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Erythromycin is the antibiotic of second choice. Courses should last for at least 10 weeks and, after gaining control with 500–1000 mg daily, the dosage can be cut to 250 mg daily. The condition recurs in about half of the patients within 2 years, but repeated antibiotic courses, rather than prolonged maintenance ones, are generally recommended. Topical 0.75% metronidazole gel (Formulary 1, p. 336), applied sparingly once daily, is nearly as effective as oral tetracycline and often prolongs remission. It can be tried before systemic treatment and is especially useful in treating ‘stuttering’ recurrent lesions that do not then need repeated systemic courses of antibiotics. Rarely systemic metronidazole or isotretinoin (p. 154) is needed for stubborn rosacea. Rosacea and topical steroids go badly together (Fig. 12.15); if possible patients should use traditional applications such as 2% sulphur in aqueous cream or 1% ichthammol inzinc cream. Sunscreens may help if sun exposure is an aggravating factor, but changes in diet or drinking habits are seldom of value.1 Topically, metronidazole gel (Metrogel, Rozex) twice daily may be helpful. If this is ineffective, the usual oral treatment is tetracycline, initially 1 g daily, reducing to 250 mg daily after a few weeks and continued for 2 to 3 months. Erythromycin is an alternative. Repeated treatment is often needed. Isotretinoin can be used but is less effective than in acne. Plastic surgery is required for rhinophyma.2 The most important first step in the treatment of rosacea is the avoidance of triggers. Triggers are both exposures and situations that can cause a flare-up of the flushing and skin changes in rosacea. Principal among these is sun exposure. Rosacea patients must be advised always to apply a nonirritating facial sun block when outdoors. Stress, through autonomic activation, can also increase the flushing. Alcohol consumption, while not a cause in itself, can aggravate this condition through peripheral vasodilation. Spicy foods can also aggravate the symptoms of rosacea through autonomic stimulation. Finally, care must be taken to use only those facial cleansers, lotions, and cosmetics that are nonirritating, hypoallergenic, and noncomedogenic. Rosacea should be treated at its earliest manifestations to mitigate progression to the stages of edema and irreversible fibrosis. Antibiotics have traditionally been considered the first line of therapy, although their success is considered to be primarily due to anti-inflammatory effects rather than antimicrobial ones.4 Topical metronidazole, which is effective for stage I and stage II rosacea and avoids the toxicity of systemic
is more consistently effective and has fewer gastrointestinal side effects than the hyclate form.0% formulation.17 Specifically. In 1999 Maddin16 compared once-daily applications of azelaic acid with topical metronidazole 0. burning.18 Daily use of an over-the-counter cosmetic 5.6 Oral therapy is generally continued until inflammatory lesions clear or for 12 weeks. although the monohydrate formulation. erythema.5 g/d divided into 2 to 4 daily doses. and is generally well tolerated while retaining most of the therapeutic activity of retinoic acid. and stinging. improvements were found in erythema and telangiectasias.75% cream for treatment of papulopustular rosacea.75% cream or gel and in a newer once-daily 1.4 Rosacea responds well to oral antibiotics.17 Retinaldehyde is intermediate in the natural metabolism of retinoids. 17 The drawbacks of retinoic acid therapy include delayed onset of effectiveness.13. however.0% 2 .0% medicine and the twice-daily 0. at a dosage of 1.treatment. Maddin concluded that both medicines were equally effective in reducing the number of inflammatory lesions and the associated signs and symptoms of rosacea.12 Sulfacetamide lotion can also be used in place of metronidazole.0 to 1. and maintains long-term control. The patients involved in the study also preferred the azelaic acid.12 Tetracycline is the primary oral antibiotic prescribed for rosacea therapy. prevents relapse when oral therapy is discontinued. the azelaic acid was considered to be considerably more effective. dry skin. in a dosage of 100 mg once daily. In certain patients. Minocycline at 100 mg two times a day is an acceptable alternative. has been found to be as effective as doxycycline but with a more benign side effect profile. Topical vitamin C preparations have recently been studied in the reduction of the erythema of rosacea.16 Topical retinoic acid has been shown to have a beneficial effect on the vascular component of rosacea.17 Daily application of a 0. whichever comes first. When the study physicians’ rating of the overall improvement was considered.4 No significant difference in efficacy has been found between the once-daily 1. between retinal and retinoic acid.14 Clarithromycin.15 New Therapies Azelaic acid is a naturally occurring.75% medicine.05% retinaldehyde cream for 6 months was found to yield positive and statistically significant outcomes in 75% of those patients undergoing treatment.11 Metronidazole is available in a twice-daily application of 0. is considered first-line therapy. It is available as a 20% cream and is generally used as an alternative treatment for acne vulgaris. dicarboxylic acid possessing antibacterial activity. 13 Doxycycline is another acceptable alternative. 250 mg to 500 mg twice daily. sulfacetamide might be less irritating than metronidazole. Starting treatment with simultaneous oral and topical therapy reduces initial prominent symptoms. the vascular components of rosacea.
does not respond well to medical therapy. which is difficult to clear. such as rhinophyma. Avoidance of obvious vasodilators and irritants is clearly helpful. Stage IV of rosacea. but is rarely sufficient.18 It was suggested that free-radical production might play a role in the inflammatory reaction of rosacea. Female patients of childbearing age must be strongly advised to use effective birth control. has serious side-effects. longterm studies. of course. the patient should be referred for cosmetic surgery. signs. major reductions in erythema. the prominent visibility of these changes often yields intense psychosocial distress. Topical treatment along the lines of that for acne is also helpful. and symptoms can be readily alleviated by the primary care physician. Since effective rosacea treatments have been in existence for over 40 years.vitamin C (L-ascorbic acid) preparation was used in an observer-blinded and placebocontrolled study. Although the exact cause of rosacea is unknown. At that point.4 Rosacea can be a difficult disease to treat. In the aging US population. such as cryosurgery and laser therapy. Recalcitrant cases of rosacea have been successfully treated with 0. Although some would relegate all but the most rigorous studies to the realm of medical folklore. its progression. there are relatively few recent large-scale studies. Recent reports indicate that synthetic retinoids are also effective. Nine of the 12 participants experienced both objective and subjective improvement in their erythema. which should be avoided). rosacea is an increasingly common disorder. Although rosacea causes only limited physical effects. and telangiectasias were noted by the ninth week of treatment. which may need to be repeated.19 Isotretinoin reduces the size of sebaceous glands and alters keratinization. involving irreversible fibrotic changes. In a recent study of 22 patients with mild to moderate rosacea. Topical steroids should not be used as they have minimal effect and cause a severe rebound erythema.12 Isotretinoin. The treatment of rosacea is with long term courses of oxytetracycline. at least in part because the predisposing vasodilation is largely unresponsive to topical or systemic therapy (with the exception of corticosteroids. and that the antioxidant effect of Lascorbic acid might be responsible for its effect.most notably its teratogenic potential. Avoiding hot and spicy foods may help.5 mg/kg/d of isotretinoin. papules. These promising preliminary results still need to be confirmed in larger. in the case 3 . Treatment of Advanced Disease Recalcitrant rosacea can respond to oral isotretinoin therapy.
The response is not immediate and sometimes several weeks are required before any benefit is seen. and it appears to be about as effective as topical metronidazole. * Then tapered.1 % qd [cream or gel] 3 Oral Tetracycline 250–500 mg qd to bid[*] 1 Doxycycline 50–100 mg qd to bid[*] 20 mg bid.3 -.75% and 1% qd to bid [cream. respectively. Azelaic acid cream is useful in patients with rosacea. (2) retrospective study or large case series. 90. Applied once or twice daily. depending on dose] 3 Azithromycin 250–500 mg (5–10 mg/kg) 3 times/week 2 Isotretinoin 10 to 40 mg qd[‡] 2 For telangiectasias and rhinophyma.of rosacea. Key to evidence-based support: (1) prospective controlled trial. THERAPEUTIC LADDER FOR THE MEDICAL TREATMENT OF ROSACEA Drug Dosage/Frequency Level of evidence Topical Metronidazole 0. gel or lotion] 1 Sodium sulfacetamide (with or without sulfur and/or urea) 10% qd to bid [cream. 100 mg qd to bid[*]. ‡ Higher doses have been used anecdotally. Table 38. suspension or wash] 1 (with sulfur) or 2 Azelaic acid 15% and 20% bid [cream or gel] 1 Benzoyl peroxide/clindamycin 5%/1% qd [gel] 1 Tretinoin 0. lotion.01% to 0. (3) small case series or individual case reports. 40. 40 mg qd 2 Minocycline 50. foam. † Especially for children with perioral dermatitis. 250.3). 75. 135 mg (1 mg/kg) qd 1 or 2 Erythromycin[†] 200. Topical Therapy Metronidazole is a major topical therapy for rosacea[42–44]. 400. the 585 nm pulsed dye laser and electrosurgery can be used. 333. 500 mg (30–50 mg/kg/daily) [bid to qid. it is most active against inflammatory lesions and may have some effect on erythema due to inflammation (as opposed to fixed telangiectasias). the currently available data are based primarily on smaller prospective trials as well as retrospective series (Table 38.Therapeutic ladder for the medical treatment of rosacea. Benzoyl peroxide preparations that are not irritating 4 .
Interestingly. Trimethoprim–sulfamethoxazole and ciprofloxacin both can improve inflammatory rosacea.5-1% precipitated sulfur and applied twice daily to treat mild rosacea. Tetracyclines decrease the chemotactic response of neutrophils. Dermatologists should take care to avoid the use of unnecessary longterm oral antibiotics in rosacea patients by repeatedly attempting to taper the medication. Topical tretinoin–perhaps counter-intuitively. tetracyclines can be given in surprisingly small dosages (e. The initial use of sub-antimicrobial doses of doxycycline (e. clindamycin and tetracycline appear to have little effect on rosacea. Tetracycline is weakest. At this point.g. and doxycycline and minocycline are approximately equipotent. However. However. the relative potency of the tetracyclines’ inhibition of granuloma formation parallels their clinical activity. Oral Therapy Tetracyclines are the most commonly prescribed oral medications for the treatment of rosacea[48–50]. but may be due to its effect on the elastolysis seen in chronic rosacea. Typically. treatment is started at a higher dose (see Table 38. because of concerns regarding the generation of resistant bacterial populations and hypersensitivity reactions with the former. Erythromycin is used for pediatric patients with granulomatous periorificial dermatitis. The anti-inflammatory activity of the tetracyclines is well documented[51–53]. and inhibit protein kinase C. 40 mg [extended release] once daily) or lower doses of minocycline (1 mg/kg/day) has been advocated by some clinicians. Clinical improvement is not thought to be related to its effect on follicular keratinization. because of concerns 5 . given that a bacterial stimulus for this disease has not been proven. Their mechanism of action in this disease is primarily anti-inflammatory. Hydrocortisone 1% cream may be compounded with 0. Comparison studies of the effects on resistance patterns of short courses of higher doses of tetracyclines followed by similar low doses versus initial low doses are needed. sodium sulfacetamide is an older medication that can be helpful for treating mild rosacea and as an adjunct for more severe disease. inhibit granuloma formation. Topical erythromycin. but they are rarely used. there is justifiable concern about the overuse of antibiotics and the spread of resistant organisms.g. inhibit MMPs (see above). 250 mg of tetracycline or 50 mg of doxycycline daily or every other day). because of the absence of comedones in rosacea–has been reported to be helpful over the long term in treating rosacea patients.3) that is then lowered once the disease is under control.are also useful in treating the inflammatory forms of rosacea. Other oral antibiotics are occasionally useful for treating patients with rosacea.
Discrete domed inflamed papules. In general. nose. but it carries a greater risk of scarring. the periorbital and peri-oral areas are spared (Fig. B. such as is seen in acne treated with recommended cumulative doses. has no comedones or seborrhoea. occasionally. Lymphoedema. penicillins and cephalosporins are of little use in the treatment of rosacea. rarely. KOMPLIKASI The cheeks. Lasting remissions of vascular rosacea are sometimes achieved.with staining of teeth with tetracyclines. 140). Recontouring via electrosurgery or the CO2 laser is the only established method of improving fibrotic rhinophyma (see Ch. 12. a lasting response.55]. conjunctivitis and. and chin are most commonly affected. and patients may require long-term maintenance therapy with oral tetracyclines.13) that is more common in males. unlike acne. PENCEGAHAN C. nodules develop later. centre of forehead. Rosacea. caused by hyperplasia of the sebaceous glands and connective tissue on the nose. Results are best if treatment is initiated before significant fibrosis has developed. It is usually symmetrical. Isotretinoin The most severe forms of rosacea may require oral isotretinoin therapy[47. does not occur as frequently. Unfortunately. Intermittent flushing is followed by a fixed erythema and telangiectases. Rhinophyma. below the eyes and on the forehead. Isotretinoin is also helpful in treating early rhinophyma. keratitis.12). is a striking complication (Fig. Its course is prolonged.57]. is a tiresome feature in a few cases. Some patients treated with potent topical steroids develop a 6 . Inflammatory lesions and particularly refractory nodules typically respond well to 0. Electrocoagulation of telangiectasias is also effective. Complications include blepharitis. Surgical Treatments Telangiectasias and persistent erythema are effectively treated with intense pulsed light or pulsed dye lasers[56. but lower doses may be effective.5 to 1 mg/kg/day. papulopustules and. 12. with exacerbations and remissions.
1 Typical rosacea with papules and pustules on a background of erythema.rebound flare of pustules. worse than the original rosacea.1 Marked rhinophyma1 7 . when this treatment is stopped. Note he also has a patch of scaly seborrhoeic eczema on his brow.
A perioral dermatitis following withdrawal of the potent topical steroid that had been wrongly used to treat seborrhoeic eczema.2 D.1 Rosacea with rhinophyma in a woman. PROGNOSIS REFERENCES 8 . Rhinophyma usually affects men.
Buxton. BMJ Bookshop London. Aron. 9 . David. 2002. 59 5. Cohen.A. Clinical Review Diagnosis and Treatment of Rosacea. Tiemstra. J Am Board Fam Pract May–June 2002 Vol. M.Savin. Jeffrey D. 2003.Dahl.1. Gawkrodger. 3rd Edition. Clinical Dermatology. Blackwell Publishing company. Australia. 156-158 2. J.V. 2-4 4. J.A. 3.Paul K. f. 61 3.V. J. Dermatology An Illustrated colourtext. Hunter. ABC OF DERMATOLOGY Fourth Edition. 15 No.
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