Managing acne rosacea

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Reference: May 2025 | Issue 5 | Vol 11 | Page 35

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Acne rosacea, often simply called rosacea, is a common dermatological condition that typically presents in adults between the ages of 30 and 50, with a higher prevalence among fair-skinned individuals.¹ The condition is characterised by persistent facial erythema, papules, pustules, and telangiectasia, which may progress to more severe forms such as phymatous rosacea.

Although the disease is not life-threatening, it can significantly impact patients’ quality of life, leading to psychological distress, social embarrassment, and functional impairment.²

The exact cause of acne rosacea remains elusive, but it is thought to be multifactorial, involving genetic, environmental, and inflammatory components. The pathogenesis is believed to involve an exaggerated immune response, dysregulated vascular responses, and possibly microbial factors, including the role of Demodex mites.³

Given the chronic nature of rosacea and its potential for exacerbation, early intervention is crucial. Treatment primarily focuses on controlling inflammation, reducing erythema, and preventing disease progression. Traditional treatments include topical therapies such as metronidazole and oral antibiotics like tetracyclines. In recent years, novel treatments, including brimonidine and biologics, have been introduced to better address the underlying inflammatory processes and provide more targeted therapy.⁴

Pathophysiology

Recent advances in genome-wide association studies have identified several genetic variants that may predispose individuals to acne rosacea, particularly those related to immune response and vascular regulation,⁵ suggesting that alterations in genes involved in inflammatory pathways, such as those encoding for cytokines and immune system receptors, may play a central role in the development of rosacea.

Environmental factors are known to trigger or exacerbate rosacea symptoms, with sun exposure being one of the most common and well-documented triggers, as ultraviolet radiation leads to the dilation of blood vessels, causing erythema and the appearance of telangiectasias.⁶ Other triggers include spicy foods, hot beverages, alcohol, and extreme weather conditions, all of which can provoke an inflammatory response that worsens symptoms, while stress – particularly anxiety and emotional distress – can exacerbate flares by promoting vasodilation and increased vascular permeability.

The central pathophysiological mechanisms of acne rosacea are thought to involve an exaggerated vascular response, with vasodilation and inflammation at the core of the condition. Dysregulation of vascular tone is characterised by increased telangiectasia and erythema, and a key contributor is the elevated expression of pro-inflammatory cytokines like interleukin-1 and tumour necrosis factor-alpha, which recruit inflammatory cells.⁷

Studies suggest that Demodex mites are found in higher numbers in rosacea patients, and may trigger the inflammatory response by compromising skin barriers, while recent research has also highlighted the role of the skin microbiome, particularly the interaction between Demodex, bacteria, and the immune system.⁸ In addition, other evidence links Helicobacter (H) pylori to rosacea, with reports suggesting that eradication of H pylori may improve symptoms, especially in patients with digestive complaints, although further research is needed to confirm this association.⁹

Acne rosacea is characterised by distinct clinical features that vary in severity and presentation, typically manifesting in four main subtypes, although patients may show overlapping characteristics from more than one subtype. The disease often progresses from early signs like erythema and flushing to more severe changes such as papules, pustules, and phymatous alterations.

Classification

• Subtype 1: Erythematotelangiectatic rosacea is marked by persistent erythema and telangiectasia on the central face, including the cheeks, nose, and forehead, with frequent flushing triggered by environmental factors like heat, spicy food, and alcohol. Telangiectasia may become more prominent over time.
• Subtype 2: Papulopustular rosacea presents with inflamed papules and pustules resembling acne, but without comedones, and it is often mistaken for acne vulgaris, although it typically includes more intense facial redness that worsens with inflammation.
• Subtype 3: Phymatous rosacea involves thickened, coarse skin texture and often affects the nose, leading to rhinophyma – an enlarged, bulbous nose due to sebaceous gland hypertrophy – with potential involvement of the chin and ears, contributing to notable cosmetic disfigurement.
• Subtype 4: Ocular rosacea affects the eyes and presents with dryness, irritation, redness, and a gritty sensation, which in severe cases may progress to conjunctivitis, keratitis, or corneal damage. While ocular involvement often coexists with cutaneous manifestations, it may also occur in isolation.¹⁰

Diagnosis

The diagnosis of acne rosacea is primarily based on the patient’s history and physical examination as there are no specific laboratory tests for rosacea. However, differential diagnoses such as acne vulgaris, lupus erythematosus, and seborrhoeic dermatitis must be considered to exclude other conditions with similar features.¹¹ To assist in diagnosis, dermoscopy has been gaining popularity as a non-invasive technique to observe microvascular patterns and characteristic features of rosacea.

The US National Rosacea Society diagnostic criteria require the presence of at least one major and one minor criterion for a rosacea diagnosis. Major criteria include flushing, persistent erythema, papules and pustules, and telangiectasia, while minor criteria include burning or stinging, dry appearance, oedema, and ocular symptoms such as dry eyes or conjunctivitis.

For patients presenting with ocular symptoms, a thorough eye examination is essential to assess the degree of ocular involvement. Diagnostic tools such as the Schirmer test to measure tear production and lid margin biopsy can aid in confirming ocular rosacea with common findings including meibomian gland dysfunction and conjunctival hyperaemia.¹² In cases of suspected ocular rosacea, an ophthalmologic evaluation is crucial, especially when symptoms such as conjunctivitis or corneal damage are present.¹³

Treatment

The treatment of acne rosacea focuses on controlling symptoms and preventing disease progression. There is no cure, but a variety of therapies are available to manage the condition. Treatment plans should be individualised based on the subtype and severity of the disease, and should focus on reducing symptoms, controlling flare-ups, and preventing long-term complications such as skin thickening or permanent erythema.

Topical metronidazole (0.75% gel or cream) remains a first-line treatment for most patients with papulopustular rosacea. It is well-tolerated and can significantly reduce inflammatory lesions and erythema. Azelaic acid (15% gel) is an effective alternative or adjunct for reducing the appearance of papules, pustules, and erythema. It is often recommended for patients who cannot tolerate metronidazole.

Ivermectin (1% cream) is increasingly used in combination with other topical treatments for its efficacy against both inflammatory lesions and the Demodex mite. For patients with moderate to severe rosacea, or for those who fail to respond to topical treatments, oral therapies may be necessary.

Low-dose doxycycline (40mg daily) has shown significant efficacy in reducing inflammatory lesions and improving skin appearance, with fewer side effects compared to higher doses. Minocycline and tetracyclines are also commonly used to manage moderate to severe papulopustular rosacea, although doxycycline remains the most widely prescribed.

For patients with phymatous rosacea and rhinophyma, early intervention is key to preventing progression and disfigurement. Topical retinoids such as tretinoin can be effective in controlling skin thickening in the early stages of rhinophyma by promoting cell turnover and reducing sebaceous gland hyperplasia. In more severe cases, laser therapy (such as CO² laser or pulsed dye laser) may be employed to treat skin thickening and telangiectasia. Laser therapy can help improve the texture and appearance of the skin, reducing the need for surgery in many cases. Surgical procedures (such as dermabrasion or electrosurgery) may be considered for advanced rhinophyma if other treatments fail.

Ocular rosacea requires a comprehensive approach, as untreated cases can lead to vision-threatening complications. Management strategies include lubricating eye drops and oral tetracyclines to reduce inflammation in the meibomian glands. Ocular corticosteroids may be used in severe cases under ophthalmologist supervision, although long-term use is discouraged due to potential side effects like cataracts. Lid hygiene and warm compresses help maintain the health of the eyelid margins and reduce inflammation.¹⁴

Latest developments

In recent years, significant progress has been made in the treatment of acne rosacea. New therapies have emerged, and ongoing research continues to improve understanding of the condition’s pathogenesis, providing hope for more effective treatments.

Brimonidine gel (3mg/g) works by selectively constricting blood vessels to reduce redness and facial flushing. It has shown promising results in clinical trials, with some patients experiencing improvements in erythema and overall appearance within hours of application. It is primarily used for short-term flare management and as part of an integrated treatment regimen.¹⁵

Oxymetazoline (1%), another vasoconstrictor, is a newer treatment for persistent erythema in rosacea. Studies have demonstrated its efficacy in reducing facial redness by targeting alpha-adrenergic receptors in blood vessels, leading to a decrease in visible redness. It has a rapid onset of action and is well tolerated by patients.¹⁶

Research is exploring the benefits of combining both brimonidine and oxymetazoline in treating rosacea. Preliminary studies suggest that this combination therapy may provide a more durable effect on both erythema and papulopustular lesions.

Intense pulsed light and pulsed dye laser therapies have also become more widely used in managing rosacea-associated erythema and telangiectasia.¹⁷ These non-invasive treatments target the blood vessels under the skin, providing improvement in redness without the need for prolonged topical treatments.

Lifestyle factors

While medications play a central role in managing rosacea, lifestyle and environmental factors should also be considered. Education about triggers is vital. Patients with acne rosacea should also be advised to use mild, non-abrasive cleansers and avoid harsh skincare products or scrubs that can irritate the skin; to moisturise regularly to protect the skin’s barrier and prevent dryness; and to minimise the use of cosmetics, especially those containing alcohol, as they can irritate the skin and worsen rosacea symptoms.

As rosacea is a chronic condition, ongoing monitoring is crucial. Regular follow-up visits are recommended to assess treatment efficacy, monitor for potential side effects, and adjust the management plan as necessary.¹⁸

Emerging evidence and research

Another significant development is the FDA approval of Emrosi, a low-dose extended-release minocycline, for treating inflammatory lesions associated with rosacea. Two Phase 3 trials demonstrated Emrosi’s superiority over both doxycycline and placebo in reducing lesion count and erythema, with a favourable safety profile.¹⁹

Also in the realm of novel pharmacological approaches, a case series reported the use of Janus Kinase inhibitors, specifically upadacitinib and abrocitinib, in patients with refractory rosacea. Both treatments led to rapid improvements in erythema, flushing, and pruritus, with upadacitinib showing sustained benefits even after dose reduction.²¹ Additionally, a Phase I clinical trial assessed the safety and tolerability of topical trametinib, a mitogen-activated protein kinase inhibitor, in rosacea patients. The study concluded that trametinib was well-tolerated, suggesting its potential as a targeted treatment option.²²

Another recent study investigated the efficacy of a repairing facial mask in patients with mild to moderate rosacea. This two-centre randomised controlled trial found that the mask, when used alongside oral minocycline, significantly improved skin barrier function, reduced erythema, and alleviated flushing and dryness, with no reported adverse events.²⁰ These studies underscore the ongoing research and development in rosacea treatments, offering promising new options for patients with varying disease severities and treatment responses.

Conclusion

Acne rosacea is a complex and chronic inflammatory skin condition with a range of clinical manifestations. Treatment is tailored to the subtype and severity of rosacea, with topical therapies like metronidazole, azelaic acid, and ivermectin remaining first-line options. Oral antibiotics, especially doxycycline, are reserved for moderate to severe cases, while advanced treatments like laser therapy offer promising outcomes for phymatous rosacea.

As new therapies continue to emerge, acne rosacea treatment is becoming more individualised, allowing for better long-term management and quality of life for patients. Early intervention and a multidisciplinary approach are essential for optimal outcomes.