Canadian Clinical Practice Guidelines for Rosacea

Abstract

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

Antibiotic Resistance Considerations of Importance to Clinical Dermatologists

“…[35][36][37][38][39][40][41][42][43] The large body of evidence supporting an inflammatory pathogenesis of rosacea that is not triggered by a bacterial etiology has led globally to rosacea management recommendations supporting that avoidance of an antibiotic effect whenever possible is favorable in order to reduce the emergence of antibiotic-resistant bacteria. [44][45][46][47] In their rosacea medical management guidelines, the American Acne & Rosacea Society stated the following: "The lack of data supporting a bacterial component definitively related to the pathogenesis of rosacea suggests overall that medical therapies which are anti-inflammatory in nature are best considered for initial treatment of rosacea, especially the inflammatory (papulopustular) subtype, with oral antibiotic agents used in cases that are poorly responsive to a reasonable trial of topical therapy and/or oral anti-inflammatory therapy". 44 To achieve this, available topical agents with demonstrated anti-inflammatory effects, efficacy, and safety in rosacea would include azelaic acid and ivermectin.…”

“…44 To achieve this, available topical agents with demonstrated anti-inflammatory effects, efficacy, and safety in rosacea would include azelaic acid and ivermectin. 41,42,[44][45][46][47][48][49] Sub-antibiotic dose doxycycline (such as the modified-release 40 mg capsule once daily or 20 mg immediate-release tablet twice daily) provides anti-inflammatory effects with efficacy and favorable safety for rosacea, without inducing antibiotic selection pressure. 40,[44][45][46][47]50 …”

An update on the treatment of rosacea

“…9,13 Topical therapies are recommended for at least six weeks to effectively review the response. 5,9 Topical corticosteroids should be avoided. 14 Treatment for flushing and erythema may involve oral drugs with vasoconstriction properties including adrenergic antagonists including mirtazapine (alpha blocker), propranolol (beta blocker) or carvedilol (both alpha and beta blocker).…”

“…Because there is no specific test, the diagnosis relies on the physician's Rosacea can be classified into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular. 1,5 Erythematotelangiectatic rosacea Erythematotelangiectatic rosacea is characterised by flushing and persistent central facial erythema. Redness may also involve the peripheral face, ears, neck and upper chest, but periocular skin is typically spared.…”

“…It is applied once daily for up to four months, and the course may be repeated if needed. 5,15 Topical dapsone is a sulfone antibacterial with antiinflammatory actions. It was recently approved for acne in Australia, but in the USA it is approved for rosacea.…”