This paper is Part 2 in the series of Standard Management Options for Rosacea. Part 1 was devoted to the Overview and Broad Spectrum of Care. Now, Part 2 will expand to discuss management options according to the rosacea subtype.

Some History

Lets do some quick revision. In 2002, the National Rosacea Society Expert Committee reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes. In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.

The standard classification system for rosacea breaks rosacea down in to 4 sub types.

• Subtype 1: Erythematotelangiectatic Rosacea (ETTR)
• Subtype 2: Papulopustular Rosacea (PPR)
• Subtype 3: Phymatous Rosacea (PR)
• Subtype 4: Ocular Rosacea (OR)

Understanding that some rosacea  sufferers may have multiple subtypes, the overall management of rosacea symptoms should be keyed to the rosacea subtype in question.

So below is a summary of the 2009 Standard management options for rosacea, part 2. I have given a quick view of each section. For further details, including several disclaimers about the information supplied, see the full text of the paper.

The PDF can be read online here. I can also email a copy if you would like to read a copy for your own rosacea treatment.

Many of the rosacea experts credited as authoring this paper have links to pharmaceutical companies, and their links are listed. Interestingly Dr. Wilkin is listed as “a scientific and regulatory affairs consultant for 145 companies, including some that products for rosacea.” Wow that is a lot of consulting !

See also Standard Management Options 1: overview and broad spectrum of care.

Erythematotelangiectatic Rosacea

The following therapeutic approaches are listed according to the grade of the redness and broken blood vessels of ETTR.

Grade	Typical Features	Therapeutic Approach
1 – mild	Occasional mild flushing, faint persistent erythema, rare telangiectases	Identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation may be especially important in addition to an appropriate skin care regimen; nonirritating cosmetics may conceal the appearance of erythema and telangiectases
2 – moderate	Frequent troublesome flushing, moderate persistent erythema, several distinct telangiectases	In addition to above: long-pulsed dye or KTP lasers or IPL devices can remove telangiectases and reduce vascular erythema, and may reduce flushing
3 – severe	Frequent severe flushing pronounced persistent erythema; possible edema; many prominent telangiectases; possible burning, stinging, or scaling	In addition to above: flushing may be moderated by drugs specific to individual causes such as NSAIDs for dry flushing, alpha-agonists or beta blockers for neurally induced flushing, HRT for menopausal flushing; thermoregulatory flushing can be reduced by cooling the neck and mouth; emotionally induced flushing may benefit from psychological counseling or biofeedback

The committee notes that no drugs to reduce flushing have been approved by the FDA but off-label use may have some moderating effects for grade 2 and 3 flushing.

Papulopustular Rosacea

An approach of topical and oral therapies is detailed to bring the papules and pustules of rosacea into remission.

Additionally the following advice is offered for use a tetracycline other than the FDA approved-for-rosacea Oracea;

In some cases, oral drug therapy for grades 2 and 3 and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followedby 0.5 g/d for 2 to 3 weeks.

Some physicians may prescribe higher doses, longer courses, or other tetracyclines
such as doxycycline or minocycline.

Further, here you will find some less common known oral and topical therapies ;

In refractory cases, off label oral trimethoprimsulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

The possibility of some role for demodex, and the resulting therapy of topical permethrin and systemic ivermectin is also mentioned. Caution is suggested when using these potentially irritating agents.

This is the first time that I have seen the recommendation of demodex mite treatments in such a distinguished paper on rosacea.

Grade	Features	Therapeutic Approach
1 - mild	Few to several papules or pustules without plaques, mild persistent erythema	Topical therapy, possible with an antibiotic, to bring symptoms under control, and use topical medication alone to maintain remission; a controlled release anti-inflammatory dose of oral antibiotic may be used
2 - moderate	Several to many papules or pustules without plaques, moderate persisten erythema	In addition to above; possible an oral antibiotic in divided doses or an anti-inflammatory dose until remission is achieved, with or follow by long-term topical therapy
3 - severe	Numerous and/or extensive papules or pustules, sever persistent erythema, possible burning and stinging	In addition to above; in refractory cases, alternative oral and topical therapies may be used; skin care regimen may address burning and stinging.

Phymatous Rosacea

Grade 1 symptoms are treated with topical and systemic antibiotics.  We are told that Isotretinoin (accutane) has been shown to decrease nasal volume in younger patients with less advanced disease – although the volume may increase again after accutane is stopped. Topical retinoids may also reduce fibrosis, elastosis and sebaceous gland hypertrophy.

Grade	Features	Therapeutic Approach
1 - mild	Patulous follicles with no contour changes	Topical and systemic therapy as described for PPR if inflammatory lesions are present; carefully monitored isotretinoin may reduce incipient rhinophyma
2 - moderate	Change in contour without nodular component	In addition to above: may require surgical therapy, including cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting and dermabrasion; CO2 or erbium:YAG lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose.
3 - severe	Change in contour with nodular component	see above

Ocular Rosacea

We are reminded that ocular symptoms may appear before skin symptoms and that more than 60% of patients with skin symptoms of rosacea also may have ocular symptoms.

Grade	Features	Therapeutic Approach
1 - mild	Signs and symptoms affecting the eyelid margin and meibomian glands	Artificial tears and cleansing of eyelashes
2 - moderate	Signs and symptoms affecting the inner eyelid, tear secretion and/or ocular surface	In addition to above: ophthalmic antibiotic ointment may be applied to eyelashes; an oral antibiotic also may effective; if severity increases consultation with an ophthalmologist may be needed
3 - severe	Advanced or non responsive disease of the eyelid margin or ocular surface; episcleritis, iritis, or keratitis in addition to corneal damage and potential vision loss	Care by an ophthamologist is require and may include a topical steroid, alternative oral medications and potential surgery

Conclusion

As another stake in the ground, this paper will serve rosacea sufferers very well.

The committee suggests that the classification and grading of rosacea symptoms can help by subsequently leading to an effective management regime. Certainly attacking your rosacea symptoms by dividing and conquering the subtypes is a good place to start.

Those interested in a more thorough treatment of up to date rosacea treatment and diagnosis may be interested in my Book Review: Rosacea: Diagnosis and Management, Frank C. Powell which was written by one of the expert authors of this paper.

Standard management options for rosacea, part 2: options according to subtype.

Cutis. 2009 Aug;84(2):97-104.

Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J;

and further Collaborators

Bamford J, Berg M, Del Rosso J, Geronemus R, Goldberg D, Granstein R, James W, Kligman A, Mannis M, Marks R, Pelle M,Scheinfeld N, Sires B, Torok H, Wolf J, Yaar M

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss the standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) management options according to subtype. The menu of options is considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanisms of action of therapies are more definitively established.

[NEW]: Make way for Treating by Phenotype

Recent updates to the way that doctors are approaching their rosacea patients is to treat each phenotype separately.

Related Articles

• Standard Management Options 1: overview and broad spectrum of care
• Book Review: Rosacea Diagnosis and Management
• Standard Classification of Rosacea
• Rosacea Grading System
• Rosacea Phenotypes Explained
• How to diagnose Rosacea has radically changed (Phenotypes are now in)
• Rosacea Phenotype Report Card – track with your doctor