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Rosacea - Management
How should I treat a person with rosacea?

  • Assess the predominant symptoms and rule out acne vulgaris (this usually affects younger people and areas other than the face; it features comedones, and does not feature erythema, telangiectasia, or flushing; see the CKS topic on Acne vulgaris).
  • Flushing, erythema (without inflammation), telangiectasia, and rhinophyma — there is no effective treatment for these symptoms in primary care, so management should consist of lifestyle advice (for mild rosacea) or referral. Some drugs can aggravate flushing (e.g. calcium-channel blockers), so avoid these where possible.
  • Mild or moderate papulopustular rosacea (i.e. limited number of papules and pustules, no plaques) — treat with a topical drug.
    • Metronidazole is usually preferred as it is well tolerated. Prescribe the gel (0.75%) or cream (1%) according to the person's preference (the cream may be more suitable for sensitive skin).
    • Azelaic acid is an alternative to metronidazole that may be more effective, especially in people who do not have sensitive skin. However, it may cause transient stinging.
  • Moderate or severe papulopustular rosacea (i.e. extensive papules, pustules, or plaques) — prescribe an oral tetracycline or erythromycin.
    • Tetracycline and oxytetracycline are both licensed for rosacea; they need to be taken twice a day on an empty stomach.
    • Doxycycline 100 mg and lymecycline are not licensed for rosacea; they need to be taken once a day (optionally with food).
    • A low-dose modified-release formulation of doxycycline 40 mg is now available. It is licensed for rosacea and is taken once a day.
    • Erythromycin is an option for pregnant or breastfeeding women, and other groups in whom tetracyclines are contraindicated.
  • Ocular rosacea — eye symptoms are usually treated with a combination of eyelid hygiene measures, ocular lubricants (for dry eye symptoms), and oral tetracyclines. For further information, see the CKS topic on Blepharitis.

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