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Independents' Day

Treating rosacea - the evidence base

The latest in our series offering evidence-based advice not covered by official guidelines

The latest in our series offering evidence-based advice not covered by official guidelines

Clinical picture

• Rosacea is a chronic skin disease with paroxysmal exacerbations. It is most common in women aged 30 to 50.

• The etiology is not known.

• The typical clinical presentation includes acne-like pustules, dilated blood vessels (telangiectasia), and redness of the skin.

• The typical site is the central area of the face.

• There are no comedones.

• Ocular rosacea may present with skin involvement around the eyes, or even with intact skin, which makes the diagnosis difficult. In mild cases the symptoms include dryness and smarting of the eyes.

• Exacerbating factors include hot drinks, strong spices, sunlight and sauna baths. Reaction to these factors varies among individuals.

• Steroid creams may cause a rosacea-like dermatitis on the face.

Differential diagnosis

• Acne occurs in younger patients and is associated with comedones.

• Perioral dermatitis is situated around the mouth and lacks telangiactasia.

• The skin affection in SLE may be difficult to differentiate from rosacea. The lack of systemic symptoms aids in diagnosis.


• Metronidazole ointment (1%) is the drug of choice (level of evidence B).

• There is also evidence on the effectiveness of azelaic acid1 (level of evidence B) and permethrin2 ointments in rosacea.

• Steroids must absolutely be avoided.

• Patients whose rosacea becomes worse in the spring may benefit from sun-protective creams.

• Tetracycline as a course lasting one to two months is usually effective (level of evidence B). The dose is smaller than in the treatment of acne. After an initial daily dose of 750 to 1,000mg the dose can be decreased to 250mg daily.

• In the more severe forms of rosacea, isotretinoin may be used at discretion of a specialist in dermatology3.

• Sebaceous gland hyperplasia in the nose (rhinophyma) sometimes requires surgical treatment. Isotretinoin often controls hyperplasia effectively.

• Patients with intense keratitis symptoms associated with rosacea should be seen by an ophthalmologist.

This synopsis is taken from EBM Guidelines, a collection of treatment and diagnosis guidelines supported by evidence summaries.

© Duodecim Medical Publications.

Distributed by Wiley-Blackwell. For more information, email or visit

Levels of evidence

A high

B moderate

C low

D very low


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