National Rosacea Society Publishes Updated Guideline on Standard Rosacea Management

The National Rosacea Society has released an update to their guideline on standard treatment options for rosacea, including new recommendations for topical therapies, oral therapies, and light-based devices. The guideline update was published in the Journal of the American Academy of Dermatology.

In this update, a panel of experts from the National Rosacea Society convened to review the literature regarding the efficacy and safety of various therapies for the treatment of rosacea. Some of the diagnostic features of rosacea included in this guideline’s new standard classification system included phymatous changes and fixed centrofacial erythema. Major features of rosacea outlined by the guideline committee included flushing, papules/pustules, telangiectasia, and ocular manifestations. In addition, secondary rosacea features mentioned in the classification system included burning sensation, stinging sensation, edema, dryness, and ocular manifestations.

Recommendations and Insights Into Light Devices

Devices and surgical interventions the committee agreed are the most effective for fixed phymas include ablative lasers such as CO2 and erbium, cold steel, electrosurgery, and radiofrequency. The ablative lasers may be appropriate for removing tissue and resculpting the rhinophymatous nose, the guideline reported.

Pulsed dye laser and potassium titanyl phosphate laser are the most well-established lasers in clinical practice. In some studies, the expert panel noted, these 2 lasers have been highly effective in reducing erythema. The most effective light therapies for telangiectasia, based on the experts’ conclusion from the literature, include intense pulsed light, pulsed dye laser, and potassium titanyl phosphate. Intense pulsed light may also be effective for reducing flushing and decreasing the impact meibomian gland disease has on activities of daily living.

Role of Oral and Topical Treatments

According to the panel, effective oral therapies for the major diagnostic feature of papules/pustules include azithromycin, doxycycline, minocycline, isotretinoin, and trimethoprim/sulfamethoxazole. Tetracycline and clindamycin were also mentioned as possibly effective oral treatment approaches to papules/pustules, but their efficacy profiles do not appear as strong as the others. The expert committee advises against using oral isotretinoin and tetracycline during pregnancy, because of concerns surrounding fetal and maternal toxicity.

Oral and topical combination therapies are often prescribed to patients with rosacea. Current FDA-approved topical treatments for persistent facial erythema in adults with rosacea include brimonidine topical gel 0.33% and oxymetazoline hydrochloride cream 1%. For inflammatory papules/pustules of rosacea, the FDA-approved topical therapies include azelaic acid 15%, ivermectin cream 1%, metronidazole 1% and 0.75%, and sodium sulfacetamide 10%.

In addition, the expert panel highlighted the off-label use of certain drugs for controlling flushing associated with rosacea. Drugs commonly prescribed for off-label use in controlling flushing include nonsteroidal anti-inflammatory drugs, antihistamines, clonidine, and β-blockers. The panel of experts noted that there are few data on the use of off-label oral antibiotics and retinoids in cases where first-line inflammation treatments are inadequate or when rosacea is severe.

Ocular Rosacea Recommendations

The committee continues to recommend eyelash hygiene and oral omega 3 supplementation for managing ocular rosacea. In terms of hygiene, the patient is recommended to apply a warm compress to the eyelids and to clean the eyelashes twice daily with baby shampoo. In addition, antibiotic ointment is suggested as a potentially helpful tool for reducing bacteria and softening collarettes. Following these mainstays of treatment, the committee also recommend topical azithromycin or calcineurin inhibitors.

Effective topical therapies for ocular rosacea described in the guideline include azithromycin, cyclosporin, and tacrolimus. Oral cyclosporin for 2 to 3 months was considered mildly effective for ocular rosacea, based on the current literature. The expert committee wrote that long-term use of oral cyclosporine can cause topical steroid rosacea-like reaction.

Lifestyle Management

In addition to medical care, the guideline recommends lifestyle changes, including avoidance of environmental factors that can trigger flares. Patients are recommended to keep a daily lifestyle and environmental exposure diary in an effort to identify personal triggers. Sun exposure, emotional stress, heavy exercise, alcohol consumption, hot weather, wind, cold weather, and spicy foods are all common factors associated with rosacea flares.

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Skin Care

Gentle skin care is recommended for managing rosacea, as patients with rosacea typically have sensitive skin that can be easily irritated.

Sunscreen continues to be a primary skin care recommendation for patients with rosacea, because sun exposure often increases flushing and erythema. Physical sunscreens containing either zinc oxide or titanium dioxide, rather than sunscreens with chemical filters, are recommended.

Gentle cleansers and nonocclusive moisturizers are also recommended to keep the skin cleansed and to maintain skin barrier integrity. The face should be allowed to dry completely after cleansing before applying a topical therapy.

“The new phenotype-based standard classification and management of rosacea provide important insights and guidance for the selection of treatments and broad spectrum of care to achieve optimal patient outcomes,” the guideline committee wrote in their conclusion.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Thiboutot D, Anderson R, Cook-Bolden F, et al.  Standard management options for rosacea: the 2019 update by the National Rosacea Society expert committee [published online February 6, 2020]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2020.01.077