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Rosacea

Key sources
The following summarized guidelines for the evaluation and management of rosacea are prepared by our editorial team based on guidelines from the American Academy of Ophthalmology (AAO 2022), the British Association of Dermatologists (BAD 2021), and the Swiss Society of Dermatology and Venereology (SSDV 2017).
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Guidelines

1.Classification and risk stratification

Clinical classification
Use the classification of phenotypes identified by Gallo et al when characterizing the clinical subtypes and symptoms of rosacea which encompasses the objective clinical signs and the subjective symptoms experienced by the patient with rosacea. Recognize that diagnostic phenotypes include characteristic fixed centrofacial erythema or phymatous changes; other features include flushing, papules or pustules, telangiectasia, ocular changes, burning or stinging sensations, edema, and dryness.
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Take into account the older classification system for rosacea which was based on clinical signs: erythematotelangiectatic, papulopustular, phymatous, or ocular. Characterize the clinical subtypes and symptoms of rosacea affecting the patient according to these clinical signs.
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2.Medical management

Topical therapies: as per BAD 2021 guidelines, offer either ivermectin, metronidazole or azelaic acid as first-line topical treatment options in patients with papulopustular rosacea. Discuss the potential for irritancy of different products and formulations before prescribing the topical agent.
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  • Systemic therapies

3.Nonpharmacologic interventions

Lifestyle modifications: advise limiting exposure to known aggravating factors such as alcohol, sun exposure, hot drinks, or spicy food in patients with rosacea.
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  • Skin care

  • Psychological support

4.Therapeutic procedures

Laser and intense pulsed light therapy: as per BAD 2021 guidelines, consider performing pulsed dye laser, Nd-YAG laser or intense pulse light in patients with rosacea where the main presenting feature is persistent facial erythema. Consult an appropriately qualified laser practitioner to ensure safe and high-quality practice.
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  • Botulinum toxin injections

5.Specific circumstances

Patients with rhinophyma: consider performing nasal de-bulking in patients with significant rhinophyma by laser ablation or surgical intervention depending on local expertise.
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  • Patients with ocular rosacea (nonpharmacologic management)

  • Patients with ocular rosacea (pharmacotherapy)

  • Patients with ocular rosacea (indications for referral)

6.Patient education

Patient education: provide a patient information leaflet to patients with rosacea.
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