Rosacea is a chronic rash of the central face that tends to affect people over 30. It is characterised by recurrent episodes of facial flushing, erythema, telangiectasia, papules and pustules. Blepharitis may be associated. Rule out acne vulgaris (presence of open comedones) before commencing treatment. There are three main subtypes, which can overlap:

Erythematotelangectatic rosacea - this lacks inflammatory papules and pustules and tends to be associated with fair and very sensitive skin. Topical treatments are often unsuccessful.

Papulopustular – this is more like acne, and tends to respond to the treatments listed below

Rhinophymatous – thickening of sebaceous skin, particularly round the nose.

General advice to those with rosacea includes:

• Avoidance of triggers that cause flushing (will vary from patient to patient)
• Minimise UV exposure
• Avoidance of occlusive make-up (for the papulopustular variant)
• Avoidance of topical steroids on the area

Mild papulopustular rosacea

Metronidazole 0.75% gel / cream

• Apply twice daily for 3-4 months
• See section 13.10.1 Antibacterial preparations

Azelaic acid 15% gel

• Apply twice daily (sensitive skin, once daily until irritation ceases)
• See section 13.6.1 Topical preparations for acne

Moderate or severe papulopustular rosacea

Topical treatments

Metronidazole 0.75 % gel / cream

• Apply twice daily for 3-4 months
• See section 13.10.1 Antibacterial preparations

Ivermectin 1% cream

• Apply once daily for 4 months; discontinue after 3 months if no improvement is seen
• See section 13.6.3 Topical preparations for rosacea
• May be used as an alternative to metronidazole in moderate disease

Systemic treatments

Lymecycline (unlicensed)

• 408mg once daily. Review at 2 months and continue for a total of 3 months if responding well. Repeat 3 monthly course when rosacea flares
• May be taken with food but avoid antacids, iron and zinc at the same time
• NICE Clinical Knowledge Summaries recommend a number of oral tetracyclines for the management of rosacea including lymecycline
• See section 5.1.3 Tetracyclines

Doxycycline 40mg modified release

This preparation is licensed for the treatment of rosacea. A course of doxycycline 40mg modified release is almost three times more expensive than a course of lymecycline.