(IGA) score of 1 (almost clear) or 0 (clear) in four randomized clinical trials of treatment with ivermectin 1% cream, metronidazole 0.75% cream, or vehicle. Evaluations included time to relapse, the Dermatology Life Quality Index (DLQI) and subject assessment of improvement in rosacea. Patients with complete clearing had almost half a year longer relapse-free period compared to those rated ‘almost clear’ (>8 months vs 3 months, P<.0001). In addition, quality of life was significantly better in the ‘clear’ group. A clinically relevant improvement in DLQI score was statistically significantly more likely in those who achieved ‘clear’ compared to ‘almost clear’ (59% vs 44%, P<.001). Further, a large majority of those rated ‘clear’ (84%) had a final DLQI score of 0-1, indicating rosacea no longer adversely affected their quality of life (P<.001 vs ‘almost clear’ at 66%). The authors noted that improving treatment with “earlier effective treatment and longer remission times might not only control symptoms, but also delay progression of disease.†Notably, a comparative study of ivermectin 1% cream QD versus metronidazole 0.75% cream BID in subjects with moderate to severe rosacea showed that more subjects were judged “clear†with ivermectin (34.9% vs 21.7% with metronidazole).32 The difference in treatment efficacy was even more marked in the subgroup of individuals with severe rosacea, where clearing was 27.5% with ivermectin vs 12.3% with metronidazole.32
Topical treatments for rosacea target papules/pustules and include metronidazole 0.75% cream, ivermectin 1% cream, azelaic acid 15% gel and foam, and sodium sulfacetamide 10% with or without sulfur 5%. Topical treatments for erythema include brimonidine 0.33% gel and oxymetazoline 1% cream. These treatments can be combined for best results, and the recent MOSAIC study showed that initiation of therapy with a combination regimen of ivermectin 1% cream plus brimonidine 0.33% gel was associated with superior efficacy and good patient acceptance.33 In addition, medical and physical therapies may be used together for good results.34,35 Commonly used oral therapies for rosacea include tetracycline-type agents in an antibiotic dose and in a sub-antimicrobial dose. Clinician-directed skin care (cleanser, moisturizer, sun protection) should be a part of the rosacea regimen to improve therapeutic outcomes and decrease the likelihood of skin irritation.11 Treatment can now be individualized to the patient’s presentation, taking into account the specific signs and symptoms present, trigger factors, and patient preferences.
Topical treatments for rosacea target papules/pustules and include metronidazole 0.75% cream, ivermectin 1% cream, azelaic acid 15% gel and foam, and sodium sulfacetamide 10% with or without sulfur 5%. Topical treatments for erythema include brimonidine 0.33% gel and oxymetazoline 1% cream. These treatments can be combined for best results, and the recent MOSAIC study showed that initiation of therapy with a combination regimen of ivermectin 1% cream plus brimonidine 0.33% gel was associated with superior efficacy and good patient acceptance.33 In addition, medical and physical therapies may be used together for good results.34,35 Commonly used oral therapies for rosacea include tetracycline-type agents in an antibiotic dose and in a sub-antimicrobial dose. Clinician-directed skin care (cleanser, moisturizer, sun protection) should be a part of the rosacea regimen to improve therapeutic outcomes and decrease the likelihood of skin irritation.11 Treatment can now be individualized to the patient’s presentation, taking into account the specific signs and symptoms present, trigger factors, and patient preferences.
CONCLUSIONS
Rosacea is a complex disease that is often under-diagnosed,
particularly in dark-skinned individuals. For best outcomes, it
is important for clinicians to be able to recognize rosacea and
differentiate it from other diseases with similar presentations.
Patients with rosacea typically have multiple signs and symptoms
that require different therapies, which may include medical
and physical approaches as shown in the MOSAIC Study. In addition, clinicians may need to have different discussions with
patients, depending on what manifestations are present at the
given time. Optimally, all signs/symptoms should be addressed
at the same time to increase patient satisfaction with outcomes.
Today there are different drugs with targeted mechanisms of
action and complete clearance is a realistic, achievable clinical
goal.
DISCLOSURES
Editorial services for this publication were provided by Galderma
Laboratories. All authors have served as consultants for
Galderma. The authors wish to acknowledge Valerie Sanders,
Sanders Medical Writing, for assistance with preparation of this
publication.
REFERENCES
1. Del Rosso JQ, Gallo RL, Kircik L, et al. Why is rosacea considered to be an inflammatory disorder? The primary role, clinical relevance, and therapeutic correlations of abnormal innate immune response in rosacea-prone skin. J Drugs Dermatol. 2012;11:694-700.
2. Napierkowski DB. Rosacea: Diagnosis and management. Nurse Pract. 2016;41:8-13.
3. Navaratna AF, Walsh A , Magin P. More than meets the (painful red) eye. Aust Fam Physician. 2016;45:383-4.
4. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-8.
5. Tan J, Steinhoff M, Berg M, et al. Shortcomings in rosacea diagnosis and classification. Br J Dermatol. 2017;176:197-9.
6. Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician. 2002;66:435-40.
7. Berg M , Liden S. An epidemiological study of rosacea. Acta Dermato-venereologica. 1989;69:419-23.
8. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 1: a status report on the disease state, general measures, and adjunctive skin care. Cutis. 2013;92:234-40.
9. Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol. 1987;17:70-3.
10. Tidman MJ. Improving the management of rosacea in primary care. Practitioner. 2014;258:27-30,3.
11. Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermaotl. 2012;5:16-25.
12. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46:584-7.
13. Quarterman MJ, Johnson DW, Abele DC, et al. Ocular rosacea. Signs, symptoms, and tear studies before and after treatment with doxycycline. Arch Dermatol.1997;133:49-54.
14. Alexis AF. Rosacea in patients with skin of color: uncommon but not rare. Cutis. 2010;86:60-2.
15. Taylor SCD, J. N. Acne and rosacea: a closer look at skin of color. Medscape 2012.
16. Del Rosso JQ. Advances in understanding and managing rosacea: part 2: the central role, evaluation, and medical management of diffuse and persistent facial erythema of rosacea. J Clin Aesthet Dermatol. 2012;5:26-36.
17. National Rosacea Society. Rosacea triggers survey.
18. Kligman AM. Ocular rosacea. Current concepts and therapy. Arch Dermatol. 1997;133:89-90.
19. Kuflik JH. Acneiform eruptions clinical presentation. Medscape 2016.
20. Friedman P, Sabban EC, Cabo H. Usefulness of dermoscopy in the diagnosis and monitoring treatment of demodicidosis. Dermatol Pract Concept. 2017;7:35-8.
21. Errichetti E , Stinco G. Dermoscopy in general dermatology: a practical overview. Dermatol Ther (Heidelb). 2016;6:471-507.
22. Zhao YE, Wu LP, Peng Y, et al. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol. 2010;146:896-902.
23. Walling HW, Sontheimer RD. Cutaneous lupus erythematosus: issues in di-
2. Napierkowski DB. Rosacea: Diagnosis and management. Nurse Pract. 2016;41:8-13.
3. Navaratna AF, Walsh A , Magin P. More than meets the (painful red) eye. Aust Fam Physician. 2016;45:383-4.
4. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-8.
5. Tan J, Steinhoff M, Berg M, et al. Shortcomings in rosacea diagnosis and classification. Br J Dermatol. 2017;176:197-9.
6. Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician. 2002;66:435-40.
7. Berg M , Liden S. An epidemiological study of rosacea. Acta Dermato-venereologica. 1989;69:419-23.
8. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 1: a status report on the disease state, general measures, and adjunctive skin care. Cutis. 2013;92:234-40.
9. Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol. 1987;17:70-3.
10. Tidman MJ. Improving the management of rosacea in primary care. Practitioner. 2014;258:27-30,3.
11. Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermaotl. 2012;5:16-25.
12. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46:584-7.
13. Quarterman MJ, Johnson DW, Abele DC, et al. Ocular rosacea. Signs, symptoms, and tear studies before and after treatment with doxycycline. Arch Dermatol.1997;133:49-54.
14. Alexis AF. Rosacea in patients with skin of color: uncommon but not rare. Cutis. 2010;86:60-2.
15. Taylor SCD, J. N. Acne and rosacea: a closer look at skin of color. Medscape 2012.
16. Del Rosso JQ. Advances in understanding and managing rosacea: part 2: the central role, evaluation, and medical management of diffuse and persistent facial erythema of rosacea. J Clin Aesthet Dermatol. 2012;5:26-36.
17. National Rosacea Society. Rosacea triggers survey.
18. Kligman AM. Ocular rosacea. Current concepts and therapy. Arch Dermatol. 1997;133:89-90.
19. Kuflik JH. Acneiform eruptions clinical presentation. Medscape 2016.
20. Friedman P, Sabban EC, Cabo H. Usefulness of dermoscopy in the diagnosis and monitoring treatment of demodicidosis. Dermatol Pract Concept. 2017;7:35-8.
21. Errichetti E , Stinco G. Dermoscopy in general dermatology: a practical overview. Dermatol Ther (Heidelb). 2016;6:471-507.
22. Zhao YE, Wu LP, Peng Y, et al. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol. 2010;146:896-902.
23. Walling HW, Sontheimer RD. Cutaneous lupus erythematosus: issues in di-
