CKS did not identify any national referral criteria or guidelines for rosacea. In the absence of established policy, these recommendations are based on pragmatism and what is accepted in the UK as good clinical practice.

• A dermatologist is in a position to offer several pharmacological treatments that are not suitable for the treatment of rosacea in primary care. In general, there is a lack of evidence from controlled trials to support these treatments, rather than evidence of no effect. Therefore, an expert may trial them on an individual basis. These include [Pelle et al, 2004; Powell, 2005; Baldwin, 2006]:
• Other topical treatments, such as benzoyl peroxide, topical antibiotics (other than metronidazole), tacrolimus, or retinoids (e.g. tretinoin).
• Other oral antibiotics, such as clarithromycin, azithromycin (useful if erythromycin is poorly tolerated), or minocycline.
• The combined oral contraceptive pill (if a hormonal cause is suspected in a woman).
• Oral isotretinoin or clonidine (for flushing).
• Cardiovascular drugs to prevent flushing (e.g. beta-blockers or spironolactone).
• Some forms of rosacea are resistant to pharmacological treatment. Referral to secondary care allows for other options to be considered:
• Persistent erythema is often mistakenly attributed to heavy drinking, and this can cause considerable stigma [Powell, 2005; Baldwin, 2006]. Erythema can be masked with camouflage makeup; the dermatology department should be able to provide the person with the relevant local contact information (see www.timewarp.demon.co.uk/redcross.html for details of the Red Cross Beauty Care and Cosmetic Camouflage Service).
• Treatment options for telangiectasia and phymatous disease in secondary care include laser treatment and corrective electrosurgery [Pelle et al, 2004; Powell, 2005]. However, these are not generally available on the NHS.