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The Management of Rosacea

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Abstract

Rosacea is a multiphasic disease which is associated with flushing, erythrosis, papulopustular rosacea and phymas; each phase is likely to have its own treatment. Flushing is better prevented rather than treated, and its etiology investigated. ß-Blockers, atenolol in particular, are worthy of prophylactic trials examining their efficacy in treating the flushing associated with rosacea. Currently, clonidine is the only drug available for the treatment of flushing.

Treatment for erythrosis includes topical and systemic therapies. Metronidazole 1% cream and azelaic acid 20% cream have been reported to reduce the severity score of erythema. The systemic treatment of erythrosis is based on the association of Helicobacter pylori with rosacea. However, this role is still being debated. Eradication of H. pylori can be achieved using a triple therapy regimen lasting 1 to 2 weeks [omeprazole and a combination of two antibacterials (a choice from clarithromycin, metronidazole or amoxicillin)]. Both the flashlamp-pumped long-pulse dye laser and the potassium-titanyl-phosphate laser may be used in the treatment of facial telangiectases.

Both systemic and topical remedies may be used to treat the papulopustules of rosacea. Systemic treatment includes metronidazole, doxycycline, minocycline, clarithromycin and isotretinoin, while topical treatment is based on metronidazole cream and gel. The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not. Crotamiton 10% cream or permethrin 5% cream may be useful medications for papulopustular rosacea, although they are rarely successful in eradicating D. folliculorum. Oral or topical ivermectin may also be useful in such cases.

Ocular involvement is common in patients with cutaneous rosacea and can be treated with orally administered or topical antibacterials.

Once rhinophyma starts to be evident, the only way to correct it is by aggressive dermatosurgical procedures. Decortication and various types of lasers can also be used.

Associated conditions, such as seborrheic dermatitis and possible contact sensitizations, deserve attention.

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References

  1. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol 1989; 69: 19–23

    Google Scholar 

  2. Weston WL, Morelli JG. Steroid rosacea in prepubertal children. Arch Pediatr Adolesc Med 2000; 154: 62–4

    PubMed  CAS  Google Scholar 

  3. Rapoza PA, Quinn TC, Terry AC, et al. A systematic approach to the diagnosis and treatment of chronic conjunctivitis. Am J Ophthalmol 1990; 109: 138–42

    PubMed  CAS  Google Scholar 

  4. Moss S, Calam J. Helicobacter pylori and peptic ulcers: the present position. Gut 1992; 33: 289–92

    Article  PubMed  CAS  Google Scholar 

  5. Yamada T, Chiba T. Somatostatin. In: Makhlouf GM, editor. Handbook of physiology: the gastrointestinal system. Bethesda (MD): American Physiological Society, 1989: 431–53

    Google Scholar 

  6. Tsuji S, Kawano S, Tsujii M, et al. Helicobacter pylori extract stimulates inflammatory nitric oxide production. Cancer Lett 1996; 108: 195–200

    Article  PubMed  CAS  Google Scholar 

  7. Szlachcic A, Sliwoski Z, Karczewska E, et al. Helicobacter pylori and its eradication in rosacea. J Physiol Pharmacol 1999; 50: 777–86

    PubMed  CAS  Google Scholar 

  8. Utas S, Ozbakir O, Turasan A, et al. Helicobacter pylori eradication treatment reduces the severity of rosacea. J Am Acad Dermatol 1999; 40: 433–5

    Article  PubMed  CAS  Google Scholar 

  9. Lonne-Rahm SB, Fischer T, Berg M. Stinging and rosacea. Acta Derm Venereol 1999; 79: 460–1

    Article  PubMed  CAS  Google Scholar 

  10. Roihu T, Kariniemi AL. Demodex mites in acne rosacea. J Cutan Pathol 1998; 25: 550–2

    Article  PubMed  CAS  Google Scholar 

  11. Pu LL, Smith PD, Payne WG, et al. Overexpression of transforming growth factor beta-2 and its receptor in rhinophyma: an alternative mechanism of pathobiology. Ann Plast Surg 2000; 45: 515–9

    Article  PubMed  CAS  Google Scholar 

  12. Parodi A, Guarrera M, Rebora A. Flushing in rosacea: an experimental approach. Arch Dermatol Res 1980; 269: 269–73

    Article  PubMed  CAS  Google Scholar 

  13. Breneman D, Stewart D, Hevia O, et al. A double-blind, multicenter clinical trial comparing efficacy of once-daily metronidazole 1% cream to vehicle in patients with rosacea. Cutis 1998; 61: 44–7

    PubMed  CAS  Google Scholar 

  14. Jorizzo J, Lebwohl M, Tobey R. The efficacy of metronidazole 1% cream once daily compared with metronidazole 1% cream twice daily and their vehicles in rosacea: a double-blind clinical trial. J Am Acad Dermatol 1998; 395: 502–4

    Article  Google Scholar 

  15. Bjerke R, Fyrand O, Graupe K. Double-blind comparison of azelaic acid 20% cream and its vehicle in treatment of papulo-pustular rosacea. Acta Derm Venereol 1999; 79: 456–9

    Article  PubMed  CAS  Google Scholar 

  16. Rebora A, Drago F, Picciotto A. Helicobacter pylori in patients with rosacea. Am J Gastroenterol 1994; 89: 1603–4

    PubMed  CAS  Google Scholar 

  17. Zentilin P, Brusati C, Pivari M, et al. Prevalence of Helicobacter pylori infection in patients with rosacea [abstract]. Gastroenterology 2000; 118: A728

    Article  Google Scholar 

  18. Son SW, Kim IH, Oh CH, et al. The response of rosacea to eradication of Helicobacter pylori. Brit J Dermatol 1999; 140: 984–5

    Article  CAS  Google Scholar 

  19. Bermejo F, Boixeda D, Gisbert JP, et al. Rapid urease test utility for Helicobacter pylori infection diagnosis in gastric ulcer disease. Hepatogastroenterology 2002; 49: 572–5

    PubMed  Google Scholar 

  20. Gisbert JP, del Mar Cabrera M, Pajares JM. Detección del antigeno de Helicobacter pylori en heces para el diagnóstico inicial de la infección y para la confirmación de su erradicación tras el tratamiento. Med Clin (Barc) 2002; 118: 401–4

    Google Scholar 

  21. Graham DY, Lew GM, Malaty HM, et al. Factors influencing the eradication of Helicobacter pylori with triple therapy. Gastroenterology 1992; 102: 493–6

    PubMed  CAS  Google Scholar 

  22. Mansour-Ghanaei F, Fallah M, Shafaghi A. Eradication of Helicobacter pylori in duodenal ulcer disease tetracycline & furazolidone vs. metronidazole & amoxicillin in omeprazole based triple therapy. Med Sci Monit 2002; 8: P127–30

    Google Scholar 

  23. Osato MS, Reddy SG, Piergies AA, et al. Comparative efficacy of new investigational agents against Helicobacter pylori. Aliment Pharmacol Ther 2001; 15: 487–92

    Article  PubMed  CAS  Google Scholar 

  24. Eriksson G, Nord CE. Impact of topical metronidazole on the skin and colon microflora in patients with rosacea. Infection 1987; 15: 8–10

    Article  PubMed  CAS  Google Scholar 

  25. West TB, Alster TS. Comparison of the long-pulse dye (590-595nm) and KTP (532nm) lasers in the treatment of facial and leg telangiectasias. Dermatol Surg 1998; 24: 221–6

    Article  PubMed  CAS  Google Scholar 

  26. Smith KW. Perioral dermatitis with histopathologic features of granulomatous rosacea: successful treatment with isotretinoin. Cutis 1990; 46: 413–5

    PubMed  CAS  Google Scholar 

  27. Persi A, Rebora A. Metronidazole and Demodex folliculorum. Acta Derm Venereol 1981; 61: 182–3

    PubMed  CAS  Google Scholar 

  28. Bannatyne RM. Metronidazole, its bioactive metabolites and acne. Curr Med Res Opin 1999; 15: 298–9

    Article  PubMed  CAS  Google Scholar 

  29. Esterly NB, Furey NL, Flanagan LE. The effect of antimicrobial agents on leukocyte chemotaxis. J Invest Dermatol 1978; 70: 51–5

    Article  PubMed  CAS  Google Scholar 

  30. Grove DI, Mahmoud AAF, Warren KS. Suppression of cell-mediated immunity by metronidazole. Int Arch Allergy Appl Immunol 1977; 54: 422–7

    Article  PubMed  CAS  Google Scholar 

  31. Gnarpe H, Persson S, Belsheim J. Influence of metronidazole and tinidazole on leukocyte chemotaxis in Crohn’s disease. Infection 1978; 1 Suppl.: 107–9

    Article  Google Scholar 

  32. Tanga MR, Analani JA, Kabade SS. Clinical evaluation of metronidazole as an antiinflammatory agent. Int Surg 1975; 60: 75–6

    PubMed  CAS  Google Scholar 

  33. Miyachi Y, Imamura S, Niwa Y. Anti-oxidant action of metronidazole: a possible mechanism of action in rosacea. Br J Dermatol 1986: 114: 231–4

    Article  PubMed  CAS  Google Scholar 

  34. Akamatsu H, Oguchi M, Nishijima S, et al. The inhibition of free radical generation by human neutrophils through the synergistic effect of metronidazole with palmitoleic acid: a possible mechanism of action of metronidazole in rosacea and acne. Arch Dermatol Res 1990; 282: 449–54

    Article  PubMed  CAS  Google Scholar 

  35. Nielsen H. Antibiotics and human monocyte function; II: phagocytosis and oxidative metabolism. APMIS 1989; 97: 447–51

    Article  PubMed  CAS  Google Scholar 

  36. Anderson R, Oosthuizen R, Maritz C, et al. Effects of metronidazole on certain functions of human blood neutrophils and lymphocytes. S Afr Med J 1979; 55: 593–6

    PubMed  CAS  Google Scholar 

  37. Diav-Citrin O, Shechtman S, Gotteiner T, et al. Pregnancy outcome after gestational exposure to metronidazole: a prospective controlled cohort study. Teratology 2001; 63: 186–92

    Article  PubMed  CAS  Google Scholar 

  38. Roe FJ. Safety of nitronidazoles. Scand J Infect Dis Suppl 1985; 46: 72–81

    PubMed  CAS  Google Scholar 

  39. Friedman GD, Selby JV. Metronidazole and cancer [letter]. JAMA 1989; 261: 866

    Article  PubMed  CAS  Google Scholar 

  40. Sneddon IB. A clinical trial of tetracycline in rosacea. Br J Dermatol 1966; 78: 649–52

    Article  PubMed  CAS  Google Scholar 

  41. Torresani C, Pavesi A, Manara GC. Clinical trial on clarithromycin versus doxycycline in the treatment of rosacea. Int J Dermatol 1997; 36: 938–46

    Article  Google Scholar 

  42. Erdogan F. Efficacy of low-dose isotretinoin in patients with treatment-resistant rosacea. Arch Dermatol 1998; 134: 884–5

    Article  PubMed  CAS  Google Scholar 

  43. Lehman PA, Henderson WR. Retinoid-induced inhibition of eosinophil LTC4 production. Prostaglandins 1990; 39: 569–77

    Article  PubMed  CAS  Google Scholar 

  44. Isotretinoin. In: Reynolds JEF, editor. Martindales’: the extra pharmacopoeia. 30th ed. London: The Pharmaceutical Press, 1993: 760-1

  45. Jick SS, Kremers HM, Vasilakis-Scaramozza C. Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide Arch Dermatol 2000; 136: 1231–6

    Article  PubMed  CAS  Google Scholar 

  46. Isotretinoin. Physicians Desk reference Generics. 1st ed. Montvale (NJ): Medical Economics Data Production Co., 1995: 1623

  47. Forstinger C, Kitter H, Binder M. Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream. J Am Acad Dermatol 1999; 41: 775–7

    Article  PubMed  CAS  Google Scholar 

  48. Wilkin JK. Use of topical products for maintaining remission in rosacea. Arch Dermatol 1999; 135: 79–80

    Article  PubMed  CAS  Google Scholar 

  49. Dahl MV, Katz HI, Krueger GC, et al. Topical metronidazole maintains remissions of rosacea. Arch Dermatol 1998; 134: 679–83

    Article  PubMed  CAS  Google Scholar 

  50. Guarrera M, Brusati C, Rebora A. Topical metronidazole does not abate UVB-induced erythema. Dermatology 2001; 203 (2): 121–3

    Article  PubMed  CAS  Google Scholar 

  51. Hoekzema R, Hulsebosch HJ, Bos JD. Demodicidosis or rosacea: what did we treat? Br J Dermatol 1995; 133: 294–9

    Article  PubMed  CAS  Google Scholar 

  52. Shelley WB, Shelley ED, Burmeister V. Unilateral demodectic rosacea. J Am Acad Dermatol 1989; 20: 915–7

    Article  PubMed  CAS  Google Scholar 

  53. Lempert SL, Jenkins MS, Brown SI. Chalazia and rosacea. Arch Ophthalmol 1979; 97: 1652–3

    Article  PubMed  CAS  Google Scholar 

  54. Seal DV, Wright P, Ficker L, et al. Placebo controlled trial of fusidic acid gel and oxytetracycline for recurrent blepharitis and rosacea. Br J Ophthalmol 1995; 79: 42–5

    Article  PubMed  CAS  Google Scholar 

  55. Hallock GG. Laser treatment of rhinophyma. Aesth Plast Surg 1988; 12: 171–4

    Article  CAS  Google Scholar 

  56. Clark DP, Hanke CW. Electrosurgical treatment of rhinophyma. J Am Acad Dermatol 1990; 22: 831–7

    Article  PubMed  CAS  Google Scholar 

  57. Linehan JW, Goode RF, Fajardo LF. Surgery vs electrosurgery for rhinophyma. Arch Otolaryngol 1970; 91: 444–8

    Article  PubMed  CAS  Google Scholar 

  58. Greenbaum SS, Krull EA, Watnick K. Comparison of CO2 laser and electrosurgery in the treatment of rhinophyma. J Am Acad Dermatol 1988; 18: 363–8

    Article  PubMed  CAS  Google Scholar 

  59. Wheeland RG, Bailin PL, Ratz JL. Combined carbon dioxide laser excision and vaporization in the treatment of rhinophyma. J Dermatol Surg Oncol 1987; 13: 172–7

    PubMed  CAS  Google Scholar 

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Acknowledgments

The author wishes to thank Leonardo Marini and Reeja Stankovic of SDC, Trieste, Italy for their assistance in writing the section on cryotherapy and laser therapy. No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.

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Correspondence to Alfredo Rebora.

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Rebora, A. The Management of Rosacea. Am J Clin Dermatol 3, 489–496 (2002). https://doi.org/10.2165/00128071-200203070-00005

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