rosacea up (AutoRecovered).docx updated rosacea treatment guidelines

updated rosacea treatment

1. Diagnosis
The diagnosis of rosacea is clinical and based on specific features according to the ROSacea COnsensus
expert panel (ROSCO) and the National Rosacea Society (NRS). On clinical exclusion of other conditions
with similar presenting features, the diagnosis of rosacea is established with either:لافصن ( 1)
phymatous changes, or (2) centrofacial persistent erythema In their absence, diagnosis can be
established by the presence of any two of the following major features: flushing/transient erythema,
papules and pustules, telangiectases , or ocular rosacea . Minor features, such as burning, stinging, dry
sensation of the skin, or edema are not diagnostic of rosacea). The diagnosis of rosacea in darker skin
types (Fitzpatrick phototypes V and VI is difficult as erythema and telangiectasia may not be readily
visible, and a high level of suspicion based on minor features is required. A less common variant of
rosacea is granulomatous rosacea, with multiple brown, yellow, or red cutaneous papules of uniform
size. Occasionally, skin biopsy may be useful for diagnostic support.
Cutaneous Rosacea FeaturesDescription centrofacial هلك
Diagnostic features1 لا نم2
Phymatous changesFacial skin thickening due to fibrosis and/or sebaceous glandular hyperplasia.
Most commonly affects the nose, where it can impart a bulbous appearance.
Persistent erythemaBackground ديزتبو هدوجوم ongoing centro facial redness. May periodically
intensify ب minor in response to variable triggers. In darker skin phototypes (V and VI), erythema may
be difficult to detect visually.
Major features2 لا نم4
Flushing/transient erythemaTemporary increase in centrofacial redness, معتلwhich may include
sensations of warmth, heat, burning and/or pain.
TelangiectasesVisible vessels in the centrofacial region but not only in the alar area.
Papules and pustulesRed papules and pustules, usually in the centrofacial area. Some may be larger
and deeper.
Ocular Rosacea FeaturesDescription
Lid margin telangiectasiaVisible vessels around the eyelid margins. May be difficult to detect
visually in darker skin phototypes (V and VI).
BlepharitisInflammation of the eyelid margin, most commonly arising from Meibomian gland
dysfunction.
Keratitis Inflammation of the cornea that can lead to defects and, in the most severe cases, vision
loss.

2. ConjunctivitisInflammation of the mucous membranes lining the inner surface of the eyelids and
bulbar conjunctiva. Typically associated with injection or vascular congestion and conjunctival oedema.
Anterior uveitisInflammation of the iris and/or ciliary body.
Minor features ساسحإ
Burning sensation of the skinAn uncomfortable or painful feeling of heat, typically in the centrofacial
region.
Stinging sensation of the skinAn uncomfortable or painful sharp, pricking sensation, typically in the
centrofacial region.
Dry sensation of the skinSkin that feels rough. May be tight, scaly and/or itchy.
EdemaLocalized facial swelling. تااامتحلاا لك Can be soft or firm (nonpitting) and may be self-limited in
duration or persistent.
Evaluation and Differential Diagnosis
Differential diagnoses of rosacea depend on the clinical feature(s) present (Table 3). Examples include
contact dermatitis, photodermatitis, seborrheic dermatitis, and systemic lupus erythromatous for facial
erythema; هنابعت اهتي
%%سفن ت%%س
perimenopausal flushing, emotional flushing, carcinoid syndrome, and
mastocytosis for flushing; and acne vulgaris and folliculitis for papules and pustules.16 Exclusion of
mimics can be established by taking an adequate history, performing a directed physical evaluation for
distinguishing features, and further testing as required.
Distinguishing Clinical FeatureDifferential DiagnosisOther Clinical Features
Facial erythema Contact dermatitisItching, eczematous features
Photodermatitis Tender erythema in photo-distribution
Seborrheic dermatitisScaly erythema at frontal hairline, scalp, eyebrows, and nasolabial folds
Systemic lupus erythematosus (SLE)Cheilitis and other manifestations of SLE
Flushing
Perimenopausal flushingTransient episodes of intense heat sensation
Flushing of chest, head, and neck , Profuse drenching sweats Episodes lasts 3-5 minutes up to 20 times a
day and are frequently followed by chills accompanied by palpitations and sense of anxiety
Emotional flushingEpisodes of flushing are correlated with emotional upset or feelings of
embarrassment
Carcinoid syndromeAssociated diarrhea, , and abdominal pain wheezing
MastocytosisAssociated diarrhea, abdominal pain, and musculoskeletal pain

3. Papules and pustulesAcne vulgarisPresence of comedones
FolliculitisMonomorphous lesions, no centrofacial erythema
Associated Comorbidities
Associations between rosacea and metabolic, cardiovascular, gastrointestinal (GI), neurologic, and
psychiatric diseases have been established هيل Some of these share common innate inflammatory
elements with rosacea, such as macrophage and macrophage-derived mediators, reactive oxygen
species, matrix metalloproteinases, interleukin-1b (IL-1b), and tumor-necrosis-factor (TNF).
Associated ComorbidityOR 95% CIP-ValueReference
Metabolic
Type 1 diabetesو DyslipidemiaCardiovascular, Hypertension, Coronary artery disease
Gastrointestinal
Ulcerative colitis, Crohn’s disease, Inflammatory bowel disease, Celiac disease, Gastroesophageal
reflux disease
Neurologic/psychiatric
Depression, Migraine
Management
The goals of rosacea treatment are to reduce the severity of features and the frequency and intensity of
flares. 1 General management includes routine skin care: gentle cleansers, moisturizers, sun protection,
and avoidance of triggers. 2 Specific treatments should be targeted at clinical features. If multiple
features are present, combination treatment should be considered. The phenotype approach allows for
such feature-based treatment according to the severity and impact of the presentation
Persistent erythema b0
Topical brimonidine0.33% gel
Topical oxymetazoline1% cream
Papules and pustules AIRA
Dicarboxylic acids , Topical azelaic acid15% foam
Topical azelaic acid is superior to topical metronidazole15% gel azelaic acid, 0.5% gel metronidazole

4. Antiparasitics
Topical ivermectin1% cream, Topical ivermectin is superior to topical metronidazole
Retinoids
Oral isotretinoin0.25 mg/kg, 0.30 mg/kg
Antibiotics
Topical minocycline1.5% or 3% foam
Oral doxycycline40 mg MR Oral doxycycline 100 mg is ass0ciated with GIT upset which
impacts adherence , sub-antimicrobial dose showed comparable efficacy and superior safety
Oral tetracycline250 mg
Oral doxycycline is just as effective as oral minocycline40 mg doxycycline, 100 mg minocycline
Oral doxycycline is similar to oral azithromycin100 mg doxycycline, 500 mg three times a week then
tapered azithromycin
Oral doxycycline (low dose) is similar to oral doxycycline (high dose)40 mg, 100 mg doxycycline
Telangiectasias
PDL, Nd:YAG, IPL
Clinically non-inflamed phyma
Ablative laser surgery, Er:YAG modalities, electrosurgery, cryosurgerybut recommended by experts
Clinically inflamed phyma
Oral doxycycline MR form improve efficacy and reduce side effects , Oral isotretinoin
Ocular rosacea OC
Omega-3 fatty acids180 mg eicosapentaenoic acid and 120 mg docosahexaenoic acid
Cyclosporine ophthalmic emulsion is superior to artificial tears0.05% cyclosporine ophthalmic
emulsion 9
Combination therapies
Topical brimonidine with topical ivermectin0.33% gel brimonidine, 1% topical ivermectin
Topical metronidazole with oral doxycycline is superior to topical metronidazole alone1% gel
metronidazole, 40 mg MR doxycycline
Oral minocycline with topical azelaic acid is just as effective as oral
minocycline without azelaic acid45 mg minocycline, 15% gel azelaic acidN/AModerate

5. Topical clindamycin phosphate with tretinoin1.2% clindamycin phosphate, 0.025% gel tretinoin
N/AModerate Higher than vehicle/placebo; N/AModerate
Maintenance therapies AIM
Topical metronidazole 0.75% gel for papules and pustules
Topical ivermectin for papules and pustules1% cream
Topical azelaic acid for papules and pustules15% gel
Flushing/Transient Eryth5ema