Ac as
De mosifiliog .
2019;110(7):533---545
CONSENSUS
DOCUMENT
Spanish
Consensus
Documen
on
he
T ea men
Algo i hm
o
Rosacea夽
M.
Salle as,a,∗M.
Aleg e,bV.
Alonso-Use o,cP.
Boixeda,dJ.
Domínguez-Sil a,e
J.
Fe nández-He e a, X.
Ga cía-Na a o,gN.
Jiménez,dM.
Llamas, C.
Nadal,h
J.
del
Pozo-Losada,iI.
Que ol,jI.
Salgüe o,kM.
Schalle ,lJ.
So o
de
Delásm
aSe icio
de
De ma ología,
Hospi al
Uni e si a io
Sag ado
Co azón,
Ba celona,
Spain
bSe icio
de
De ma ología,
Hospi al
Pla ó,
Ba celona,
Spain
cSe icio
de
De ma ología,
Hospi al
Nisa
9
de
Oc ub e,
Valencia,
Spain
dSección
de
De ma ología,
Hospi al
Ramón
y
Cajal,
Mad id,
Spain
eSe icio
de
De ma ología,
Hospi al
Uni e si a io
de
G an
Cana ia
Doc o
Neg ín,
Las
Palmas
de
G an
Cana ia,
Spain
Sección
de
De ma ología,
Hospi al
de
La
P incesa,
Mad id,
Spain
gSe icio
de
De ma ología,
Conso ci
Sani a i
del
Ga a ,
Ba celona,
Spain
hSe icio
de
De ma ología,
Hospi al
Son
Lla ze ,
Palma
de
Mallo ca,
Spain
iSe icio
de
De ma ología,
Hospi al
Uni e si a io
A
Co u˜
na,
La
Co u˜
na,
Spain
jUni e sidad
de
Za agoza,
Za agoza,
Spain
kSe icio
de
De ma ología,
Hospi al
Uni e si a io
Pue a
de
Hie o
Majadahonda,
Mad id,
Spain
lDepa amen o
de
De ma ología,
Uni e sidad
de
Klinikum,
Tubinga,
Ge many
mSe icio
de
De ma ología,
Policlínica
Gipuzkoa,
San
Sebas ián,
Spain
Recei ed
3
Augus
2018;
accep ed
1
Janua y
2019
KEYWORDS
Rosacea;
B imonidine;
Me onidazole;
Doxycycline;
Ligh
sou ces;
Iso e inoin;
I e mec in
Abs ac
Recen
scien ific
e idence
and
he
inco po a ion
o
new
d ugs
in o
he
he apeu ic
a senal
agains
osacea
ha e
made
i
necessa y
o
e iew
and
upda e
ea men
c i e ia
and
s a egies.
To
his
end,
a
panel
o
15
de ma ologis s,
all
expe s
in
osacea,
was
o med
o
sha e
expe iences
and
discuss
ea men
op ions,
esponse
c i e ia,
and
changes
o
ea men .
Based
on
a
c i ical
e iew
o
he
li e a u e
and
a
discussion
o
he
ou ine
p ac ices
o
Spanish
de ma ologis s,
he
panel
p oposed
and
deba ed
di e en
op ions,
wi h
conside a ion
o
he
expe ience
o
p o essionals
and
he
p e e ences
o
pa ien s
o
equali y
c i e ia.
Following
al-
ida ion
o
he
p oposals,
he
final
ecommenda ions
we e
o mula ed
and,
oge he
wi h
he
e idence
om
he
main
in e na ional
guidelines
and
s udies,
used
o
p oduce
his
consensus
documen .
The
goal
o
his
consensus
documen
is
o
p o ide
de ma ologis s
wi h
p ac ical
ecommenda ions
o
he
managemen
o
osacea.
©
2019
Else ie
Espa˜
na,
S.L.U.
and
AEDV.
Published
by
Else ie
Espa˜
na,
S.L.U.
All
igh s
ese ed.
夽Please
ci e
his
a icle
as:
Salle as
M,
Aleg e
M,
Alonso-Use o
V,
Boixeda
P,
Domínguez-Sil a
J,
Fe nández-He e a
J,
e
al.
Documen o
de
consenso
espa˜
nol
pa a
el
algo i mo
de
a amien o
de
la
osácea.
Ac as
De mosifiliog .
2019;110:533---545.
∗Co esponding
au ho .
E-mail
add ess:
[email p o ec ed]
(M.
Salle as).
1578-2190/©
2019
Else ie
Espa˜
na,
S.L.U.
and
AEDV.
Published
by
Else ie
Espa˜
na,
S.L.U.
All
igh s
ese ed.
534
M.
Salle as
e
al.
PALABRAS
CLAVE
Rosácea;
B imonidina;
Me onidazol;
Doxiciclina;
Fuen es
de
luz;
Iso e inoína;
I e mec ina
Documen o
de
consenso
espa˜
nol
pa a
el
algo i mo
de
a amien o
de
la
osácea
Resumen
Las
úl imas
e idencias
cien íficas
y
la
inco po ación
de
nue os
á macos
al
a senal
e apéu ico
de
la
osácea
hacen
necesa io
e isa
y
ac ualiza
los
c i e ios
y
es a egias
de
a amien o.
Con
es e
fin,
un
g upo
de
15
de ma ólogos
expe os
en
es a
en e medad
apo -
a on
y
discu ie on
ace ca
de
las
di e en es
e apias
y
los
c i e ios
de
espues a
y
cambio
de
a amien o.
Pa iendo
de
la
e isión
c í ica
de
la
bibliog a ía
y
de
la
exposición
de
los
hábi os
de
los
de ma ólogos
espa˜
noles
en
su
p ác ica
clínica,
se
o mula on
dis in as
p opues as
que
ue on
deba idas
eniendo
en
conside ación
an o
la
expe iencia
p o esional
como
las
p e e en-
cias
de
los
pacien es
o
los
c i e ios
de
equidad.
Una
ez
alidadas
las
p opues as,
se
o mula on
las
ecomendaciones
finales
que,
jun o
con
la
e idencia
apo ada
po
las
p incipales
guías
y
es udios
in e nacionales,
die on
luga
al
p esen e
documen o.
El
obje i o
de
es e
consenso
es
o ece
al
de ma ólogo
un
en oque
p ác ico
pa a
abo da
la
osácea.
©
2019
Else ie
Espa˜
na,
S.L.U.
y
AEDV.
Publicado
po
Else ie
Espa˜
na,
S.L.U.
Todos
los
de echos
ese ados.
In oduc ion
Rosacea
is
a
common
ch onic
skin
disease
ha
causes
ed-
ness,
papules,
and
pus ules
mainly
on
he
ace.
The
eyes
can
also
become
comp omised
and
he
skin
may
hicken
and
inc ease
in
olume
in
he
phyma ous
o m
o
he
disease.1
Al hough
epidemiologic
s a is ics
a y,
s udies
in
Eu ope
and
he
Uni ed
S a es
es ima e
ha
he
incidence
anges
om
less
han
1%
o
mo e
han
20%
in
di e en
gene al
popula ions.2Howe e ,
compa isons
a e
di ficul
because
o
a ia ions
in
me hodology.
Examples
o
o e all
p e alence
a es
epo ed
a e
2.2%
o
Ge many,3be ween
1.3%
and
2.1%
o
he
Uni ed
S a es,4and
22%
o
Es onia.5
Rosacea
ends
o
appea
be ween
he
ages
o
30
and
50
yea s6and
mo e
o en
in
women
han
men,4al hough
men
a e
mo e
likely
o
de elop
he
phyma ous
o m.7Any
acial
o
e hnic
g oup
may
be
a ec ed,
bu
pe sons
wi h
pale
skin
ha e
g ea e
p opensi y.6
Few
s udies
ha e
looked
a
he
pa hogenesis
o
osacea,
bu
some
e idence
suppo s
he
hypo hesis
ha
a
gene ic
p edisposi ion
plays
a
key
ole8,9 and
ha
changes
in
he
inna e
immune
sys em
a e
in ol ed.
The e
is
also
e idence
o
ce ain
en i onmen al
and
o he
p edisposing
ac o s,
o
igge s,2among
hem
oods,
emo ions,
o
he
use
o
ce ain
opical
ea men s.10
In
spi e
o
he
a ailabili y
o
scien ific
e idence,
c i e-
ia
o
diagnosing
and
ea ing
he
disease
di e
and
a e
no
always
in
acco dance
wi h
clinical
sub ypes.4Recen
yea s
ha e
seen
many
ad ances
in
he
ea men
o
acial
e y hema,11,12 unde lining
he
need
o
e iew
and
upda e
diagnos ic
c i e ia
and
he apeu ic
app oaches.
This
consensus
s a emen
was
d a ed
on
he
basis
o
guidelines
and
sys ema ic
e iews
o
he
e idence
on
osacea,
among
hem
he
ones
published
by
he
Ame i-
can
Acne
and
Rosacea
Socie y13---17 and
he
Coch ane
s udy
o
in e en ions,8which
also
ook
supplemen a y
da a
om
a
Ge man
guideline
in o
conside a ion.
Thus,
he
p esen
Spanish
consensus
b ings
oge he
he
la es
e i-
dence
a ailable,19 including
s udies
ela ed
o
he
clinical
assessmen
o
he
disease,
ea men
objec i es,
and
he a-
pies.
I
is
mean
o
p o ide
a
poin
o
e e ence
and
p ac ice
ecommenda ions
o
de ma ologis s
who
ea
osacea.
The
s a emen
does
no
include
less
common
and
complex
o ms
o
he
disease,
such
as
hose
caused
by
in es a ions
o
mi es
(Demodex
species),
g anuloma ous
osacea,
o
osacea
ul-
minans.
No
does
i
discuss
he
a ious
cosme ic
p oduc s
o en
used
by
pa ien s
wi h
osacea
(cleanse s,
mois u ize s,
sunsc eens,
e c.).
Such
p oduc s,
e en
hough
conside ed
necessa y
by
he
panel
o
expe s,
a e
no
co e ed
by
his
s a emen .
Me hods
Fi een
de ma ologis s
we e
selec ed
o
he
panel
o
expe s
on
he
basis
o
hei
le el
o
knowledge
and
clin-
ical
and
esea ch
expe ience
(see
online
supplemen a y
ma e ial,
in
Spanish).
One
o
he
expe s
(M.S.)
se ed
as
coo dina o ;
he
o he s
all
pa icipa ed
in
he
discussion
and
alida ion
s eps.
The
coo dina o
p o ided
a
lis
o
opics
consis ing
o
clinically
impo an
ques ions
ha
would
be
add essed
by
he
panel’s
ecommenda ions.
She
hen
collec ed
and
in e -
p e ed
a ailable
e idence
a e
a
e iew
o
he
li e a u e
and
d a ed
a
se
o
ecommenda ions
o
submi
o
he
panel
o
expe
de ma ologis s.
To
cha ac e ize
he
app oaches
he
expe
panel
applied
in
hei
own
clinical
p ac ices,
he
de ma ologis s
answe ed
23
ques ions
ela ed
o
hei
diagnosis
and
ea men
o
he
disease
(Table
1).
(See
online
supplemen a y
ma e ial,
Table
S1
o
he
mos
impo an
esul s,
in
Spanish.)
Based
on
he
su ey
and
he
e iew
o
he
li e a u e,
he
coo dina-
o
d a ed
ecommenda ions
on
which
he
panel
eached
consensus
h ough
discussion.
Discussion
ocused
mainly
on
ques ions
abou
which
opinions
di e ged
o
o
which
e i-
dence
was
lacking.
Sea ch
S a egy
and
A icle
Selec ion
The
ollowing
da abases
we e
sea ched
o
loca e
and
selec
a icles:
MEDLINE/PubMed,
he
Coch ane
Lib a y,
and
Google
Schola .
The
sea ch’s
ocus
was
on
finding
o iginal
and
e iew
a icles
in
English
o
Spanish
published
be ween
Spanish
Consensus
Documen
on
he
T ea men
Algo i hm
o
Rosacea
535
Table
1
Ini ial
Ques ionnai e
o
De e mine
he
P ofiles
o
he
Panel
o
Expe s
and
Thei
App oaches
o
Rosacea
To
be
answe ed
by
he
expe
de ma ologis s
1.
De ma ologis ’s
a filia ion:
Indica e
you
age
g oup:
<30
31---40
41---50
>
50
y
P o ince
whe e
you
wo k:
Type/loca ion
o
you
de ma ology
p ac ice:
P i a e
p ac ice
Na ional
heal h
se ice
(public
sec o )
Bo h
2.
Which
ype
o
p ac ice
accoun s
o
mos
o
you
caseload?
P i a e
p ac ice
Na ional
heal h
se ice
(public
sec o )
3.
How
many
pa ien s
do
you
ea
e e y
week
on
a e age?
<
30
Be ween
30
and
50
>
50
4.
App oxima ely
how
many
pa ien s
do
you
ea
o
p oblems
ela ed
o
osacea
in
a
ypical
week?
0 --- 5
pe
week
5---10
pe
week
10---15
pe
week
>15
pe
week
5.
Rosacea
is
classified
as
ollows:
e y hema o elangiec a ic,
papulopus ula ,
phyma ous,
and
ocula .
Do
you
ag ee
wi h
his
classifica ion?
Yes
(I
yes,
do
you
use
his
classifica ion
in
you
clinical
p ac ice?)
No
(I
no ,
speci y
he
classifica ion
you
use
in
you
clinical
p ac ice.)
6.
Wha
c i e ia
do
you
use
o
de e mine
he
se e i y
o
a
pa ien ’s
osacea?
Clinical
sub ype,
as
indica ed
abo e
Numbe
o
lesions
(in
cases
o
papulopus ula
osacea)
Impac
on
quali y
o
li e
(DLQI)
7.
How
do
you
p oceed
in
cases
o
sub ype
1
osacea
(e y hema o elangiec a ic)?
Only
ea
i
he
pa ien
eques s
i
(DLQI)
Sugges
ea men
i
signs
a e
e iden
Always
ea ,
as
he e
is
isk
o
de eloping
papulopus ula
osacea
Do
no
ea
8.
In
cases
o
sub ype
2
osacea
(papulopus ula )
How
many
lesions
would
you
say
indica e
a
mild
case?
0---10
lesions
11---20
lesions
>
20
lesions
How
many
lesions
would
you
say
indica e
a
mode a e
le el
o
se e i y?
0---10
lesions
11---20
lesions
>
20
lesions
How
many
lesions
would
you
say
indica e
a
se e e
case?
0---10
lesions
11---20
lesions
>
20
lesions
Does
he
de elopmen
o
nodules/g anulomas
change
you
pe cep ion
o
se e i y
in
osacea?
Yes,
I
immedia ely
judge
he
case
o
be
se e e
Yes,
I
conside
osacea
wi h
2
o
mo e
nodules
o
be
se e e
Yes,
I
conside
a
case
wi h
3
o
mo e
nodules
o
be
se e e
No,
he
p esence
o
nodules
does
no
al e
my
pe cep ion
o
se e i y
in
osacea
9.
Wha
pe cen age
o
you
pa ien s
wi h
osacea
all
in o
he
ollowing
le els
o
se e i y?
Mild
osacea
Mode a e
osacea
Se e e
osacea
536
M.
Salle as
e
al.
Table
1
(Con inued)
10.
Is
he
p oblem
o
an ibio ic
esis ance
impo an
in
you
opinion?
Yes
No
11.
A e
de ma ologic
ea men s
con ibu ing
o
an ibio ic
esis ance
in
you
opinion?
Yes
No
12.
When
you
selec
an
app oach
o
ea ing
osacea,
do
you
conside
an ibio ics?
Yes
No
13.
Wha
ea men s
do
you
usually
p esc ibe
o
osacea?
(ac i e
ing edien s)
Topical:
Me onidazole
Azelaic
acid
I e mec in
Clindamycin
E y h omycin
Sul ace amide
O he
O al:
Minocycline
Doxycycline
40
mg
Doxycycline
50/100/200
mg
Me onidazole
Mac olides
(e y h omycin,
cla i h omycin,
azi h omycin)
O he
14.
Fo
wha
pe iod
do
you
ins uc
he
pa ien
o
use
opical
an ibio ic
he apy
o
osacea
on
a e age?
0---1.5
mo
1.5---3
mo
3 --- 2
mo
Indefini ely
15.
Fo
how
long
do
you
p esc ibe
o al
an ibio ic
he apy
o
osacea
on
a e age?
0---1.5
mo
1.5---3
mo
3---12
mo
Indefini ely
16.
Wha
e ec
a e
you
seeking
when
you
p esc ibe
an
o al
o
opical
an ibio ic
o
osacea?
An i-inflamma o y
An ibac e ial
Bo h
17.
Which
o
he
ollowing
s a emen s
desc ibe
you
easons
o
p esc ibing
a
opical
an ibio ic
o
osacea?
I
is
necessa y
o
ea ing
a
disease
in
which
mi es
a e
a
con ibu ing
ac o .
I
only
p esc ibe
opical
an ibio ics
o
hei
an i-inflamma o y
e ec .
I
don’
eel
com o able
no
using
using
an
an ibio ic
o
ea
an
in ec ious
disease.
Pa ien s
ask
o
an ibio ic
ea men .
I ’s
wha
I’m
used
o
doing.
18.
Which
o
he
ollowing
s a emen s
desc ibe
you
easons
o
p esc ibing
an
o al
an ibio ic
o
osacea?
I
is
necessa y
o
ea ing
a
disease
in
which
mi es
a e
a
con ibu ing
ac o .
I
only
p esc ibe
opical
an ibio ics
o
hei
an i-inflamma o y
e ec .
I
don’
eel
com o able
no
using
using
an
an ibio ic
o
ea
an
in ec ious
disease.
Pa ien s
ask
o
an ibio ic
ea men .
I ’s
wha
I’m
used
o
doing.
The
suban imic obial
dose
o
doxycycline
(40
mg)
is
e ec i e
o
he
papulopus ula
lesions
o
osacea
and
does
no
induce
esis ance.
19.
Wha
is
you
main
eason
o
p esc ibing
o al
iso e inoin?
Failu e
o
o al
an ibio ics
I
don’
wan
o
use
o al
an ibio ics
because
osacea
is
no
an
in ec ious
disease.
Se e i y
o
osacea
Pa ien ’s
eques
20.
Do
you
ake
in o
accoun
he
ollowing
ac o s
when
you
p esc ibe
an
o al
iso e inoin?
(Ma k
all
ha
apply.)
Ad e se
e ec s/skin
in ole ance
specific
o
osacea
Spanish
Consensus
Documen
on
he
T ea men
Algo i hm
o
Rosacea
537
Table
1
(Con inued)
P io
ea men
ailu es
Pa ien ’s
a i ude
Need
o
p esc ibe
con acep i es
( emale
pa ien )
Iso e inoin,
a he
han
cu ing
osacea,
a enua es
disease
ac i i y
while
i
is
aken.
O he
(please
speci y)
21.
How
do
you
ea
each
ype
o
lesion?
(I
you
indica e
mo e
han
1
ea men ,
i
is
assumed
you
use
hem
in
combina ion.)
Fi s
line:
Second
line:
Main enance:
22.
Do
you
ecommend
cosme ic
p oduc s
along
wi h
con en ional
medica ions?
(Eg,
cleanse s,
sunsc eens,
mois u ize s,
make-up)
Yes
No
I
you
answe ed
yes:
Wha
ins uc ions
do
you
gi e?
Use
hem
be o e
he
ea men
Use
hem
a e
he
ea men
Use
hem
be o e
and
a e
he
ea men
23.
Do
you
hink
ha
he e
is
a
comple e
ange
o
osacea
ea men s
a ailable
a
p esen ?
Yes
No.
(Wha
gaps
mus
be
filled?)
Abb e ia ion:
DLQI,
De ma ology
Quali y
o
Li e
Index.
2002
and
2015.
Limi e s
ela ed
o
me hods
we e
as
ollows:
e iews;
case
se ies;
p e alence,
coho
o
case---con ol
s udies;
non andomized
and
andomized
con olled
ials;
and
me a-analyses.
All
o iginal
esea ch
had
o
include
pa ien s
wi h
osacea.
The
a icles
loca ed
we e
e alua ed
o
iden i y
hose
wi h
da a
use ul
o
answe ing
he
clin-
ical
ques ions
and
make
ecommenda ions
based
on
he
highes
a ailable
le els
o
e idence.
The
CASPe
c i e ia
(C i ical
App aisal
Skills
P og amme,
Spanish
e sion)20 we e
used
o
assess
quali y
and
alidi y.
F om
hese
c i e ia
he
s eng h
o
e idence
o e ed
by
each
s udy
was
in e ed,
o
de e mine
he
le el
o
impac
each
would
ha e
on
ecom-
menda ions.
The
panel
hen
assessed
he
quali y
o
e idence
o
he
esul s
o e all
and
ca ego ized
he
ecommenda ions
acco ding
o
he
GRADE
sys em
(G ading
o
Recommenda-
ions
Assessmen ,
De elopmen
and
E alua ion),21 which
p o ides
explici ,
sys ema ic
classifica ions.
C i e ia
aken
in o
accoun
in
he
p ocess
o
e alua ing
he
le el
o
e i-
dence
we e
me hodological
sho comings,
consis ency
o
esul s,
gene alizabili y
o
conclusions,
and
e ec
size.
Once
he
li e a u e
had
been
assessed,
ecommenda ions
we e
d a ed
based
on
he
bes
a ailable
e idence,
clinical
expe ience,
and
applicabili y.
The
d a ed
ecommenda-
ions
we e
hen
classified
and
p io i ized
o
implemen a ion
in
ounds
o
discussion
o
he
ques ions
posed
o
he
panel
o
expe s.
P ocedu es
o
Reaching
Consensus
Twen y
a fi ma ions
we e
g ouped
unde
4
headings:
a)
defini ion
o
osacea,
b)
impac
on
quali y
o
li e
(QoL),
c)
he apeu ic
app oach,
and
d)
ea men s.
The
panel
o
expe s
me
o
open
discussion
o
all
he
p oposed
s a emen s,
deba ing
each
one
indi idually
and
p oposing
imp o emen s
o
inco po a e
in o
he
final
ecommenda-
ions.
To
acili a e
he
measu emen
o
deg ee
o
consensus,
he
expe s
a ed
hei
ag eemen
wi h
each
ecommen-
da ion
on
a
Like
scale.22 I
a
leas
75%
o
hem
ag eed
o
o ally
ag eed
wi h
an
i em,
consensus
was
assumed.
In
he
fi s
ound
o
o ing,
consensus
was
eached
on
17
ecommenda ions.
On
8
o
hem
ag eemen
was
high.
Two
o he
i ems
we e
alida ed
by
consensus
a e
he
sec-
ond
ound
o
discussion
and
assessmen .
Thus,
a
o al
o
19
ecommenda ions
and
4
ea men
algo i hms,
one
o
each
sub ype
o
osacea,
we e
app o ed
(Fig.
1).
(See
Appendix
BS1,
online
supplemen a y
ma e ial,
in
Spanish.)
Table
2
summa izes
he
consensus-based
ecommenda ions
issued
by
he
panel
o
expe s
a e
e iew
o
he
a ailable
e idence.
Consensus
Rega ding
he
T ea men
o
Rosacea
Defini ion
o
Rosacea
Rosacea
is
a
common
ch onic
skin
disease
wi h
a iable
symp oms
ha
usually
a ec
he
con ex
a eas
in
he
cen e
o
he
ace
(cheeks,
chin,
nose,
and
cen e
o
he
o e-
head).
This
condi ion
includes
a ious
cu aneous
signs
such
as
ansien
flushing,
non ansien
e y hema,
elangiec asia,
edema,
papules,
pus ules,
ocula
in ol emen ,
and
phyma-
ous
changes.
Mos
pa ien s
mani es
only
a
ew
o
hese
signs,
bu
o he s
may
de elop
mo e
han
one
mani es a ion
o
he
disease
simul aneously.23
Fou
o ms,
o
sub ypes,
o
osacea
a e
cu en ly
desig-
na ed,
as
ollows:
1,
e y hema o elangiec a ic
osacea,
2,
papulopus ula
osacea,
3,
ocula
osacea,
and
4,
phyma-
ous
osacea.
Howe e ,
in o ma ion
abou
hei
signs
and

538
M.
Salle as
e
al.
Table
2
Recommenda ions
Issued
by
he
Panel
o
Expe s
Recommenda ion
Basis
o
Recommenda ion
Quali y
o
E idence/S eng h
o
Recommenda ion
Rosacea
is
a
common
ch onic
skin
disease
wi h
a iable
symp oms
ha
usually
a ec
he
cen al
a ea
o
he
ace.
Expe
consensus
NA
The
classifica ion
o
osacea
in o
4
sub ypes
is
p ac ical
when
applied
o
he
esul s
o
clinical
esea ch.
Expe
consensus
NA
The
clinical
sub ypes
o
osacea
a e
use ul
o
classi ying
signs
and
symp oms;
howe e ,
hey
do
no
cla i y
such
aspec s
as
ch onici y
o
he
cou se
o
disease
as
i
is
exp essed
in
indi idual
ea u es
o
he
disease.
Expe
consensus
NA
Rosacea
can
a ec
an
indi idual’s
psychological
and
social
well-being.
De ma ologis s
should
bea
in
mind
osacea’s
impac
on
he
pa ien ’s
quali y
o
li e
when
deciding
on
a
ea men
app oach.
E idence
based25 Mode a e
quali y
S ong
ecommenda ion
Allow
ime
o
a
ea men
o
ake
e ec
be o e
changing
o
ano he
one,
p o ided
he
ea men
is
ole a ed.
Expe
consensus
NA
I
he e
is
no
esponse
o
a
fi s -line
ea men ,
ano he
fi s -line
ea men
can
be
p esc ibed
o
a
second
ea men
can
be
added.
Expe
consensus NA
Choice
o
a
main enance
he apy
should
be
indi idualized.
Gi e
p e e ence o
he
leas
agg essi e
he apy
ha
achie es
con ol
o
symp oms.
Expe
consensus NA
P esc ibe
mo e
han
one
ea men
when
he
signs
o
symp oms
o
osacea
a e
se e e.
Expe
consensus
NA
Topical
b imonidine
o
o al
ˇ-blocke s
can
be
conside ed
o
ea ing
ansien
e y hema
(flushing).
E idence
based11,26
Expe
consensus
High
quali y
S ong
ecommenda ion
NA
Pulsed
dye
lase
and
IPL
he apy
a e
he
fi s -choice
ea men s
o
non ansien
e y hema;
b imonidine
can
be
used
o
symp oma ic
ea men .
E idence
based18 High
quali y
S ong
ecommenda ion
IPL
and
lase
ea men s
a e
fi s -line
choices
o
elangiec asia.
Expe
consensus
NA
Topical
agen s
such
as
i e mec in
and
me onidazole
a e
he
fi s -line
ecommenda ions
o
ea ing
osacea
wi h
mild
inflamma o y
lesions
(papules
and
pus ules).
O al
doxycycline
can
be
conside ed
an
al e na i e.
E idence
based32,33 Mode a e
quali y
S ong
ecommenda ion
Topical
agen s
such
as
i e mec in
and
me onidazole
and
o al
doxycycline
a e
he
fi s -line
ecommenda ions
o
ea ing
osacea
wi h
mode a ely
se e e
inflamma o y
lesions
(papules
and
pus ules).
E idence
based15,18,34 High
quali y
S ong
ecommenda ion
Sys emic
ea men
(doxycycline
o
iso e inoin)
wi h
o
wi hou
associa ed
opical
he apy
(i e mec in
o
me onidazole)
o
physical
ea men s
a e
he
fi s -line
ecommenda ions
o
osacea
wi h
se e e
inflamma o y
lesions
(papules
and
pus ules).
E idence
based16,19 High
quali y
S ong
ecommenda ion
I
e acyclines
a e
conside ed
o
he
inflamma o y
lesions
o
osacea,
he
minimum
e ec i e
dose
o
doxycycline
is
ecommended
in
o de
o
minimize
he
isk
o
bac e ial
esis ance.
E idence
based17,18,35 High
quali y
S ong
ecommenda ion
Sys emic
ea men
wi h
doxycycline
o
iso e inoin
is
he
fi s -line
ecommenda ion
o
ac i e
phyma ous
lesions.
Expe
consensus
NA
Su gical
p ocedu es
such
as
de mab asion,
elec odesicca ion,
o
lase
ea men s
a e
ecommended
as
fi s -line
ea men s
o
phyma ous
lesions
wi hou
clinical
inflamma ion.
Scanned
o
pulsed
ca bon
dioxide
lase
in
con inuous
mode
is
p e e ed
because
i
a o ds
he
abili y
o
sculp
and
p o ide
hemos asis
simul aneously.
Expe
consensus
NA
De ma ologis s
should
be
able
o
ecognize
he
ocula
mani es a ions
o
osacea.
Pa ien s
wi h
al e ed
ision,
conjunc i al
in ol emen ,
o
signs
o
co neal
in ol emen
should
be
e e ed
o
an
oph halmologis .
Expe
consensus
NA
The
ea men
o
ocula
osacea
depends
on
se e i y.
Gene al
measu es
o
ake
a e
adequa e
cleansing,
he
applica ion
o
opical
p epa a ions
(me onidazole,
e acyclines,
o
ciclospo in),
and
he
use
o
sys emic
he apy
(doxycycline,
sho - e m
co icos e oids,
o
iso e inoin).
Expe
consensus
NA
Abb e ia ions:
IPL,
in ense
pulsed
ligh ;
NA,
no
applicable.
Spanish
Consensus
Documen
on
he
T ea men
Algo i hm
o
Rosacea
539
symp oms,
he
ela ions
be ween
he
sub ypes,
and
he
po en ial
o
p og ession
om
one
o
ano he
emains
scan .24
The
expe s’
opinion
was
ha
al hough
his
classifica ion
sys em
is
clinically
uncon incing
i
is
p ac ical
o
esea ch.
Recommenda ions:
Rosacea
is
a
common
ch onic
skin
disease
wi h
a iable
symp oms
ha
usually
a ec
he
cen al
a ea
o
he
ace.
The
classifica ion
o
osacea
in o
4
sub ypes
is
p ac ical
when
applied
o
he
esul s
o
clinical
esea ch.
The
clinical
sub ypes
o
osacea
a e
use ul
o
classi y-
ing
signs
and
symp oms;
howe e ,
hey
do
no
cla i y
such
aspec s
as
ch onici y
o
disease
cou se
in
e ms
o
indi idual
clinical
ea u es.
E ec
on
QoL
Rosacea
mainly
a ec s
he
ace
and
i s
impac
on
a
pa ien ’s
QoL
is
indispu able.
All
s udies
on
QoL
in
osacea
ha e
shown
ha
pa ien s
eel
emba assmen
and
anxie y.25 They
may
also
expe ience
lack
o
confidence,
low
sel -es eem,
a
nega i e
body
image,
and
dep ession.
Unde s anding
he
pa ien ’s
iew
o
QoL
is
ex emely
impo an
o
dis-
ease
managemen
and
choosing
an
app op ia e
ea men .
Knowledge
o
concomi an
condi ions,
such
as
mig aine
o
gas oin es inal
diso de s,
will
also
influence
choice
o
he -
apy.
I
is
impo an
o
bea
in
mind
how
long
i
will
ake
o
a
ea men ’s
ac i e
ing edien
o
ake
e ec .
The
du a ion
o
ea men
should
also
be
aken
in o
accoun .
Finally,
each
medica ion’s
ad e se
e ec s
mus
be
wa ched
o .1
The
osacea
pa ien
is
some imes
anxious
because
o
p io
expe iences
wi h
ailed
he apy
o
unsa is ac o y
ou -
comes.
I
he
esponse
comes
slowly,
he
clinician
mus
insis
on
wai ing
un il
a
medica ion
can
ake
e ec
unless
he
pa ien
canno
ole a e
i s
ad e se
e ec s.
T ea ing
an
ou -
b eak
o
osacea
usually
akes
6
o
8
weeks.
Al hough
i
is
gene ally
said
ha
second-line
ea -
men s
should
only
be
used
once
fi s -line
ea men s
p o e
insu ficien ,
in
ac
he e
a e
se e al
fi s -line
ea men s
a ailable
and
he
expe
panel
ound
i
di ficul
o
ag ee
on
a
scale
o
p e e ences
o
hese
opical
he apies.
Recommenda ions:
Rosacea
can
a ec
an
indi idual’s
psychological
and
social
well-being.
Bea
in
mind
osacea’s
impac
on
he
pa ien ’s
QoL
when
deciding
how
o
app oach
ea men .
Allow
ime
o
a
ea men
o
ake
e ec
be o e
changing
o
ano he
one,
p o ided
he
ea men
is
ole a ed.
I
he e
is
no
esponse
o
a
fi s -line
ea men ,
ano he
fi s -line
ea men
can
be
p esc ibed
o
a
second-line
ea -
men
can
be
added.
The apeu ic
app oach
Rosacea
should
be
ea ed
acco ding
o
sub ype.
When
he
sub ype
is
diagnosed,
a
medica ion
wi h
app op ia e
ac i e
ing edien s
o
ha
ype
should
be
selec ed.
Gene al
ad ice
o
pa ien s
wi h
osacea
includes
gen le
cleansing,
equen
use
o
a
mois u ize ,
and
ou ine
use
o
sunsc eens
wi h
a
p o ec ion
ac o
be ween
30
and
50.
These
measu es
and
he
elimina ion
o
a enua ion
o
agg a a ing
ac o s
o
clima e
and
die ,
o
example,
a e
e y
impo an
o
managing
common
symp oms
such
as
d yness,
p u i us,
o
a
bu ning
sensa ion.
Membe s
o
he
panel
o
expe s
acknowledged
hem
in
discussion,
al hough
hey
we e
no
specifically
e alua ed.
How
is
main enance
he apy
app oached?
Is
i
always
nec-
essa y?
Is
i
p o ided
only
i
he
pa ien
asks
o
i ?
The
ch onic
na u e
o
osacea
jus ifies
he
use
o
some
ype
o
main enance
he apy
app op ia e
o
he
pa ien ’s
cou se
o
disease.
Some
pa ien s
en e
in o
emission
and
emain
so
o
long
pe iods,
whe eas
o he s
expe ience
many
elapses
wi hin
sho
pe iods
o
ime.
A
main enance
ea men
can
keep
a
pa ien
ee
o
lesions
o
be ween
1
and
3
yea s,
depending
on
se e i y.
Tailo ing
is
necessa y.
The
physician’s
a i ude
and
ecommenda ion
will
be
ele an ,
bu
he
final
decision
is
he
pa ien ’s.
The
goal
is
o
educe
he
likeli-
hood
o
ecu ence.
Al hough
a
opical
ea men
is
usually
p esc ibed,
he
pa ien ’s
p e e ence
mus
be
conside ed.
A
combina ion
o
opical
and
o al
he apy
is
op imal
in
mode a e
o
se e e
osacea.
Bo h
he
physician
and
pa ien ’s
iew
o
se e i y
a e
ele an ,
along
wi h
how
quickly
he
pa ien
desi es
o
see
esul s.17)
Recommenda ions:
Choice
o
a
main enance
he apy
should
be
indi idual-
ized.
Gi e
p e e ence
o
he
leas
agg essi e
he apy
ha
achie es
con ol
o
symp oms.
P esc ibe
mo e
han
one
ea men
when
he
signs
o
symp oms
o
osacea
a e
se e e.
T ea men
E y hema
and
elangiec asia:
sub ype
1
osacea
Facial
e y hema,
whe he
i
is
a
cons an ,
unde lying
p es-
ence
(no
ansien )
o
appea s
occasionally
ei he
as
a
esul
o
a
clea
igge
ac o
o
wi hou
one
( ansien
e y hema,
also
known
as
flushing),
is
p obably
he
mos
com-
mon
ea u e
o
osacea
and
one
o
he
g ea es
conce ns
om
he
pa ien ’s
poin
o
iew.
E y hema
migh
espond
su ficien ly
well
o
he
appli-
ca ion
o
opical
␣2
ad ene gic
ecep o
agonis s,
which
induce
he
cons ic ion
o
supe ficial
essels
and
a enu-
a e
unde lyling
e y hema
o
se e al
hou s;
howe e ,
hey
do
no
ac
on
elangiec asia.17 Lase
and
o he
ligh
he a-
pies
such
as
in ense
pulsed
ligh
(IPL)
ea men s
can
also
be
p esc ibed
o
e y hema
and
a e
he
main
ea men s
o
elangiec asia.17,18
T ansien
e y hema
(flushing)..
Topical
b imonidine
a -
a e
in
a
0.5%
gel
o mula ion
applied
once
daily
in
he
mo ning
has
been
e alua ed
in
2
andomized
double-blind
con olled
ials
(phase
3)
ha
compa ed
he
ac i e
o -
mula ion
o
ehicle
o
he
ea men
o
mode a e
o
se e e
e y hema
in
osacea
whe he
ansien
(flushing)
o
pe manen .11,26 The
ials
demons a ed
he
o mula ion
was
e ec i e
in
a ound
70%
o
pa ien s.
Onse
o
e ec
occu s
abou
30
minu es
a e
applica ion.
The
peak
e ec
is
be ween
3
and
9
hou s
la e ,
and
i
dec eases
un il
i
disappea s
a
abou
12
hou s.
B imonidine
is
he e o e
indi-
ca ed
o
ea
he
acial
edness
o
osacea27,28 as
a
fi s -line
op ion.
Howe e ,
e en
hough
i
is
conside ed
he
mos
sig-
nifican
ad ance
in
he
ea men
o
ansien
e y hema
o
da e,
i
is
poo ly
ole a ed
by
some
pa ien s.
Fu he mo e,
540
M.
Salle as
e
al.
i
is
impo an
o
no e
ha
b imonidine
o e s
symp oma ic,
no
defini i e
he apy
o
he
disease,
a
poin
ha
is
made
in
he
summa y
o
p oduc
cha ac e is ics.29
Lase
and
o he
ligh
he apies
(by
hemsel es
o
in
combina ion
wi h
b imonidine)
con inue
o
be
he
main
op ions
in
he
he apeu ic
a senal
agains
e y hema,27,30
e en
hough
hese
physical
ea men s
a e
mo e
e ec i e
agains
elangiec asia
and
less
e ec i e
agains
e y hema.
In
pa icula ,
when
known
igge
ac o s
a e
in ol ed,
ligh
he apies
only
lead
o
pa ial
imp o emen .
Flushing
can
also
be
ea ed
wi h
oxyme azoline
1%
c eam
and
o al
clonidine,
␤-blocke s
(p op anolol,
ca edilol),
naloxone
o
ondanse on.
Howe e ,
only
limi ed
e idence
suppo s
his
use
o
hese
agen s.28 The
panel
o
expe s
suppo ed
he
use
o
o al
␤-blocke s
and
o he
an i-
hype ensi e
d ugs
as
o -label,
second-line
ea men s
o
ansien
e y hema.
Non ansien
(pe manen )
e y hema..
Non ansien
acial
e y hema
in
osacea
can
espond
o
specific
lase
o
o he
ligh
he apies
such
as
pulsed
dye
lase
(PDL)
and
IPL,16
which
ha e
been
shown
o
ha e
simila
e ec s.18 B i-
monidine
mono he apy
as
a
symp oma ic
ea men
o
pe manen
e y hema
can
also
be
a
good
choice.18 The
panel
o
expe s
ecommended
combining
PDL
o
IPL
wi h
b imoni-
dine
as
a
fi s
line
o
he apy.
Some
o
he
an ihype ensi e
agen s
men ioned
abo e
can
be
used
o
ea
pe manen
as
well
as
ansien
e y hema.
␤-blocke s,
which
ac
as
asocons ic o s
on
cu a-
neous
a e ies
by
blocking
he
␤2-ad ene gic
pa hway,
a e
used
o
label
o
e y hema.31 The
expe s,
who
epo ed
ha ing
only
sligh
expe ience
wi h
hese
d ugs,
ad ised
using
ascula
lase
he apy
fi s ,
sa ing
o al
␤-blocke s
o
label
as
a
second-line
op ion
o
pe manen
e y hema.
Telangiec asia.
Bo h
PDL
and
IPL
ea men s
ha e
ben-
eficial
e ec s
on
elangiec asia.30 These
2
ypes
o
ligh
he apy
a e
fi s -line
ea men
choices
and
can
be
used
in
combina ion.
The
expe s
disag eed
ega ding
he
use
o
elec odesic-
ca ion
on
elangiec asia.
I
no
o he
echnique
is
a ailable,
i
is
possible
o
ob ain
good
esul s
wi h
he
elec ic
scalpel
in
he
igh
hands,
al hough
elec odesicca ion
is
no
gen-
e ally
conside ed
o
be
a
fi s -choice
ool
o
his
pu pose.
The e o e,
he
expe s
placed
i
among
second-line
ea -
men s.
Recommenda ions:
Topical
b imonidine
o
o al
␤-blocke s
can
be
conside ed
o
ea ing
ansien
e y hema
(flushing).
PDL
and
IPL
he apy
a e
he
fi s -choice
ea men s
o
non ansien
e y hema;
b imonidine
can
be
used
o
symp-
oma ic
ea men .
IPL
and
lase
ea men s
a e
fi s -line
choices
o
elang-
iec asia.
Table
3
summa izes
he
expe s’
consensus
on
he
ea -
men
o
e y hema o elangiec a ic
osacea
(sub ype
1).
Papulopus ula
osacea:
sub ype
2
Fi s -line
ea men s
o
mild
inflamma o y
papulopus ula
lesions
include
opical
i e mec in
o
me onidazole
and
o al
doxycycline,
al hough
hei
e ficacy
is
no
exac ly
he
same
in
his
clinical
se ing.1
Eu opean
and
o he
in e na ional
consensus
s a emen s
include
azelaic
acid
as
a
fi s -line
ea men ,17,18 bu
he
expe
panel
epo ed
ha
su eys
o
Spanish
p ac i ione s
indica e
ha
ew
o
hem
conside
his
op ion
fi s .
Ins ead,
hey
use
i
as
a
complemen a y
he apy
o
a
main enance
ea men
be ween
exace ba ions.
The e o e,
hey
choose
mainly
be ween
me onidazole
and
i e mec in.14,32 Sul ac-
e amide
in
associa ion
wi h
a
bisulfi e
is
also
ou inely
used
in
some
coun ies,
such
as
he
Uni ed
S a es,
bu
hese
p od-
uc s
a e
no
a ailable
in
Spain.
De ma ologis s
ou inely
use
me onidazole
and
i e -
mec in
based
on
hei
clinical
expe ience
and
pa ien
cha ac e is ics
such
as
adhe ence
o
p esc ip ion,
socioe-
conomic
le el,
and
heal h
ca e
co e age.
One
andomized
in es iga o -blinded
ial
(phase
2)
wi h
960
pa ien s
ound
ha
i e mec in
1%
c eam
once
daily
was
supe io
o
me on-
idazole
0.75%
c eam
wice
daily
a e
16
weeks
o
ea men
(83.0%
s
73.3%,
P
<
.001)
and
ha
i e mec in’s
e ficacy
ended
o
imp o e
wi h
ime,
e en
in
pa ien s
wi h
mo e
se e e
disease.32 I e mec in’s
sa e y
and
ole ance
p ofile
was
also
supe io
o
ha
o
me onidazole
in
ha
s udy.
S ein
Gold
e
al12 compa ed
he
sa e y
o
long- e m
use
o
i e mec in
1%
c eam
and
azelaic
acid
15%
gel
as
main-
enance
ea men s
o
papulopus ula
osacea
in
40-week
in es iga o -blinded
ex ensions
o
2
p io
phase-3
ials.
They
epo ed
ha
mo e
ou comes
we e
eco ded
as
‘‘clea
o
almos
clea ’’
(in es iga o ’s
global
assessmen )
in
he
i e mec in
g oup
han
in
he
azelaic
acid
g oup.
Sa e y
and
ole ance
du ing
ollow-up
we e
also
be e
in
he
i e -
mec in
g oup.
Topical
he apy
is
usually
adequa e
o
ea ing
mild
papulopus ula
osacea.
Howe e ,
mode a e
o
se e e
dis-
ease
usually
equi es
he
addi ion
o
sys emic
he apy.17,19
I e mec in,
me onidazole,
and
azelaic
acid
we e
once
again
he
fi s -line
choices
o
papulopus ula
lesions
and
mode a ely
in ense
pe ilesional
e y hema.17 Te acyclines
we e
also
fi s -line
op ions.
Some
s udies
ha e
e alua ed
me onidazole
o
azelaic
acid
in
combina ion
wi h
o al
doxycycline,
finding
ha
com-
bined
opical
and
sys emic
he apy
is
mo e
e ec i e
han
opical
he apy
alone,
wi hou
causing
a
ise
in
ad e se
e ec s.14 Likewise,
phase-3
s udies
ha e
shown
ha
an
an i-
inflamma o y
(suban imic obial)
doxycycline
dose
(40
mg/d)
can
be
used
as
a
fi s -line
ea men
in
mono he apy
o
papulopus ula
osacea.34 In
ac
US
and
Ge man
guidelines
ecommend
his
app oach
o
ea ing
his
sub ype
o
he
disease.15,18
Del
Rosso
e
al17 compa ed
he
sa e y
and
e ficacy
o
an
an i-inflamma o y
dose
o
a
slow- elease
o mula-
ion
o
doxycycline
(40
mg)
e sus
an
an imic iobial
dose
(100
mg/d)
o e
a
pe iod
o
16
weeks.
The
p ospec i e,
an-
domized
con olled
mul icen e
ial
en olled
96
pa ien s
and
led
o
he
conclusion
ha
bo h
doses
we e
equally
e ec i e
in
ea ing
se e e
osacea,
al hough
an
ad an age
o
he
lowe
dose
was
ha
i
was
associa ed
wi h
ewe
ad e se
e ec s
and
did
no
con ibu e
o
he
de elopmen
o
esis ance.35 A
US
consensus
epo
also
concluded
ha
esis ance
was
a oided
by
p esc ibing
he
40-mg
dose.17
Con o e sy
o e
an ibio ic
use
in
osacea.
The
con o-
e sy
su ounding
he
use
o
an imic obial
doses
(50---200
mg)
o
e acyclines
e sus
an
an i-inflamma o y
dose
(40
mg)
was
ully
discussed
du ing
he
consensus
mee ing.
Spanish
Consensus
Documen
on
he
T ea men
Algo i hm
o
Rosacea
541
Table
3
T ea men s
o
E y hema/Telangiec asia
T ansien
E y hema
Non ansien
E y hema
Telangiec asia
1s -line
he apy Mono he apy
Topical
b imonidine
PDL
IPL
Topical
b imonidinea
PDL
IPL
Combina ion
Topical
b imonidine
+
ascula
lase
he apy
o
IPL
PDL
o
IPL
+
opical
b imonidine
PDL
+
IPL
2nd-line
he apy
Mono he apy
O al
␤-blocke s
(o
label)
O he
ascula
lase
he apies
O al
␤-blocke s
(o
label)
Elec odesicca ion
Combina ion
Abb e ia ions:
IPL,
in ense
pulsed
ligh ;
PDL,
pulsed
dye
lase .
aSymp oma ic
ea men .
An i-inflamma o y
ea men
is
conside ed
he
mos
app op ia e
choice
o
managing
osacea,
pa icula ly
he
papulopus ula
o m,
gi en
ha
osacea
is
an
inflamma-
o y
disease,
no
an
in ec ious
one.
Howe e ,
he
panel
o
expe s
ecognized
ha
clinicians
ou inely
con inue
o
p esc ibe
an ibio ics
a
an imic obial
doses.
O al
doxycy-
cline
(50---200
mg/d)
is
s ill
he
mos
common
p esc ip ion
in
cases
ha
espond
poo ly
o
a
easonable
ial
pe iod
o
opical
ea men .
Only
occasionally
is
a
suban imic o-
bial
dose
o
doxycycline
(40
mg/d)
p esc ibed.17 Minocycline
(100
mg/d)
is
ano he
e acycline
ha
is
widely
used
and
has
been
shown
o
be
e ec i e
in
papulopus ula
osacea.18
O he
e acyclines
a e
also
used
in
coun ies
whe e
hey
a e
a ailable.
Pa ien s
who
a e
alle gic,
in ole an ,
o
esis an
o
e acyclines
o
who
ha e
con aindica ions
o
hei
use
(p egnancy
o
age
unde
10
yea s)
can
ake
mac olides
such
as
e y h omycin,
cla i h omycin,
o
azi h omycin.
O al
e y h omycin
a
a
dose
o
250
o
1000
mg/d
is
consid-
e ed
highly
e ec i e,
al hough
due
o
ad e se
e ec s
i
is
no
usually
ecommended.18 O he
mac olides
a e
p e e ed.
Al hough
in e na ional
consensus
ends
o
own
on
he
use
o
an imic obial
doses
o
an ibio ics
o
osacea,17,18
gi en
ha
an ibio ics
a e
o
in e es
solely
o
hei
an i-
inflamma o y
e ec ,
which
can
be
achie ed
wi h
a
low
dose
(40
mg
in
he
case
o
doxycycline),
his
panel
o
expe s
insis ed
ha
a
dose
o
100
mg
was
mo e
e ec i e
in
hei
expe ience
and
ha
he
ideal
app oach
would
p obably
be
o
p esc ibe
high
doses
o
e acyclines
a
he
s a
o
ea men
and
a
low
dose
(40
mg/d)
o
main enance.
Fewe
ad e se
e ec s
(such
as
candidiasis
o
he
de elop-
men
o
esis ance)
a e
associa ed
wi h
he
lowe
dose.
The
expe s
indica ed
ha
al hough
his
app oach
was
he
mos
ecommendable,
i
did
no
always
coincide
wi h
clinical
p ac ice.
Se e e
cases
o
osacea,
o
e ac o y
ones
a e
a
ial
o
s anda d
he apy,
can
be
ea ed
wi h
o al
iso e inoin,
whose
e ficacy
in
se e e
osacea
has
been
demons a ed.19
Once
poo
adhe ence
o
o he
he apies
has
been
uled
ou
in
pa ien s
wi h
papulopus ula
osacea
e ac o y
o
ea -
men ,
o al
iso e inoin
can
be
p esc ibed17 a
lowe
doses
(0.25
mg/kg/d)
han
hose
indica ed
o
acne.
A
di e ence,
howe e ,
is
ha
iso e inoin
a enua es
osacea
ac i i y
while
i
is
being
aken
bu
does
no
cu e
he
condi ion
as
i
does
acne.
Finally,
lase
he apies
(eg,
wi h
PDL
and
neodymium-
YAG
[y ium-aluminum-ga ne ])
and
IPL
ea men s
a e
e ec i e
in
se e ely
and
pe sis en ly
dila ed
supe ficial
blood
essels
ha
do
no
espond
o
medica ions
used
o
ea
papules
and
pus ules.16 This
app oach
add esses
bo h
linea
elangiec asia
and
mo e
confluen
ne wo ks
o
es-
sels.
Recommenda ions:
Topical
agen s
such
as
i e mec in
and
me onidazole
a e
he
fi s -line
ecommenda ions
o
ea ing
osacea
wi h
mild
inflamma o y
lesions
(papules
and
pus ules).
O al
doxy-
cycline
can
be
conside ed
an
al e na i e.
Topical
agen s
such
as
i e mec in
and
me onidazole
and
o al
doxycycline
a e
he
fi s -line
ecommenda ions
o
ea ing
osacea
wi h
mode a ely
se e e
inflamma o y
lesions
(papules
and
pus ules).
Sys emic
ea men
(doxycycline
o
iso e inoin)
wi h
o
wi hou
associa ed
opical
he apy
(i e mec in
o
me onidazole)
o
physical
ea men s
a e
he
fi s -line
ec-
ommenda ions
o
osacea
wi h
se e e
inflamma o y
lesions
(papules
and
pus ules).
I
e acyclines
a e
conside ed
o
he
inflamma o y
lesions
o
osacea,
he
minimum
e ec i e
dose
o
doxy-
cycline
is
ecommended
in
o de
o
minimize
he
isk
o
bac e ial
esis ance.
Table
4
summa izes
he
expe s’
consensus
on
he
ea -
men
o
papulopus ula
osacea
(sub ype
2).
Phyma ous
osacea:
sub ype
3
Ac i e
phyma ous
lesions
(wi h
inflamma ion)
Bo h
doxycycline
and
iso e inoin
ha e
p o en
e ec-
i e
in
he
ea men
o
ac i e
phyma ous
osacea.15,19
Iso e inoin
is
p esc ibed
a
low
doses
(0.1---0.5
mg/kg/d)
o
6
o
8
mon hs19,36 and
has
been
shown
o
ha e
he
po en-
ial
o
slow
phyma ous
p og ession.37 Some
o
hese
ci ed
au ho s
ha e
hough
ha
combina ions
o
lase
ascula
su ge y,
doxycycline,
and
iso e inoin
can
be
beneficial
when
mo e
han
one
sub ype
o
osacea
is
p esen .
Good
esul s
ha e
also
been
epo ed
o
IPL
he apy
in
clinical
ials
acco ding
o
one
upda e.30