British guidelines for the management of rosacea

Reference

Hampton PJ, Berth-Jones J, Duarte Williamson CE, et al, for the British Association of Dermatologists’ Clinical Standards Unit. British Association of Dermatologists guidelines for the management of people with rosacea 2021. Br J Dermatol 2022;185(4):725-735.

Synopsis

This was a generally well-constructed guideline, based on systematic reviews, but without any primary care representation in the guideline panel (a dermatologist, an ophthalmologist, a patient representative, and methodologists). The authors recommend that persons with rosacea avoid known triggers, which can include alcohol, sun exposure, hot drinks, and spicy food. Treatment should be based on the patient's diagnostic phenotype (erythematotelangiectatic/vascular, papulopustular/inflammatory, ocular, phymatous), as well as other features such as the presence of papules or pustules, flushing, ocular involvement, burning or stinging, edema, dryness, and the presence of telangectasias. First-line therapy for papulopustular rosacea consists of topical metronidazole, azelaic acid, or ivermectin, with topical minocycline foam as a further option. For patients with more severe papulopustular rosacea, oral antibiotics (azithromycin, clarithromycin, doxycycline, erythromycin, lymecycline, and oxytetracycline) are recommended as first-line therapy, with no evidence of superiority for any specific antibiotic. Minocycline should be avoided because of a higher risk of adverse effects. For patients with a primary presenting symptom of facial erythema, topical brimonidine or oxymetazoline is recommended. For patients with transient facial erythema as the primary symptom, oral propanolol is an option. For patients with persistent severe rosacea, intermittent courses of low-dose isotretinoin (0.25 mg/kg) are a treatment option. Persons with ocular rosacea should avoid environmental factors such as cosmetics or dry or smoky air. Local treatments for ocular rosacea include warm compresses, lid hygiene, ocular lubricants, and liposomal sprays. Finally, laser therapy for facial erythema and laser or surgical debulking for rhinophyma are recommended treatment options.