2021 Guidelines of Rosacea Management

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Guidelines for the management of patients with rosacea are summarized.

The British Association of Dermatologists (BAD) published new 2021 guidelines for the management of patients with rosacea in the British Journal of Dermatology. In the report, the BAD guidelines outline recommendations for mitigating rosacea aggravation, classifying patients based on phenotypes, using topical and systemic therapies, and employing procedural interventions, among several other recommendations.

Summary of the BAD Rosacea Recommendations

Recommendations made in the BAD guidelines were based on a systematic literature review of the rosacea literature, which included articles published up to February 2020. The recommendations were designed to be implemented in the UK National Health Service.

Key stakeholders involved in the development of the BAD guidelines included consultant dermatologists, a consultant ophthalmologist, patient representatives, as well as a guideline research fellow and a project manager.

General recommendations in the BAD guidelines include:

  • Dermatologists and other clinicians should advise patients with rosacea to limit exposure to factors known to aggravate their disorder. These factors may include sun exposure, hot drinks, alcohol, and spicy food.
  • As the optimal duration of antibiotic therapy in patients with rosacea remains unknown, clinicians should avoid long-term use of oral antibiotics in this patient population. The pros and cons of long-term oral antibiotic therapy should be carefully evaluated in each patient.
  • Classification of rosacea phenotypes should include objective clinical signs and subjective symptoms of the patient.
  • Diagnostic phenotypes of rosacea could include characteristic fixed centrofacial erythema or phymatous changes, along with additional features such as flushing, papules or pustules, telangiectasia, burning or stinging sensations, ocular changes, edema, and skin dryness.
  • Dermatologists and other clinicians should advise patients with rosacea to wash the skin with emollients, moisturize regularly, and use sunscreen and other sun protective measures daily. Clinicians should advise patients with rosacea to avoid soaps and cleansers with surfactants or detergents, as these could worsen symptoms.
  • Referral to extern psychosocial support or psychiatric services could be helpful for managing “hidden” symptoms associated with rosacea, including anxiety and depression. Primary care is typically the initial setting for when these symptoms are/can be identified.

In addition, the BAD 2021 guidelines on rosacea provide several recommendations in regard to topical and systemic therapies:

  • In patients with papulopustular rosacea, recommended first-line topical therapies include ivermectin, metronidazole, or azelaic acid. Clinicians should discuss the risk for irritancy with different topical treatments and formulations before prescribing these agents to patients.
  • Topical minocycline foam could be considered in patients with papulopustular rosacea.
  • In patients with rosacea who predominantly present with facial erythema, topical brimonidine or topical oxymetazoline may be considered.
  • Several oral antibiotics can be considered as first-line treatments for severe papulopustular rosacea, including azithromycin, clarithromycin, daily 40 mg doxycycline (modified release), daily 100 mg doxycycline, erythromycin, lymecycline, and oxytetracycline.
  • If other treatment options are available, systemic minocycline should be avoided in patients with rosacea, given the therapy’s potential for adverse effects.
  • Intermittent courses of low-dose isotretinoin could be considered in patients with persistent and severe rosacea.

The BAD guidelines also offer some recommendations on certain procedures and ocular therapies:

  • Pulsed dye laser, neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, or intense pulsed light could be considered in patients with rosacea who primarily present with persistent facial erythema.
  • Nasal debulking by laser surgical intervention or laser ablation could be considered in some patients who have significant rhinophyma.
  • In patients with ocular rosacea, dermatologists and other clinicians should advise patients to reduce exposure to air conditioning, excessive indoor heating, periocular cosmetics, and smoky environments.
  • Where feasible and appropriate, clinicians should consider identifying and modifying/discontinuing systemic drugs that may trigger eye dryness, such as anxiolytics and antidepressants.
  • Over-the-counter ocular lubricants or liposomal sprays could be recommended to help reduce symptoms in patients with ocular rosacea. Preservative-free products should be emphasized if the products will be used more than 6 times per day.
  • Patients should be referred to an ophthalmologist if they have prolonged symptoms despite frequent use of topical lubricants and adequate lid hygiene and/or if the patient is experiencing reduced vision, pain when moving the eyes, and pain that prevents sleep.

Gaps in current rosacea research were also identified by the BAD. In the guideline, the writing committee identified key research areas that could inform future rosacea management guidelines:

  • Topical ivermectin on ocular rosacea
  • Topical/systemic/procedural interventions on transient erythema
  • Rhinophyma
    • Impact on psychological wellbeing
    • Effect of treatment
    • Optimal choice of surgical or laser interventions
  • Cost-effectiveness of rosacea treatments in UK patients
  • Etiology, pathophysiology, and psychological issues of rosacea
  • Treatment of sensory symptoms

The BAD guideline committee noted that the proposed revision of these recommendations is set for some time in 2026, but important updates may be necessary in the interim. Considering the duration between guideline publication and the proposed update, the BAD added that “it is recognized that under certain conditions it may be necessary to deviate from the guidelines and that the results of future studies may require some of the recommendations herein to be changed.”

Disclosure: Multiple authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.


Hampton PJ, Berth-Jones J, Duarte Williamson CE, et al. British Association of Dermatologists guidelines for the management of people with rosacea 2021. Br J Dermatol. Published online May 15, 2021. doi:10.1111/bjd.20485