observed change with minocycline initiation was not a coincidence and suggest that indeed, tetracycline affects the enzymes that we hypothesize are involved in the pathogenesis of rosacea," Dr. Gallo says. DT

Disclosure: The research has been supported in part by a seed grant from the National Rosacea Society.

Topical Rosacea Treatment

Topical Rosacea Treatment
Acne Rosacea patients have a skin that is unusually vulnerable to chemical and physical insults. All sources of local irritation, such as soaps, alcoholic cleansers, tinctures, astringents, abrasives, and peeling agents must be avoided. Only mild soaps or cleansers are advised. Protection against sunlight must be emphasized.
Antibiotics, as used in acne, are sometimes effective. Topical tetracyclines, clindamycin, and erythromycin, usually in concentrations from 0.5% to 2.0%, are commercially available. Erythromycin and clindamycin seem to be superior. Tetracycline is effective orally, but a disappointment topically. An inhibition of chemotaxis or inflammatory cells or a direct effect on vascular endothelium may be responsible for its action.
Metronidazole has become an important addition to the Anti-Rosacea repertoire. The observation that topical metronidazole was comparable in its effects to oral tetracycline (250 mg bid) led to placebo-controlled double-blind clinical studies demonstrating its effectiveness. In many countries throughout the world there is a 0.75% gel, cream, or lotion, as well as a 1% cream available. It is applied once or twice daily and has its greatest effect on papules and pustules, and reduces erythema to a lesser degree. It does not alter telangiectases or flushing. Topical metronidazole may be used as monotherapy or, in more severe forms, in combination with oral antibiotics. One study found that 0.75% metronidazole gel rapidly reduced inflammatory lesions during the first 3 weeks of treatment, potentially allowing quick tapering and discontinuation of oral medication. Long-term use of 0.75% metronidazole gel has been shown to keep Acne Rosacea in remission. A study involving 88 patients whose Acne Rosacea was initially controlled with a combination of oral tetracycline and metronidazole found that more than 80 percent of those patients given metronidazole remained in remission after 6 months, while 40 percent of those patients given placebo relapsed. The mechanism by which metronidazole ameliorates the inflammatory lesions and erythema of Acne Rosacea may be related to anti-inflammatory or immunosuppressive actions of the drug.
Imidazoles are also gaining popularity with the treatment of Acne Rosacea. Best results are with ketoconazole cream applied once or twice daily. The imidazoles are anti-inflammatory agents, affect gram-positive bacteria, and, above all, are well tolerated by most Acne Rosacea patients with sensitive skin.
Old-time remedies should not be forgotten, even though their use is not supported by evidence-based trials. Drying lotions fall into this category, with a very thin application at night recommended. Lotions with 2% to 5% sulfur have been used successfully. Because they are messy, we no longer use them. Other topical medications proven effective for treating Acne Rosacea include sulfacetamide sodium 10% lotion, as well as sulfacetamide sodium 10% and sulfur 5% lotion, which may be tinted or tint free. They are used in a similar fashion and for the same purpose as metronidazole.
Retinoids are worth a trial. In an uncontrolled clinical study, women with Acne Rosacea used 0.025% tretinoin cream over a period of several months. After a predictable early exacerbation of symptoms, the patients then appeared to develop hardening and side effects diminished. Gratifying long-term results were reported, including a reduction in erythema. Alternative topical retinoids may prove easier to use. There is preliminary evidence that 0.2% isotretinoin in a bland cream is helpful. It is less irritating than tretinoin, and suppresses inflammatory lesions in stage II and III Acne Rosacea. No data exist for adapalene, which seems to be the least irritating of all topical retinoids.
In a clinical study, 20% azelaic acid cream was more effective than its vehicle cream in reducing the number of inflammatory lesions and degree of erythema associated with Acne Rosacea. In a recent study, 20% azelaic acid cream gave results comparable to 0.75% metronidazole cream with the added benefit of increased patient satisfaction. The efficacy of azelaic acid in Acne Rosacea may be due to the anti-inflammatory properties of this compound.
As stated earlier, Demodex folliculorum mites are not considered to play a causative role in Acne Rosacea, although massive infestation of Demodex folliculorum mites may sometimes aggravate the condition. Nevertheless, it is good to check for mites. This is best done with the skin-surface biopsy technique of placing a drop of cyanoacrylate on a glass slide that is covered with immersion oil and analyzed with the 10 or 20 × objective in the light microscope. The mites are hard to control with any of the antiparasitic drugs such as lindane (hexachlorocyclohexane), crotamiton, permethrin, or benzyl benzoate. The effect of treatment on the mite population can be monitored by cyanoacrylate skin-surface biopsies.
Sunscreens, preferably of the broad spectrum UVA plus UVB and infrared type, with a skin protection factor (SPF) of 15 or higher are always recommended to Acne Rosacea patients and should be used every day of the year. The sunscreens with a base of micronized zinc oxide or titanium oxide are nonirritating and work well for anyone with the sensitive skin of Acne Rosacea, but they leave sometimes an opaque hue on the skin, especially in the spacious facial pores. For this reason patients often turn away from these products.
Glucocorticoids should never be used. The only exception is with Acne Rosacea conglobata and Acne Rosacea fulminans. In these patients, short courses of oral and topical glucocorticoids are a reasonable option because of their anti-inflammatory properties.

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.

Rosacea Treatment

Acne Rosacea Treatment
Oral antibiotics and isotretinoin.
Both the skin and eye manifestations of Acne Rosacea respond to either tetracycline or erythromycin. One gm/day is used in divided doses. Resistant cases can be treated with 100 to 200 mg/day of minocycline or doxycycline and with 200 mg of metronidazole twice daily. Medication is stopped when the pustules have cleared. The response after treatment is unpredictable. Some sufferers clear in 2 to 4 weeks and stay in remission for weeks or months. Others flare and require long-term suppression with oral antibiotics. Treatment should be tapered to the minimum dosage that provides adequate control. Sufferers who remain clear should periodically be given a trial without medication. However, many sufferers promptly revert to the low-dose oral regimen. Isotretinoin, 0.5 mg/kg/day for 20 weeks, was effective in treating severe, refractory Acne Rosacea; 85% had no relapse at the end of a year.
Topical therapy.
Topical metronidazole (Metrogel) is not as effective but may be used for initial treatment for mild cases or for maintenance after stopping oral antibiotics. Metronidazole is not very effective in inhibiting anaerobic P. acnes, but it may exert its therapeutic effect by inhibiting oxidative tissue injury by neutrophils. One study showed that clindamycin in a lotion base produced clinical results similar to those of oral tetracycline (250 mg four times a day for 3 weeks, then 250 mg twice a day for 9 weeks) and was superior in the eradication of pustules.
Sulfacetamide/sulfur lotion (Sulfacet, Novacet) controls pustules. Sulfacet-R is flesh colored and hides redness. They are effective alone or when used with oral antibiotics.
Sufferers with rhinophyma may benefit from specialized procedures performed by plastic or dermatologic surgeons. These include electrosurgery, carbon dioxide laser, and surgery. Unsightly telangiectatic vessels can be eliminated with careful electrocautery.
sufferers who do not respond to antibiotics may have Demodex folliculorum mite infestation or tinea, in which the facial pustules and scales are usually localized to one cheek; a potassium hydroxide examination confirms the diagnosis. Crotamiton (Eurax) is reported to be effective. Lindane lotion or Sulfur & Salicylic Acid soap should also be effective.

Rosacea Treatment