Rosacea: classification and treatment

Efficacy and safety of botulinum toxin for rosacea with positive impact on quality of life and self-esteem

BACKGROUND

Rosacea is a prevalent chronic inflammatory skin disease with a multifactorial pathophysiology. It compromises several skin structures, including the proliferation and dilation of dermal blood vessels, primarily in the central areas of the face, accompanied by significant psychosocial impairment, leading to reduced quality of life (QoL) and self-esteem. There are consensus guidelines for its treatment, but few options for the erythema. This study hypothesizes that treating rosacea skin lesions with botulinum toxin (BTX) could improve signs and symptoms, resulting in enhanced QoL and self-esteem.

METHODS

This interventional, open, uncontrolled, and prospective study, conducted at a single center, included 33 individuals diagnosed with rosacea, treated with standard therapeutic options according to the rosacea subtype plus superficial injections of BTX, and followed up for 90 days. Botulinum toxin injections were applied on Days 1 and 14. Clinical features and side effects were assessed at each visit; QoL, self-esteem, and medication adherence questionnaires were administered on Days 1 and 90.

RESULTS

Treatment with BTX yielded improvement in the clinical signs of rosacea, registered by the investigators, and reported by 94% of the participants. Improved QoL scores (P < 0.05) and a notable increase in self-esteem scores (P < 0.001) were demonstrated. Rare adverse events were observed.

CONCLUSIONS

The utilization of BTX superficial injections in patients with rosacea was safe and effective, improving the clinical appearance of the lesions. Despite some limitations, to our knowledge, this is the first study that showed the positive impact of this treatment modality on both QoL and self-esteem.

Anti-Inflammatories in the Treatment of Dry Eye Disease: A Review

Inflammation is an important driver of dry eye disease (DED) pathogenesis. An initial insult that results in the loss of tear film homeostasis can initiate a nonspecific innate immune response that leads to a chronic and self-sustaining inflammation of the ocular surface, which results in classic symptoms of dry eye. This initial response is followed by a more prolonged adaptive immune response, which can perpetuate and aggravate inflammation and result in a vicious cycle of chronic inflammatory DED. Effective anti-inflammatory therapies can help patients exit this cycle, and effective diagnosis of inflammatory DED and selection of the most appropriate treatment are therefore key to successful DED management and treatment. This review explores the cellular and molecular mechanisms of the immune and inflammatory components of DED, and examines the evidence base for the use of currently available topical treatment options. These agents include topical steroid therapy, calcineurin inhibitors, T cell integrin antagonists, antibiotics, autologous serum/plasma therapy, and omega-3 fatty acid dietary supplements.

An insight on topically applied formulations for management of various skin disorders

Various types of skin disorders across each age group and in each part of geographical world are very dreadful. Despite not being fatal each time they are always of social and mental concern for suffering individuals, causing complications in millions of patients every day and require comparatively longer duration of treatment. Off late, various topical/transdermal formulations have been widely explored for the treatment of various skin ailments. The efficiency of topical therapy depends on various physiochemical properties of drugs like particle size, particle size distribution, partition coefficient, viscosity of dosage form, skin permeability, skin condition and the site of application. Therefore, in plenty of examples, long-acting topical formulations have shown to be markedly excellent in comparison to conventional dosage forms. The major advantages of topical formulations accrue from their demonstrated ability: (i) Reduced serious side effects that may occur due to undesirably higher systemic absorption of drug. (ii) Enhancement of drug accumulation at the desired site. (iii) Easy incorporation of enormous range of hydrophilic and hydrophobic drugs and (iv) Reduced risk of dose dumping and comparatively easy termination of drug release. The prospective applications of topically applied formulations and the deposition of pharmaceuticals into the skin are examined.

The Development of Third-Generation Tetracycline Antibiotics and New Perspectives

The tetracycline antibiotic class has acquired new valuable members due to the optimisation of the chemical structure. The first modern tetracycline introduced into therapy was tigecycline, followed by omadacycline, eravacycline, and sarecycline (the third generation). Structural and physicochemical key elements which led to the discovery of modern tetracyclines are approached. Thus, several chemical subgroups are distinguished, such as glycylcyclines, aminomethylcyclines, and fluorocyclines, which have excellent development potential. The antibacterial spectrum comprises several resistant bacteria, including those resistant to old tetracyclines. Sarecycline, a narrow-spectrum tetracycline, is notable for being very effective against Cutinebacterium acnes. The mechanism of antibacterial action from the perspective of the new compound is approached. Several severe bacterial infections are treated with tigecycline, omadacycline, and eravacycline (with parenteral or oral formulations). In addition, sarecycline is very useful in treating acne vulgaris. Tetracyclines also have other non-antibiotic properties that require in-depth studies, such as the anti-inflammatory effect effect of sarecycline. The main side effects of modern tetracyclines are described in accordance with published clinical studies. Undoubtedly, this class of antibiotics continues to arouse the interest of researchers. As a result, new derivatives are developed and studied primarily for the antibiotic effect and other biological effects.

The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review

Rosacea, a chronic condition usually recognized by its visible presentation, can be accompanied by invisible symptoms, such as burning and stinging. The aim of this review is to gather the most recent evidence on burning and stinging, in order to further emphasize the need to address these symptoms. Inflammatory pathways can explain both the signs and symptoms of rosacea, but available treatments are still evaluated primarily on their ability to treat visible signs. Recent evidence also highlights the adverse impact of symptoms, particularly burning and stinging, on quality of life. Despite an increasing understanding of symptoms and their impact, the management of burning and stinging as part of rosacea treatment has not been widely investigated. Clinicians often underestimate the impact of these symptoms and do not routinely include them as part of management. Available therapies for rosacea have the potential to treat beyond signs, and improve burning and stinging symptoms in parallel. Further investigation is needed to better understand these benefits and to optimize the management of rosacea.

A Novel Mechanism of Carvedilol Efficacy for Rosacea Treatment: Toll-Like Receptor 2 Inhibition in Macrophages

Background

Rosacea, a chronic inflammatory skin disorder etiologically associated with immune cells and the antibacterial peptide cathelicidin LL-37, can be effectively treated by oral carvedilol administration.

Objective

To investigate the molecular mechanisms underlying carvedilol efficacy in rosacea treatment.

Methods

Skin samples of patients with rosacea were subjected to histopathological (hematoxylin and eosin) and immunohistochemical (CD68, Toll-like receptor 2 (TLR2), kallikrein 5, cathelicidin, TNF-α, and IL-1β) evaluation. An in vivo murine rosacea-like inflammation model was established by LL-37 intradermal injection with or without carvedilol gavage-based pretreatment. Erythema proportion (Image J) and skin redness (L*a*b colorimetry) were quantified. Murine skin samples underwent pathological examination for inflammatory status and immunofluorescence staining. Murine skin and lipopolysaccharide-stimulated RAW 264.7 cells with or without carvedilol pretreatment were evaluated by quantitative reverse transcription-polymerase chain reaction and western blotting. Clinical facial images of patients were obtained using the VISIA skin analysis system before, 4, and 6 months following oral carvedilol administration.

Results

Rosacea skin lesions exhibited more pronounced inflammatory cell infiltration than peripheral areas, with profound macrophage infiltration and inflammatory cytokines (TLR2, kallikrein 5, cathelicidin, TNF-α, and IL-1β). In vivo, carvedilol alleviated inflammation in LL-37 mice, down-regulating TLR2, KLK5, and cathelicidin expression. In vitro, carvedilol decreased TLR2 expression in RAW 264.7 cells, further reducing KLK5 secretion and LL-37 expression and ultimately inhibiting rosacea-like inflammatory reactions. Clinical manifestations and facial redness obviously improved during 6-month follow-up with systemic carvedilol administration.

Conclusion

Carvedilol is effective against rosacea, with inhibition of macrophage TLR2 expression as a novel anti-inflammatory mechanism.

Rosacea fulminans: two case reports and review of the literature

Rosacea fulminans is a rare and severe inflammatory dermatosis which affects predominantly childbearing women. It is characterized by sudden onset and it usually localizes exclusively on the centrofacial areas, presenting with numerous fluctuant inflammatory nodules and papules which may coalesce. Treatment with isotretinoin in combination with topical and systemic corticosteroids is successful. Clearance of lesions may be obtained under systemic treatment with no or minimal scarring outcomes. Due to rare incidence its pathophysiological mechanisms, diagnosis and management remain controversial. We report two cases of rosacea fulminans arisen in otherwise healthy people and completely healed after treatment. Our aim is to share our experience about this disease in order to increase knowledge about its diagnosis, management and its treatment. We also make a review of the literature of this peculiar dermatosis.

Clinical characteristics and management of patients with rosacea in a tertiary dermatology center in Singapore from 2009 to 2013

INTRODUCTION

Rosacea is a common chronic facial skin disease. A multiethnic society such as Singapore provides an opportunity to evaluate the demographic characteristics and their impact on clinical outcome in rosacea.

AIMS

The aim of this study was to evaluate characteristics and outcome of rosacea in a multiracial population in Singapore.

METHODS

Records of all rosacea patients between January 2009 and December 2013 were retrospectively retrieved from the electronic medical records (EMR). Descriptive analysis was performed to understand the characteristics of patients with rosacea. Multivariate logistic regression was used to evaluate the associations between the various variables and types of rosacea as well as the clinical outcome.

RESULTS

A total of 1340 patients were identified. The mean age at presentation was 42.8 years with a female predominance (65%). Most of the patients had erythematotelangiectatic rosacea (ETR) (56.3%) followed by papulopustular rosacea (PPR) (37%). With multinomial logistic regression, controlling for age, gender, and known triggers, Indians and Caucasians were more likely to have PPR compared to ETR (OR: 3.4, P = 0.01 and OR: 2.1, P = 0.01 respectively). Patients who had phymatous rosacea are also more likely to be older males (OR: 3.82 95% CI 1.64-8.92, P = 0.002).

CONCLUSION

The epidemiology and outcome of rosacea among local patients were studied. Rosacea is more common among certain racial groups such as Chinese, Caucasian, and other races. The clinical subtypes also seem to be related to races of certain skin colors and might be related to varied natural intrinsic responses to the sun among different racial groups.

Diagnosis and Treatment of Rosacea Fulminans: A Comprehensive Review

Rosacea fulminans is a rare inflammatory condition of the central face marked by the abrupt onset of erythematous coalescing papules, pustules, nodules, and draining sinuses. Due to infrequent reporting in the literature, the pathophysiology, classification, and nomenclature of this condition remain controversial. This comprehensive review evaluated a total of 135 cases of rosacea fulminans for clinical and histopathologic features and reported treatment strategies. Patients were 91% female with an average age of onset of 31.3 years. Only 19% of cases reported duration of symptoms longer than 3 months, and reports of recurrence were uncommon. A majority of patients had history of rosacea or flushing, and common triggers included hormonal shifts, emotional stress, and medications. Extrafacial or systemic involvement was rare. Though oral and topical antibiotics were frequently utilized to treat rosacea fulminans, there was a clear shift in reported treatments for rosacea fulminans following the introduction of isotretinoin use in 1987, marked by increased reliance on isotretinoin in addition to topical and systemic corticosteroids. Newer treatments were associated with superior improvement compared with antibiotic monotherapy, most notably dramatically reduced rates of scarring, though reduced rates of disease recurrence were not evident. Several patterns revealed through this review reinforce the classification of rosacea fulminans as a severe yet distinct variant of rosacea and highlight key distinguishing clinical features and treatment options for optimal management.

An observational descriptive survey of rosacea in the Chinese population: clinical features based on the affected locations

BACKGROUND

There is currently no study that has evaluated the differences in epidemiological and clinical characteristics among rosacea patients according to different facial sites.

METHODS

Clinical and demographic data were obtained from 586 rosacea patients. The patients were divided into four groups based on the main sites involved with the rosacea lesions (full-face, cheeks, nose, or perioral involvement). Clinical signs were measured through self-reported, dermatologist-evaluated grading of symptoms, and physiological indicators of epidermal barrier function.

RESULTS

There were 471 (80.4%), 49 (8.4%), 52 (8.9%), and 14 (2.4%) cases in the full-face, cheek, nasal and perioral groups, respectively. Compared with the healthy control, the full-face group had lower water content and higher transepidermal water loss (TEWL) in the cheeks, and chin; the perioral group had lower water content and higher TEWL in the chin; while the nasal group had the normal water content and TEWL. Compared with the full-face group, the nasal group had more severe phymatous changes, less severe self-reported and dermatologist-evaluated grading of symptoms. All the patients in the perioral or the nasal group had their first rosacea lesions start and remain at the chin or on the nose. In the full-face group, 55.8% of patients had their lesions start with the full face, 40.1% on the cheek, and the rest (4.1%) on the nose.

CONCLUSION

Significant differences in clinical features were observed among rosacea patients with lesions at four different sites. The lesion localization of each group was relatively stable and barely transferred to other locations.

Prevalence of rosacea in the general population of Germany and Russia - The RISE study

BACKGROUND

There is an unmet need for general population-based epidemiological data on rosacea based on contemporary diagnostic criteria and validated population survey methodology.

OBJECTIVE

To evaluate the prevalence of rosacea in the general population of Germany and Russia.

METHODS

General population screening was conducted in 9-10 cities per country to ensure adequate geographic representation. In Part I of this two-phase study, screening of a representative sample of the general population (every fifth person or every fifth door using a fixed-step procedure on a random route sample) was expedited with use of a questionnaire and algorithm based on current diagnostic criteria for rosacea. Of the subjects that screened positive in the initial phase, a randomly selected sample (every third subject) t`hen underwent diagnostic confirmation by a dermatologist in Part II.

RESULTS

A total of 3052 and 3013 subjects (aged 18-65 years) were screened in Germany and Russia respectively. Rosacea prevalence was 12.3% [95%CI, 10.2-14.4] in Germany and 5.0% [95%CI, 2.8-7.2] in Russia. The profile of subjects with rosacea (75% women; mean age of 40 years; mainly skin phototype II or III, majority of subjects with sensitive facial skin) and subtype distribution were similar. Overall, 18% of subjects diagnosed with rosacea were aged 18-30 years. Over 80% were not previously diagnosed. Within the previous year, 47.5% of subjects had received no rosacea care and 23.7% had received topical and/or systemic drugs. Over one-third (35% Germany, 43% Russia) of rosacea subjects reported a moderate to severe adverse impact on quality of life.

CONCLUSION

Rosacea is highly prevalent in Germany (12.3%) and Russia (5.0%). The demographic profile of rosacea subjects was similar between countries and the majority were previously undiagnosed.

Skin barrier in rosacea

Recent studies about the cutaneous barrier demonstrated consistent evidence that the stratum corneum is a metabolically active structure and also has adaptive functions, may play a regulatory role in the inflammatory response with activation of keratinocytes, angiogenesis and fibroplasia, whose intensity depends primarily on the intensity the stimulus. There are few studies investigating the abnormalities of the skin barrier in rosacea, but the existing data already show that there are changes resulting from inflammation, which can generate a vicious circle caused a prolongation of flare-ups and worsening of symptoms. This article aims to gather the most relevant literature data about the characteristics and effects of the state of the skin barrier in rosacea.

Therapeutical Management for Ocular Rosacea

Purpose

The purpose of this study is to describe a case of ocular rosacea with a very complex evolution. Rosacea is a chronic dermatological disease that may affect the ocular structures up to 6-72% of all cases. This form is often misdiagnosed, which may lead to long inflammatory processes with important visual consequences for affected patients. Therefore, an early diagnosis and an adequate treatment are important.

Methods

We report the case of a 43-year-old patient who had several relapses of what seemed an episode of acute bacterial conjunctivitis. Two weeks later, he developed a corneal ulcer with a torpid evolution including abundant intrastromal infiltrators and calcium deposits. He was diagnosed with ocular rosacea and treated with systemic doxycycline and topical protopic.

Results

A coating with amniotic membrane was placed in order to heal the ulcer, but a deep anterior lamellar keratoplasty to restore the patient's vision because of the corneal transparency loss was necessary.

Conclusions

Ocular rosacea includes multiple ophthalmic manifestations ranging from inflammation of the eyelid margin and blepharitis to serious corneal affectations. A delayed diagnosis can result in chronic inflammatory conditions including keratinization and loss of corneal transparency, which lead to important visual sequelae for affected patients.

Rosacea: prevalence, pathogenesis, particular features of clinical manifestations

This literature review examines principal aspects of rosacea prevalence in the Russian Federation and abroad, shows present-day opinions about the pathogenesis and histological picture of rosacea and presents actual classification and a number of key clinical forms of the disease.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective.

OBJECTIVES

To assess the efficacy and safety of treatments for rosacea.

SEARCH METHODS

We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors.

MAIN RESULTS

We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence).

AUTHORS' CONCLUSIONS

There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.

Molecular and Morphological Characterization of Inflammatory Infiltrate in Rosacea Reveals Activation of Th1/Th17 Pathways

Rosacea is a common chronic inflammatory skin disease of unknown etiology. Our knowledge about an involvement of the adaptive immune system is very limited. We performed detailed transcriptome analysis, quantitative real-time reverse-transcriptase-PCR, and quantitative immunohistochemistry on facial biopsies of rosacea patients, classified according to their clinical subtype. As controls, we used samples from patients with facial lupus erythematosus and healthy controls. Our study shows significant activation of the immune system in all subtypes of rosacea, characterizing erythematotelangiectatic rosacea (ETR) already as a disease with significant influx of proinflammatory cells. The T-cell response is dominated by Th1/Th17-polarized immune cells, as demonstrated by significant upregulation of IFN-γ or IL-17, for example. Chemokine expression patterns support a Th1/Th17 polarization profile of the T-cell response. Macrophages and mast cells are increased in all three subtypes of rosacea, whereas neutrophils reach a maximum in papulopustular rosacea. Our studies also provide evidence for the activation of plasma cells with significant antibody production already in ETR, followed by a crescendo pattern toward phymatous rosacea. In sum, Th1/Th17 polarized inflammation and macrophage infiltration are an underestimated hallmark in all subtypes of rosacea. Therapies directly targeting the Th1/Th17 pathway are promising candidates in the future treatment of this skin disease.

Managing Sjögren's Syndrome and non-Sjögren Syndrome dry eye with anti-inflammatory therapy

Dry eye from Sjögren’s syndrome is a multifactorial disease that results in dysfunction of the lacrimal functional unit. Studies have shown changes in tear composition, including inflammatory cytokines, chemokines, and metalloproteinase. T-lymphocytes have been shown to increase in the conjunctiva and lacrimal glands in patient and animal models. This inflammation is in part responsible for the pathogenesis of the disease, which results in symptoms of eye irritation, ocular surface epithelial disease, and loss of corneal barrier function. There are a number of anti-inflammatory approaches for treating this disease. The current study reviews details of immune response and anti–inflammatory therapies used to control this disease.

Facial dystonias and rosacea: is there an association?

PURPOSE

Benign essential blepharospasm (BEB) and hemifacial spasm (HFS) belong to a spectrum of focal movement disorders that cause involuntary, spasmodic contractions of the eyelid and facial muscles. In our clinical experience, we have observed an increased prevalence of rosacea in patients who present with BEB and HFS. We investigate our clinical findings with a review of disease pathophysiology and treatment.

METHODS

Retrospective study approved by the Ochsner Institutional Review Board and literature review. A total of 140 charts dated from 1990 to 2013 were reviewed, including 87 patients with BEB and 53 patients with HFS. Rosacea, BEB, and HFS were defined by standard diagnostic criteria.

RESULTS

Within our BEB and HFS patient cohort, approximately 15% of patients presented with rosacea, compared to the general American population prevalence rate of 1.34% (p < 0.001). Of the 140 patients reviewed, a total of 21 patients (13 with BEB and 8 with HFS) exhibited rosacea (p = 0.995).

CONCLUSIONS

Dry eye and tear instability often co-exist in patients with facial dystonias and rosacea, which may provide the initial drive towards tonic eyelid contractions and simultaneously exacerbate rosacea. Studies suggest that neurogenic inflammation and altered vasoregulation jointly contribute to the pathogenesis of rosacea. From our preliminary observations, we suggest the possibility of shared immune-inflammatory pathways involved in both facial dystonias and rosacea. Identification of common inflammatory mediators involved in both disease processes may facilitate a more targeted approach in drug treatment. Further biochemical analysis will likely be necessary to elucidate this potential association.

Rhinophyma--a patient case study

This is a case report about a 62-year-old gentleman who presented at the Otolaryngology department with a rhinophyma. Rhinophyma is a swelling of the soft tissue of the nose due to sebaceous gland hypertrophy, lymphoedema and fibrosis. Photography of the patient's condition highlights not only the features of the disease but is useful when comparing the contours and shape of the nose after surgical excision. Images of a relatively large rhinophyma are useful not only for their visual but also their educational value.

[Efficacy of diuretics in the treatment of Morbihan's disease: three cases]

BACKGROUND

Morbihan's disease (MD), also known as 'persistent facial oedema' or 'rosaceous lymphoedema', is an uncommon facial condition that is difficult to treat. Its cause remains unclear.

AIM

We report three new cases of solid persistent facial oedema, which, after treatment with furosemide, showed dramatic improvement.

PATIENTS AND METHODS

Three men (respectively aged 38, 66 and 76 years) presented Morbihan's disease progressing respectively for 2, 5 and 8 years. These patients presented with facial oedema, mainly affecting the eyelids. The diagnosis of MD was based on clinical and laboratory criteria (after exclusion of other aetiologies such as sarcoidosis, lupus erythematosus, facial demodicidosis and rosacea). After several unsuccessful treatments (tetracyclines, synthetic antimalarials, danazol, systemic steroids and isotretinoin), the patients received diuretics: furosemide (60 mg/d) in two cases and spironolactone 75 mg twice daily for the third patient. The patients were evaluated after 1 month, then every 3 months.

RESULTS

Regression of oedema was complete or almost complete with follow-up of between 1 and 16 years. No adverse effects were reported.

DISCUSSION

Treatment of Morbihan's disease remains difficult and empirical. Diuretics may be of value since they help significantly reduce swelling even if they do not definitely cure patients.

Neurovascular and neuroimmune aspects in the pathophysiology of rosacea

Rosacea is a common skin disease with a high impact on quality of life. Characterized by erythema, edema, burning pain, immune infiltration, and facial skin fibrosis, rosacea has all the characteristics of neurogenic inflammation, a condition induced by sensory nerves via antidromically released neuromediators. To investigate the hypothesis of a central role of neural interactions in the pathophysiology, we analyzed molecular and morphological characteristics in the different subtypes of rosacea by immunohistochemistry, double immunofluorescence, morphometry, real-time PCR, and gene array analysis, and compared the findings with those for lupus erythematosus or healthy skin. Our results showed significantly dilated blood and lymphatic vessels. Signs of angiogenesis were only evident in phymatous rosacea. The number of mast cells and fibroblasts was increased in rosacea, already in subtypes in which fibrosis is not clinically apparent, indicating early activation. Sensory nerves were closely associated with blood vessels and mast cells, and were increased in erythematous rosacea. Gene array studies and qRT-PCR confirmed upregulation of genes involved in vasoregulation and neurogenic inflammation. Thus, dysregulation of mediators and receptors implicated in neurovascular and neuroimmune communication may be crucial at early stages of rosacea. Drugs that function on neurovascular and/or neuroimmune communication may be beneficial for the treatment of rosacea.

Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review

Rosacea is a common chronic skin disease affecting the face. There are numerous treatment options, but it is unclear which are the most effective. The aim of this review was to assess the evidence for the efficacy and safety of treatments for rosacea. Searches included the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers (updated February 2011). Randomized controlled trials in people with moderate to severe rosacea were included. Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. There was some evidence that topical metronidazole and azelaic acid were more effective than placebo. Two trials indicated that doxycycline 40mg was more effective than placebo. There was no statistically significant difference in effectiveness between doxycycline 40mg and 100mg but there were fewer adverse effects. One study reported that ciclosporin ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea. Although the majority of included studies were assessed as being at high or unclear risk of bias, there was some evidence to support the effectiveness of topical metronidazole, azelaic acid and doxycycline (40mg) in the treatment of moderate to severe rosacea, and ciclosporin 0·05% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately powered randomized controlled trials are required.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some patients. A range of treatment options are available but it is unclear which are the most effective.

OBJECTIVES

To assess the evidence for the efficacy and safety of treatments for rosacea.

SEARCH STRATEGY

In February 2011 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors.

MAIN RESULTS

Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. Only two studies assessed our primary outcome 'quality of life'.Pooled data from physician assessments in three trials provided some evidence that metronidazole was more effective compared to placebo (RR 1.95, 95% CI 1.48 to 2.56). Three trials provided data, based on participants' assessments, illustrating azelaic acid was more effective than placebo (RR 1.52, 95% CI 1.32 to 1.76).Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doses of doxycycline, but there was evidence of less adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54).One study reported that cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes).

AUTHORS' CONCLUSIONS

Although the majority of included studies were assessed as being at high or unclear risk of bias there was some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately-powered randomised controlled trials are required.

Rosacea: pathogenesis, clinical forms and therapy

A rosacea az egyik leggyakoribb, krónikus gyulladásos bőrbetegség. Centrofacialisan megjelenő erythema, teleangiectasiák, papulák és pustulák jellemzik. A klinikai kép alapján az új nemzetközi klasszifikáció 4 fő alcsoportot különít el: erythemás-teleangiectasiás, papulopustulosus, phymatosus és ocularis altípust. Az egyes formák kezelése is eltérő. A folyamat patomehanizmusa a mai napig nem tisztázott pontosan. Genetikai és környezeti tényezők mellett kóros érreakciónak, dermalis mátrixdegenerációnak, egyes mikroorganizmusoknak, mint Demodex folliculorum és Helicobacter pylori tulajdonítanak szerepet. A szerzők az összefoglaló közleményben áttekintik a rosacea új klasszifikációját, a főbb patogenetikai tényezők szerepét és a terápiás lehetőségeket.

Rosacea

Rosacea, a common disease in adults, has an extremely variable presentation. Severity is also highly variable and, to some degree, the location of mild end of the rosacea spectrum is in the eye of the beholder. Rosacea has been noted since at least the Middle Ages. The red-faced drunk and the swollen nose of the self-indulgent are images from Shakespeare and Chaucer that have been used in modern political cartoons as well. This association with alcohol and excess is unfortunate since most patients are neither alcoholic nor dissipated.

Overview of the Pharmacologic Options for Rosacea

Objective:

To review available therapies for rosacea.

Data Sources:

A PubMed literature search (1985-July 2009) was conducted. Search terms included rosacea, antibiotics, and treatment.

Study Selection and Data Extraction:

English-language reviews, comparative clinical trials, and guidelines for treatment of rosacea were reviewed. Seven comparative trials were identified.

Data Synthesis:

Rosacea is a common dermatologic disease that affects about 10% of the adult population, usually before age 50. The etiology of the disease is unknown. There are 4 subtypes of rosacea: erythematotel-angiectatic (frequent flushing and redness), papulopustular (early telangiectasias, classic rosacea), phymatous (thickened skin with prominent pores), and ocular. Severity of each subtype is classified as mild, moderate, or severe. The goal of therapy is symptomatic control versus cure. For papulopustular rosacea, topical metronidazole is the first line of therapy. Azelaic acid is a newer preparation that patients have preferred over topical metronidazole in head-to-head trials. Topical sodium sulfacetamide/sulfur is another alternative. Systemic agents may be needed for nonresponders or patients with severe disease. Oral alternatives include a 40–mg dose of doxycycline, which costs significantly more than generic doxycycline 100 mg. The lowest effective oral dose should be used to reduce the possibility of bacterial resistance. Telangiectasias may require laser surgery.

Conclusions:

Several alternatives are available for the treatment of rosacea, depending on the subtype, severity of disease, and patient response. In addition to pharmacologic therapy, patients with rosacea need to be counseled about identification and avoidance of triggers that can exacerbate their symptoms, the use of broad-spectrum sunscreens, and the use of mild cleansers.

Risk factors associated with rosacea

BACKGROUND

Although rosacea is a common disease, the cause of disease is still a mystery -Helicobacter pylori infection, genetic predisposition, climatic factors, and detrimental habits are implicated as triggers of rosacea.

OBJECTIVE

The aim of current study is to evaluate several suspected risk factors coincidently.

METHODS

Patients with rosacea from a dermatology clinic and skin-healthy controls from an randomly selected employees' population enrolled the study. Skin status were evaluated by one and same dermatologist. Participants were queried for age, gender, sun-reactive skin type, and detrimental habits using a questionnaire; blood samples for detecting Helicobacter pylori serostatus were collected.

RESULTS

Totally 145 skin-healthy controls and 172 subjects either with flushing episodes or established rosacea included the study. In multivariate analysis, rosacea patients had significantly higher chance to have photosensitive skin types (OR 1.75; 95% CI 1.01-3.04; P < 0.05), positive family history to rosacea (OR 4.31; 95% CI 2.34-7.92; P < 0.0001) or previous smoking status (OR 2.01; 95% CI 1.07-3.80; P < 0.05) comparing with skin-healthy controls. There were no statistically significant differences either in gender, Helicobacter pylori serostatus, caffeine intake, alcohol consumption, occupational environment, or education level between rosacea patients and controls.

CONCLUSION

Rosacea is foremost associated with familial predisposition. There is no association between Helicobacter pylori infection and rosacea in current study.

Efficacy of topical cyclosporine for the treatment of ocular rosacea

INTRODUCTION

This study was designed to compare the efficacy of cyclosporine ophthalmic emulsion 0.05% with an artificial tear solution for the treatment of rosacea-associated eyelid and corneal pathology.

METHODS

Double-masked, randomized, 3-month clinical trial of 37 patients with rosacea-associated eyelid and corneal changes (defined as lid margin telangiectasia, meibomian gland inspissation, and/or fullness of the lid margin). All findings were standardized and compared to photographs for grading.

RESULTS

There was a statistically significant increase in Schirmer (with anesthesia) scores of 2.7+/-2.2 mm after 3 months of treatment in the topical cyclosporine group (P<0.001), compared with a mean decrease of -1.4+/-4.6 mm (P=0.271) in the artificial tears group. The mean tear break-up time score significantly improved in the topical cyclosporine group (mean increase of 3.56+/-1.5 seconds, P<0.001), but worsened in the control group, although this change was not significantly significant (mean decrease of -0.04+/-1.6 seconds, P=0.929). The topical cyclosporine group exhibited a significantly greater mean reduction in corneal staining scores (-1.3+/-0.53) compared with the control group (-0.2+/-0.83; between groups P<0.001). The topical cyclosporine group had a greater improvement in Ocular Surface Disease Index scores than those using artificial tears (P=0.022). Limitations of the study included an older, predominantly Caucasian patient population and short trial length.

CONCLUSIONS

Topical cyclosporine 0.05% is more effective than artificial tears for the treatment of rosacea-associated lid and corneal changes.

Prescription refills and healthcare costs associated with topical metronidazole in Medicaid enrolled patients with rosacea

BACKGROUND

Refill adherence to medications and healthcare costs are important factors to consider while making informed decisions regarding the treatment of rosacea patients.

OBJECTIVE

The objective of this study was to examine predictors of number of refills related to topical metronidazole and total healthcare costs in rosacea patients.

METHODS

This study utilized a longitudinal cohort design and followed rosacea patients enrolled in North Carolina Medicaid and who were prescribed at least one study medication (topical metronidazole, adapalene, azelaic acid, permethrin, and sulfacetamide). Patients' demographic characteristics, number of metronidazole refills, and different components of healthcare costs were examined.

RESULTS

Out of the total 2587 rosacea patients, the majority (approximately 69%, n=1771) had one or more prescriptions for topical metronidazole. Most of the patients in this study were white (73%). After controlling for other variables, increasing age was associated with a higher number of metronidazole refills and healthcare costs (both p<0.001). Compared with white patients, African American patients had a significantly lower number of metronidazole refills (p<0.001). Compared with white patients, African American patients and 'other' races were associated with an 8.6% and 10.3% decrease in total healthcare costs respectively (both p<0.001). An increase in the number of metronidazole refills was not associated with an increase in healthcare costs.

CONCLUSION

Patients' race is significantly associated with the number of topical metronidazole refills. Patients' healthcare costs increased with increasing age and charges paid for prescriptions. Topical metronidazole seems to be an economically feasible treatment option for Medicaid-enrolled patients with rosacea.

Tetracycline suppresses ATP gamma S-induced CXCL8 and CXCL1 production by the human dermal microvascular endothelial cell-1 (HMEC-1) cell line and primary human dermal microvascular endothelial cells

Tetracyclines (TCN) have powerful anti-inflammatory properties in addition to their anti-microbial effects. These anti-inflammatory effects are thought to play a role in inhibiting cutaneous inflammation in patients with rosacea and acne; however, the mechanism(s) of this action remains poorly understood. We have previously shown that adenosine-5'-triphosphate (ATP)gamma S, a hydrolysis-resistant ATP analogue, augments secretion of pro-inflammatory messengers by a human dermal microvascular endothelial cell line (HMEC-1). ATP released by the sympathetic nerves during stress may stimulate release of pro-inflammatory chemokines by dermal vessel endothelial cells, resulting in recruitment of inflammatory cells and exacerbation of inflammatory skin disease. Here we demonstrate that TCN inhibits ATP gamma S-induced release of pro-inflammatory mediators by HMEC-1 cells and primary human dermal microvascular endothelial cells. TCN dose-dependently inhibited ATP gamma S-induced augmentation of CXCL8 (interleukin-8) and CXCL1 (growth-regulated oncogene-alpha) production by HMEC-1 cells and primary human dermal endothelial cells in vitro. TCN and ATP gamma S did not affect HMEC-1 cell viability as determined by trypan-blue exclusion and cell counts. Inhibition of production of inflammatory mediators by endothelial cells may be one mechanism by which TCN improves inflammatory skin diseases. The ability to inhibit release of inflammatory mediators induced in HMEC-1 cells by purinergic agonists may be a useful way to screen for potential therapeutic agents for cutaneous inflammation.

Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007)

The members of the Management and Therapy Subcommittee assessed current dry eye therapies. Each member wrote a succinct evidence-based review on an assigned aspect of the topic, and the final report was written after review by and with consensus of all subcommittee members and the entire Dry Eye WorkShop membership. In addition to its own review of the literature, the Subcommittee reviewed the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force (ITF) Delphi Panel on Dry Eye. The Subcommittee favored the approach taken by the ITF, whose recommended treatments were based on level of disease severity. the recommendations of the Subcommittee are based on a modification of the ITF severity grading scheme, and suggested treatments were chosen from a menu of therapies for which evidence of therapeutic effect had been presented.

Effect of treatment of rosacea in females by Chibixiao Recipe in combination with minocycline and spironolactone

OBJECTIVE

To observe the clinical efficacy of Chibixiao Recipe (CBX) in combination with minocycline and spironolactone in treating rosacea in females.

METHODS

Sixty-eight women with rosacea were randomly assigned to the treated group (48 cases) and the control group (20 cases), both of which were treated with minocycline and spironolactone taken orally, but to the treated group, the Chinese herbal recipe, CBX was given additionally. Besides, cryotherapy with liquid nitrogen was applied to those with apparent capillary dilatation. The therapeutic course for both groups was 8 weeks. The levels of serum testosterone before and after treatment were determined by radioimmunoassay (RIA), and a 4-month follow-up was conducted.

RESULTS

In the treated group the cure-markedly effective rate was 87.5% and the recurrent rate was 6.5%, while in the control group, they were 45.0% and 41.2% respectively. Comparisons in the indexes between the two groups all showed significant difference (both P<0.01), with the cure-markedly effective rate higher, and the recurrent rate lower in the treated group. The serum level of testosterone got lowered in both groups ( P<0.05 and P<0.01), but the lowering in the treated group was more significant, showing significance when compared with that in the control group ( P<0.01).

CONCLUSION

CBX in combination with Western medicine has effect in treating rosacea superior to that of Western medicine alone, and could effectively reduce recurrent rate and the serum level of testosterone. female rosacea, testosterone, Chibixiao Recipe, minocycline, spironolactone

Rosácea granulomatosa: relato de caso - enfoque terapêutico

Os autores descrevem um caso de rosácea granulomatosa em um homem de 39 anos de idade, tratado com a associação de limeciclina oral e metronidazol gel tópico. A rosácea granulomatosa é uma variante da rosácea clássica, rara, caracterizada pela presença de pápulas vermelho-acastanhadas ou pequenos nódulos com base eritematosa e infiltrada, surgindo geralmente na superfície lateral da face e no pescoço. O exame histopatológico evidencia granulomas perifoliculares e perivasculares. A evolução é crônica, e o tratamento inclui antibióticos orais, como a tetraciclina e seus derivados, e medicações tópicas, como metronidazol, ácido retinóico, entre outras.

Tetracyclines: nonantibiotic properties and their clinical implications

Tetracyclines are broad-spectrum antibiotics that act as such at the ribosomal level where they interfere with protein synthesis. They were first widely prescribed by dermatologists in the early 1950s when it was discovered that they were effective as a treatment for acne. More recently, biologic actions affecting inflammation, proteolysis, angiogenesis, apoptosis, metal chelation, ionophoresis, and bone metabolism have been researched. The therapeutic effects of tetracycline and its analogues in various diseases have also been investigated. These include rosacea, bullous dermatoses, neutrophilic diseases, pyoderma gangrenosum, sarcoidosis, aortic aneurysms, cancer metastasis, periodontitis, and autoimmune disorders such as rheumatoid arthritis and scleroderma. We review the nonantibiotic properties of tetracycline and its analogues and their potential for clinical application.

Topical application of 1-methylnicotinamide in the treatment of rosacea: a pilot study

Rosacea is a chronic facial dermatosis with a progressive course, which is characterized by the presence of erythema, papules, pustules, telangiectasias and sebaceous gland hyperplasia. However, the aetiology is still unknown; genetic predisposition, gastrointestinal disorders (Helicobacter pylori), infestations with Demodex folliculorum and environmental stimuli are considered to be involved in the inflammatory process. A metabolite of nicotinamide, 1-methylnicotinamide (MNA(+)), has anti-inflammatory properties, and this is the first study to test the effectiveness of this agent in treating rosacea. In total, 34 patients with rosacea were treated with a gel containing 0.25% MNA(+) as a chloride salt, twice daily for 4 weeks, after which improvement was observed in 26/34 cases. The improvement was good in 9/34 and moderate in 17/34, but no clinical effect was noted in seven subjects. In only one case was skin irritation given as the reason for treatment withdrawal. These results indicate that MNA(+) might be a useful agent for treating rosacea.

Rosazea

Rosacea is a common facial dermatosis, which may have detrimental effects on the patient's psychological and social interactions. It is a disease of the middle aged, skin types I and II are more often affected than darker skin types. Clinically, pre-rosacea, and rosacea grade I-III may be distinguished. Pre-rosacea is characterized by flushing and blushing, grade I to III by erythemato-teleangiectasies, papulopustules, and inflammatory nodules. Especially severe subtypes include rosacea conglobata and rosacea fulminans. Hyperglandular subtypes lead to different forms of phyma, of which Rhinophyma is the most frequent. Pathogenetically destruction of the dermal vessels and connective tissue seems to be decisive for the development of a chronic inflammation, which leads to the phenotype of the various forms of rosacea. Mild forms can be treated exclusively by topical medication. Antibiotics (erythromycin, clindamycin, tetracyclin), metronidazol, azelaic acid, and the retinoid adapalene have been shown to be effective in well controlled randomized studies. The best evaluated topical medication is metronidazol. In severe forms systemic therapy must be applied. Systemic antibiotics are effective and especially isotretinoin has shown a very good response even in low dose regimens. Rhinophyma must be treated surgically.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved. Frequently it can be controlled, but it is not clear which treatments are most effective.

OBJECTIVES

To assess the evidence for the efficacy and safety of treatments for rosacea.

SEARCH STRATEGY

We searched the Skin Group Specialised Register (February 2005), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February 2005), EMBASE (1980 to February 2005), BIOSIS (1970 to March 2002) and the Science Citation Index (1988 to February 2005). Reference lists of trials and key review articles were searched. Relevant manufacturers and experts were contacted.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the authors to have seriously flawed methodology were excluded.

DATA COLLECTION AND ANALYSIS

Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent authors. Disagreements were resolved by discussion and consensus.

MAIN RESULTS

The evidence provided by twenty-nine included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea were included. Pooled data from two trials involving 174 participants indicated that according to the participants, topical metronidazole is more effective than placebo (odds ratio (OR) 5.96, 95% confidence interval (CI) 2.95 to 12.06). Data pooled from three between-patient trials showed a clear improvement in the azelaic acid group; the rates of treatment success were approximately 70 to 80% versus 50% to 55% (OR 2.45, 95% CI 1.82 to 3.28). A within-patient trial of azelaic cream versus placebo could not be pooled with the other three studies, but also showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians, tetracycline was effective (OR 6.06, 95% CI 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study.

AUTHORS' CONCLUSIONS

The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. Good RCTs looking at these treatments are urgently needed.