Treatment of acne rosacea should be based on the phenotype: best evidence summary

Reference

van Zuuren EJ, Fedorowicz Z, Tan J, et al. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assignments. Br J Dermatol 2019; 181(1):65-79.

Synopsis

Recent guidelines (J Clin Aesthet Dermatol 2019;12(6):17–24) recommend an approach to the management of acne rosacea based on the patient's phenotype; that is, the specific constellation of symptoms the patient exhibits. This systematic review included 46 new studies and examined the best available evidence for each phenotype. Transient erythema and flushing: no relevant clinical trials. Persistent erythema: strong evidence for brimonidine gel and moderately strong evidence for oxymetazoline cream, with good safety. Persistent erythema and telangiectasia: generally low-quality evidence supports pulsed dye laser, neodymium-doped yttrium aluminum garnet laser (Nd:YAG), and intense pulsed light therapy, with the greatest benefit for telangiectasia. Papules and pustules: high-level evidence supports topical azelaic acid and ivermectin; moderate-quality evidence supports topical minocycline and metronidazole. The evidence for systemic therapy of papules and pustules is stronger for doxycycline 100 mg (or 40 mg modified release) and minocycline 100 mg than for tetracycline. For ophthalmic rosacea, cyclosporin 0.05% emulsion is more effective than oral doxycycline. For maintenance therapy of papules and pustules, consider topical metronidazole 0.75%, azelaic acid 15% gel, or topical ivermectin 1%.