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Rosacea - Treating rosacea

NHS Choices Medical Reference

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Rosacea can be treated in a number of ways.

Lifestyle changes

The initial treatment for rosacea is to avoid known triggers, or factors that make  symptoms worse. These factors can be unique to every individual but the most important step is to avoid exposure to the sun.

Read more information about preventing rosacea.

Medication

A range of topical (skin-based) and oral (taken by swallowing) treatments have been used for rosacea.

They are effective mainly for treating inflammatory types of rosacea (papules and pustules). There is little evidence to support their use for the vascular form of rosacea (flushing, redness and thread veins). This is best treated with laser and light-based therapies (see below).

For mild rosacea, topical treatment agents include metronidazole, azelaic acid and sodium sulfacetamide-sulfur. Second line therapies include benzoyl peroxide, clindamycin, topical retinoids and calcineurin inhibitors.

For patients with moderate-to-severe rosacea or those with affected eyes (ocular rosacea), combination therapy with oral and topical agents is often needed. Options include tetracyclines and erythromycin. In severe cases, low dose isotretinoin may be effective.

Metronidazole

Metronidazole cream or gel (topical metronidazole) is usually recommended for the treatment of mild to moderate spots and pimples.

When applying metronidazole cream or gel, be careful not to get any in your eyes or mouth. You will need to apply topical metronidazole once or twice a day for several months.

Metronidazole does not usually cause side effects, although it may irritate your skin. This is usually more common with gels that contain alcohol. Avoid exposure to strong sunlight or UV light (used in some lamps and nightclubs).

Azelaic acid

An alternative to topical metronidazole is azelaic acid. Azelaic acid helps unblock pores and reduce inflammation (redness and swelling).

You will need to apply azelaic acid cream or gel twice a day, and avoid contact with your mouth and eyes. As with topical metronidazole, you may need to use azelaic acid for several months before you notice any significant improvement in your symptoms.

The side effects of azelaic acid can include:

  • burning and stinging of the skin
  • itchiness
  • dry skin

About a third of people who use azelaic acid will experience side effects. However, any side effects are usually short-lived.

Antibiotic medicines

For more serious symptoms of spots and pimples, oral antibiotics may be recommended. In this case, antibiotics are used for their ability to reduce inflammation of the skin rather than their ability to kill bacteria.

As with other treatments, you will need to take oral antibiotics for several weeks before you notice a significant improvement in your symptoms. You may need to continue the course once or twice a day for several months or longer.

Long-term use of antibiotics should be avoided. One potential strategy is to gradually lower the dose of oral antibiotics after six to 12 weeks, eventually switching to topical agents only. A new technique is to use daily doxycycline given at a low dose, which may reduce inflammatory lesions when given alone or in combination with metronidazole therapy.

The two antibiotics that are most commonly used to treat rosacea are:

Tetracyclines

These include tetracycline, oxytetracycline, doxycycline, lymecycline and minocycline.

Tetracyclines are not suitable for:

  • women who are pregnant or breastfeeding, as they can cause birth defects in unborn children and interfere with normal bone development in breastfed children
  • people with a history of kidney disease

Tetracyclines should be used cautiously in people with:

Tetracyclines may cause oral contraceptives (the contraceptive pill) to fail during the first few weeks of treatment. Sexually active women of childbearing age should use a barrier method of contraception while taking tetracyclines, such as a condom, to avoid becoming pregnant.

Tetracyclines can also make your skin more sensitive to sunlight.

Tetracyclines can interact with a number of medications, including:

  • warfarin, an anticoagulant (blood-thinning medicine) used to stop your blood clotting
  • antacids, taken to treat indigestion and heartburn

Erythromycin

Erythromycin can be used in women who are pregnant or breastfeeding. It should be used cautiously if you have:

  • a history of liver or kidney problems
  • myasthenia gravis, a condition that causes some of your muscles to become weak 

Erythromycin can interact with a number of medications, including:

  • warfarin, an anticoagulant (blood-thinning medicine) used to stop your blood clotting
  • statins, taken to lower your cholesterol levels

Isotretinoin

Isotretinoin is a medicine often used to treat severe acne. However, at low doses it is also occasionally used to treat rosacea. As isotretinoin is a strong medication, it can only be prescribed by a dermatologist (an expert in treating skin conditions) and not your GP.

Isotretinoin can cause side effects, including:

  • birth defects in unborn babies
  • dry skin, lips and eyes
  • headaches
  • back pain
  • muscle or joint pain
  • bleeding and bruising more easily
  • blood in your urine

See the patient information leaflet that comes with your medicine for a full list of side effects.

Laser and intense pulsed light (IPL) treatment

The symptoms of redness and visible blood vessels (thread veins, telangiectasias) can be successfully improved with vascular laser or intense pulsed light (IPL) treatment. These treatments may also improve flushing. A referral to a dermatologist is usually required and is unlikely to be available on the NHS, so you may need to pay for it. Two to six treatments may be needed, so cost may be significant.

Laser and IPL machines produce narrow beams of light that are aimed at the visible blood vessels in the skin. The heat from the lasers damages the dilated (widened) red veins and causes them to shrink so they are no longer visible, with minimal damage to surrounding tissue or scarring. There is evidence that the light also helps with remodelling of the skin matrix so it provides vessels with better support.

Laser treatment can cause pain, but most people do not need an anaesthetic.

Side effects of laser treatment are usually mild and can include:

  • bruising
  • crusting of the skin
  • swelling and redness of the skin
  • blisters (in rare cases) 
  • infection (in very rare cases)

These side effects usually only last a few days and are rarely permanent. An infection will require treatment with antibiotics.

Make-up

It may be possible to disguise patches of persistent red skin using specially designed 'camouflage' make-up. The charity Changing Faces offers a skin camouflage service, available nationally and free of charge, to help with the use of these creams.

Your GP or dermatologist can refer you to the skin camouflage service and prescribe skin camouflage make-up.

Surgery

Thickened skin (rhinophyma) is a symptom of rosacea that often affects the nose. If you have severe rhinophyma, your GP may refer you to a dermatologist or plastic surgeon.

Plastic surgery is not the same as cosmetic surgery. Cosmetic surgery is surgery carried out by choice (elective) and undertaken for the sole purpose of improving a person's physical appearance. It is not usually available on the NHS. Plastic surgery is for repairing and reconstructing damaged skin and tissue.

A number of surgical treatments are available to remove any excess tissue and remodel the nose into a more pleasing shape. This may be done with:

  • a carbon dioxide laser (a beam of carbon dioxide)
  • a scalpel
  • dermabrasion

Ocular rosacea

If the rosacea symptoms affect your eyes (ocular rosacea), you may require further treatment such as:

  • ocular lubricants - eye drops or eye ointment which can be used to treat dry eyes
  • eye hygiene measures - if you have blepharitis (inflammation of the eyelids), you may need to clean your eyelids with a warm compress (a cloth warmed with hot water) or cotton bud 
  • long-term oral antibiotics may be used in severe cases

People who have ocular rosacea with complications will need referral to an opthalmologist (eye specialist).

Read about treating dry eye syndrome and treating blepharitis.

Medical Review: July 01, 2012
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