Red facial rash with “granitos”
Another useful therapy is topical azelaic acid. While the evidence for scabicides in rosacea is limited, some clinicians use these medications for rosacea that is refractory to antibiotics. This is based on the idea that the Demadex mite is a causative agent in rosacea. If a patient has severe papulopustular disease refractory to antibiotics and topical treatments, the physician can start an oral isotretinoin regimen at a low dose of 0.1 to 0.5 mg/kg. Pulse-dye laser and electrosurgery can be used to treat the telangiectasias associated with rosacea.
A systematic review by Van Zuuren et al5 examined the efficacy of metronidazole, tetracycline, and azelaic acid in treating rosacea. Twenty-nine randomized controlled trials were found. Pooled data from 2 of the trials involving 174 participants indicated that, according to the participants, topical metronidazole was more effective than placebo (odds ratio [OR]=5.96; 95% confidence interval [CI], 2.95–12.06).
There was a definite 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, 1.82–3.28). Data pooled from 3 studies of oral tetracycline vs placebo involving 152 participants showed that, according to physicians, tetracycline was more effective than placebo (OR=6.06; 95% CI, 2.96–12.42).
Maintenance therapy
Because relapse occurs within weeks in about 25% of patients after the cessation of systemic therapy, topical therapy is usually used in an effort to maintain remission.6 The required duration of maintenance therapy is unknown, but a period of 6 months is generally advised. After this time, some patients report that they can keep their skin free of papulopustular lesions with topical therapy applied on alternate days or twice weekly, whereas others require repeated courses of systemic medication. After a few years, the disease may disappear spontaneously.
Patient management
Our patient was counseled about her rosacea and given the web site address for the National Rosacea Organization. She was advised to avoid sun exposure as much as possible and to use sunscreen and a hat to protect her face. She was prescribed tetracycline 500 mg and topical metronidazole to be used twice daily. Follow-up was set for 1 month. At that time, patient will be offered the option of electrocoagulation of her most prominent telangiectasias.
CORRESPONDING AUTHOR
Richard P. Usatine, MD, University of Texas Health Science Center at San Antonio, Department of Family and Community Medicine, MC 7794, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: usatine@uthscsa.edu
