Questionnaire/history: Onset, duration and severity of symptoms? Distribution, extent and severity of facial skin involvement? Symptoms of ocular rosacea? Frequency and duration of relapses? Psychosocial impact on quality of life? Trigger factors? - Sun exposure? - Diet (eg spicy foods and hots drinks)? - Exercise? - Stress? - Drugs (eg topical corticosteroids, calcium-channel blockers)? - Smoking? - Alcohol? Past medical history? Current medication? Previous treatments and symptom responses? Drug allergies? Examination: Diagnostic features? - Phymatous changes (facial skin thickening due to fibrosis and/or sebaceous glandular hyperplasia, most commonly affecting the nose, where it may have a bulbous appearance (so-called rhinophyma) (may be clinically inflamed (‘active’) or non-inflamed (‘fibrotic’ or ‘burnt out’)? - Persistent erythema (persistent centrofacial redness that may periodically intensify in response to various trigger factors (note: in darker skin phototypes (V and VI), erythema may be difficult to detect visually)? Major clinical features? - Flushing/transient erythema (temporary increase in centrofacial redness, which may include sensations of warmth, heat, burning, and/or pain, usually lasting for less than 5 minutes and may spread to the neck and chest (may be the initial presenting feature of rosacea)? - Inflammatory papules and pustules (usually in the centrofacial area, some may be larger and deeper, and may become nodules)? - Telangiectasia (visible vessels in the centrofacial region, but not only in the alar area (side of nose)? (Note: in darker skin phototypes (V and VI), erythema and telangiectasia may be difficult to detect visually) - Ocular manifestations? Minor clinical features? (May be subjective and not individually diagnostic) - Burning sensation (uncomfortable or painful feeling of heat, typically in the centrofacial region)? - Stinging sensation (uncomfortable or painful sharp, pricking sensation, typically in the centrofacial region)? - Skin dryness sensation or appearance (skin feeling rough, may be tight, scaly, and/or itchy)? - Oedema (localized facial swelling that may accompany or follow prolonged erythema or flushing, may be soft or firm (non-pitting) and may be transient or persistent)? Ocular rosacea if: - Eye symptoms such as: ----- Eye discomfort, irritation, tearing, foreign body sensation, dryness, itching, photophobia or blurred vision? Eye signs of: ----- Lid margin telangiectasia - visible vessels around the eyelid margins (note: may be difficult to detect visually in darker skin phototypes (V and VI)? There is suspected: ----- Blepharitis or acute lid infection (chalazion or hordeolum) ----- Conjunctivitis (inflammation of the mucous membranes lining the inner surface of the eyelids and bulbar conjunctiva, typically associated with injection or vascular congestion and conjunctival oedema)? ----- Keratitis ----- Anterior uveitis (inflammation of the iris and/or ciliary body)? (Note: be aware that eye symptoms or signs may present with or without skin disease) Diagnosis: ≥ diagnostic or ≥ 2 major clinical features Management Offered referral to a skin camourflage service if appropriate? Persistent erythema? - Topical brimonidine 0.5% gel once daily on and ‘as needed’ basis Mild-to-moderate papules and/or pustules? - Topical ivermectin once daily for (alternatively metronidazole 0.75% gel or azelaic acid 15% gel twice daily) for 8-12 weeks Moderate-to-severe papules and/or pustules? - Topical ivermectin + doxycycline 40 mg once daily as a modified-release preparation for 8-12 weeks (alternatively oxytetracycline 500 mg or tetracycline 500 mg or erythromycin 500 mg twice daily) for 8-12 weeks Inflamed phymatous disease? - Doxycycline 40 mg once daily as a modified-release preparation Ocular rosacea? - Lid hygiene measures - Artificial tears or ocular lubricants (for mild ocular burning and stinging symptoms and dry eyes) Follow-up arranged? Advised: - Chronic condition that may improve with treatment, but intermittent relapses may occur - Aim of treatment should be complete skin clearance, where possible - Importance of avoiding trigger factors wherever possible - Diary may be helpful to identify stimuli and triggers that may exacerbate rosacea - Importance of effective sun protection and to avoid the use of sunbeds ----- High-factor sunscreen with protection against ultraviolet A and B (for example Uvistat® or Sunsense®) can be prescribed (these are classified as 'borderline substances' and the prescription must be endorsed 'ACBS') ------ Ultraviolet protection sunglasses may be helpful for people with features of ocular rosacea - General skincare measures such as: ----- Regular non-oily emollients if the skin is dry ----- Gentle soap-free over-the-counter cleansers ----- Possible use of yellow- or green-tinted cosmetics to help camouflage skin erythema - Sources of information and support: ----- British Association of Dermatologists info ‘Rosacea’ and ‘Rhinophyma’ ----- NHS info ‘Rosacea’ ----- Patient UK info ‘Rosacea’ Reference(s): NICE CKS: Rosacea Information for patient/carer(s): British Association of Dermatologists: Rosacea British Association of Dermatologists: Rhinophyma NHS Health A to Z: Rosacea Patient UK: Rosacea