A new treatment algorithm and drug developments prompt hope for one in 10 Australians who have this condition.
An updated algorithm for the treatment of rosacea, alongside promising drug developments, offer hope to Australian rosacea patients.
Brisbane dermatologist Dr Kate DeAmbrosis, a training supervisor at Princess Alexandra Hospital, outlined the “exciting” developments in rosacea treatment at the Australasian College of Dermatologist’s Annual Scientific Meeting in Brisbane earlier this month.
One major change was the National Rosacea Society’s newly updated treatment algorithm, which now provides different pathways for the varying rosacea presentations.
The condition, which has a prevalence of 10% and an incidence of up to 18%, was previously split into four subtypes.
“However, with the explosion of research in the last 20 years, it has become clear that rosacea’s often fluctuating and seemingly unrelated signs and symptoms are part of a single underlying inflammatory continuum,” the US-based society said.
The algorithm, which was updated late March, now identifies phenotypes that could arise at different times and in different combinations.
This means patients can be diagnosed with rosacea if they have at least one of the diagnostic cutaneous signs, which include persistent erythema (previously in subtype 1) or phymatous changes (previously subtype 3).
In addition to the diagnostic phenotypes are the “major phenotypes”, which often coincide with at least one diagnostic feature but can be independent.
If patients don’t have a diagnostic phenotype, then doctors can consider a diagnosis in the presence of at least two major phenotypes, which include papules and pustules (previously subtype 2), telangiectasia (previously in subtype 1), flushing (also previously in subtype 1) and ocular rosacea (previously in subtype 4).
These are graded from mild to severe, and the algorithm provides treatment recommendations according to severity to help doctors tailor management to the individual’s specific symptoms.
“These phenotypes are often coexisting,” said Dr DeAmbrosis, noting that there was still no single treatment that addressed all the different phenotypes.
“I find it most helpful to identify what the biggest problems are phenotypically and address the treatments directed to that,” she said.
For example, patients with persistent erythema could be treated with skin care measures, brimonidine, IPL or KTP lasers, minocycline, doxycycline and carvedilol – escalating relative to the severity of the symptoms.
Likewise, mild phymatous rosacea can be treated with topical or oral retinoids and/or antibiotics, and surgery and/or ablative lasers can be added with increasing severity of symptoms.
Mild papules and pustules can be treated with topicals, such as benzoyl peroxide, ivermectin, azelaic acid, minocycline or metronidazole, with the possible addition of an initial course of oral antibiotic.
Oral minocycline or doxycycline can be effective for this presentation at any severity, and moderate symptoms may benefit from additional topical brimonidine. Patients with severe symptoms could be offered topical or oral retinoids or Bactrim.
Any patient with telangiectasia may benefit from long-pulsed dye or KTP lasers, IPL, electrosurgery and topical retinoids.
Flushing can be treated with IPL, topical therapies and oral therapies such as carvedilol, clonidine or propranolol. For severe patients, consider KTP laser, NSAIDs for dry flushing, and alpha-agonists or beta-blockers for neural flushing. HRT may help menopausal flushing.
These patients may also benefit from gentle skin care and mineral inorganic sunscreens that, as these don’t produce heat as a by-product.
Patients with ocular rosacea are encouraged to use a warm compress and cleanse the eyelashes with baby shampoo twice daily. Moderate symptoms can also be treated with topical or oral antibiotics and cyclosporine, IPL and referral to an ophthalmologist in more severe cases.
What else is new
Dr DeAmbrosis highlighted several newly described therapies providing hope for rosacea patients.
The first was sarecycline, an oral narrow spectrum tetracycline approved by the FDA for acne, which showed promise for papulopustular rosacea in a 2021 pilot study.
But the drug “of particular interest” was the new low-dose oral formulation of minocycline, DFD-29, she said.
A March phase 3 trial found a sub-antimicrobial dose of 40mg was effective and safe when compared with doxycycline and placebo.
The other exciting aspect was the apparent lack of impact on microbiome like other agents in this area have, she said. Samples from the forehead, stool and vagina of participants showed no proliferation of opportunistic infection or bacterial resistance, according to research presented in 2024 but not yet published.
While there wasn’t yet an application with the TGA for the drug, Dr DeAmbrosis said she expected it could be available here in the next year or two.
Dr DeAmbrosis also shared some insights from her clinical practice.
She said “it was time” isotretinoin was used more for rosacea and clinical guidance developed, especially for difficult-to-treat patients.
“This is where I go routinely now; low dose, very low and slow,” she said.
Dr DeAmbrosis pointed to a recent meta-analysis and systematic review of thousands of patients that showed “not only did it work really well, but the side effect profile at low dosing was next to nothing”.
Evidence was also growing for microbotox to treat residual erythematotelangiectatic rosacea, and Dr DeAmbrosis said she had seen success in her practice, often in patients who had finished a course of isotretinoin but had persistent redness.
While it may be more invasive than lasers, it could be an alternative for those who don’t want laser treatment, she said.
“I’ve been probably doing this for a year or two now, and I am yet to have a patient that it hasn’t worked on,” she said.
In contrast, the research into H. pylori and rosacea was “disappointing”, but the link could still be something to investigate if patients had prominent GI symptoms and rosacea wasn’t responding well to alternative treatments, Dr DeAmbrosis said.
One “exciting and useful” development for ocular rosacea she learnt from her ophthalmologist colleagues in the last year was treating the condition with topical ivermectin.
While the ophthalmology research used quite a large amount of the cream to make a “Demodex sleeve”, Dr DeAmbrosis said she had great results with just a cotton tip amount applied along the eyelash line. This was well-tolerated treatment for an undertreated presentation of rosacea, she added.
Dr DeAmbrosis said rosacea was an “incredibly common and complex” condition.
“In preparing for this, I realised that I was probably seeing one to two cases a day that aren’t even coming in for the presenting complaint, but just incidental diagnoses,” she said.
“It is something that is hugely under-recognised, undertreated, and probably the poor neglected little sister of acne.”
