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Rosacea BAD 2021 127
Rosacea BAD 2021 127
This is a guideline prepared for the British Association of Dermatologists (BAD) Clini-
cal Standards Unit, which includes the Therapy & Guidelines Subcommittee. Members 1.1. Exclusions
of the Clinical Standards Unit that have been involved are: N.J. Levell, B. McDonald, This guideline does not cover the diagnosis of rosacea. The
P. Laws, S.L. Chua, A. Daunton, H. Frow, I. Nasr, M. Hashme (Information Scien-
evidence supporting the recommendations does not include
tist), L.S. Exton (Senior BAD Guideline Research Fellow), L. Manounah (BAD Guide-
evidence that is specific to children.
line Research Fellow) and M.F. Mohd Mustapa (Director of Clinical Standards).
2.0 Methodology
NICE has accredited the process used by the British Association of Dermatologists to produce
clinical guidelines. The renewed accreditation is valid until 31 May 2021 and applies to
guidance produced using the process described in Updated guidance for writing a British
Association of Dermatologists clinical guidance – the adoption of the GRADE methodology This set of guidelines has been developed using the BAD’s rec-
2016. The original accreditation term began on 12 May 2010. Accreditation renewal in
progress at time of publication. More information on accreditation can be viewed at ommended methodology,1 with reference to the Appraisal of
www.nice.org.uk/accreditation
Guidelines Research and Evaluation (AGREE II) instrument
DOI 10.1111/bjd.20485 (www.agreetrust.org)2 and Grading of Recommendations
Assessment, Development and Evaluation [GRADE; Appendix L
*Plain language summary available online (see Supporting Information)].3 Recommendations were
British Journal of Dermatology (2021) 185, pp725–735 © 2021 British Association of Dermatologists
(*), are based on available evidence, as well as consensus
within the GDG and specialist experience. Good practice point
Critical
(GPP) recommendations are derived from informal consensus.
Objective response to treatment scoring systems
• Reduction in lesion counts 8
• Reduction in erythema 8 General recommendations
• Improvement in quality of life (QoL) 7 R1 (GPP) Advise people with rosacea to limit exposure to
• Adverse events and tolerability 7 known aggravating factors such as alcohol, sun exposure, hot
Important drinks and spicy food.
• Physician Global Assessment (PGA) 6
R2 (GPP) Provide a patient information leaflet (www.skin-
• Relapse/recurrence 6
healthinfo.org.uk/a-z-conditions-treatments/) to people with
• Patient global assessment 6
• Reduction in flushing 6 rosacea.
R3 (GPP) When characterizing the clinical subtypes and
symptoms of rosacea, classify the patient according to the phe-
notypes identified by Gallo et al.5 This approach encompasses
Systematic review question 2: systemic therapies
the objective clinical signs and the subjective symptoms expe-
In people with rosacea what is the clinical effectiveness and
rienced by the patient with rosacea. Diagnostic phenotypes
safety of systemic therapies, compared to topicals, each other
include characteristic fixed centrofacial erythema or phymatous
or placebo?
changes. Other features include flushing, papules or pustules,
telangiectasia, ocular changes, burning or stinging sensations,
Critical oedema and dryness.
Objective response to treatment scoring systems R4 (GPP) Take into account the older classification system for
• Reduction in lesion counts 8
rosacea, which was based on clinical signs: erythematotelang-
• Reduction in erythema 8
• Improvement in QoL 7 iectatic, papulopustular, phymatous or ocular. Characterize the
• Adverse events and tolerability 7 clinical subtypes and symptoms of rosacea affecting the person
Important according to these clinical signs.
• PGA 6 R5 (GPP) Whenever possible, avoid long-term use of oral
• Relapse/recurrence 6 antibiotics in people with rosacea (i.e. antibiotic stewardship).
• Patient global assessment 6 The optimal duration of antibiotic therapy is not known. In
• Reduction in flushing 6
acne, a lack of response after 2–3 months of antibiotic therapy
is usually regarded as treatment failure, and a similar duration
to establish benefit may be appropriate in rosacea. When
Systematic review question 3: procedural therapies antibiotics are working, the pros and cons of longer-term
In people with rosacea what is the clinical effectiveness andtreatment need to be evaluated carefully.
safety of light, laser and IPL treatments? R6 (GPP) Advise that some people with rosacea find it benefi-
cial to wash their skin with emollients, moisturize regularly
Critical and use appropriate sun protection. Soaps and washing prod-
Objective response to treatment scoring systems ucts that contain detergent are irritant in some people and
• Reduction in erythema 8 should be avoided if they worsen the symptoms.
• Reduction in telangiectasia 8 R7 (GPP) Consider skin camouflage in people with rosacea
• Improvement in QoL 7
‘whose main clinical feature is’ OR who are ‘presenting with’
• Adverse events and tolerability 7
intractable erythema.
Important
• PGA 6 R8 (GPP) Consider the need for psychological support or psy-
• Patient global assessment 6 chiatric interventions in people with rosacea who experience
• Relapse/recurrence 6 anxiety or depression. Initial assessment in primary care is
• Reduction in flushing 6 often appropriate.
Topical therapies
3.0 Summary of recommendations R9 (↑↑) Offer either ivermectin, metronidazole or azelaic acid as
first-line topical treatment options to people with papulopustular
The following recommendations and ratings were agreed
rosacea. Discuss the potential for irritancy of different products
upon unanimously by the core members of the GDG and
and formulations prior to prescribing the topical agent.
patient representatives. For further information on the word-
R10 (↑) Consider topical minocycline foam in people with
ing used for recommendations and strength of recommenda-
papulopustular rosacea (minocycline foam is currently not
tion ratings, see section 2.0. The GDG is aware of the lack of
available in the UK).
high-certainty evidence for some of these recommendations,
R11 (↑) Consider topical brimonidine in people with rosacea
therefore strong recommendations, marked with an asterisk
where the main presenting feature is facial erythema. Warn
British Journal of Dermatology (2021) 185, pp725–735 © 2021 British Association of Dermatologists
BAD guidelines for the management of people with rosacea 2021, P.J. Hampton et al. 731
eradicate the mite. Papulopustular rosacea has also been5.7. Differential diagnosis
demonstrated to respond to this therapeutic approach.27 It is
Acne vulgaris and rosacea are quite distinct diseases, although
well established that there are increased numbers of D. folliculo-
there are occasional patients in whom the distinction is diffi-
rum in the facial skin of patients with rosacea relative to con-
cult and, as both conditions are very common, it is to be
trols.28–34 Demodex mites have also been histologically
expected that, by chance, both will often occur in the same
demonstrated in the dermis associated with an inflammatory
patient. Acne vulgaris affects a younger age group and often
response and undergoing phagocytosis by multinucleate giant
has an extensive distribution over the face, neck and trunk,
cells. This phenomenon has been observed both in localized
whereas extrafacial rosacea is rare. Typical acne vulgaris lacks
and more widespread facial eruptions resembling rosacea.35,36
the redness, telangiectasia and flushing of rosacea, while rosa-
Furthermore, D. brevis is often present in the eyelid in hair fol-
cea lacks the comedones and seborrhoea characteristic of acne
licles, eyelash follicles and meibomian glands,37,38and is often
vulgaris.
reported in association with periocular pathology, including
Seborrhoeic dermatitis is often observed in association with
blepharitis and meibomianitis.39–41 These observations would
rosacea and is therefore a potential cause of confusion, espe-
suggest that the presence of Demodex mites might also play a
cially when the features of one disease predominate at one
role in some of the ophthalmic features of rosacea. The mites
consultation and features of the other at the next. However,
are associated with bacteria, which may also provoke an
the typical pattern of seborrhoeic dermatitis differs markedly
inflammatory response.
from rosacea. The former, but not the latter, characteristically
involves the scalp, the retroauricular area, the eyelids and the
5.5. Impact on quality of life nasolabial folds. Scaling is not normally a feature of rosacea
but is the rule in seborrhoeic dermatitis.
Rosacea is a facial dermatosis and therefore easily visible. It
Lupus erythematosus is an occasional cause of concern. Dis-
can cause significant embarrassment and handicap to those
coid lupus typically causes scarring, scaling and follicular
who suffer from it. This impact has been quantified in a
plugging, which are not features of rosacea. However,
limited and heterogeneous range of studies. A 2014 review
patients are often referred to the dermatology clinic with a
identified 12 studies in which the effect of rosacea on QoL
‘butterfly’ erythema and a tentative diagnosis of systemic
was evaluated using validated instruments. The Dermatology
lupus. The latter is not pustular and is usually associated with
Life Quality Index (DLQI) was the most frequently used
systemic symptoms. In some cases, lupus serology and a skin
instrument (in seven of the studies identified). DLQI scores
biopsy for histological and immunofluorescent examination
ranged from 4!1 to 17!3, depending substantially on the
may be necessary.
population studied, with the highest scores being recorded
Carcinoid syndrome is another cause of flushing often diag-
in a study examining only severe cases.42 Another review
nosed after a significant delay from the onset of symptoms,
that year found a similarly wide range of reported severity
and may initially be mistaken for rosacea. Atypical (pro-
of impairment, with DLQI scores in rosacea ranging from 2
longed, generalized or severe) flushing, or the presence of
to 17!7.43 In a 2019 study of the impact of facial ery-
additional symptoms (sweating, bronchospasm, abdominal
thema, the mean (SD) DLQI score was 5!2 (6!0), and the
pain, diarrhoea) should prompt measurement of urinary 5-
impairment in QoL was strongly correlated with the severity
hydroxyindoleacetic acid and further investigation if suspi-
of the centrofacial erythema.44 When compared with viti-
cion persists.
ligo, the mean DLQI score was 4!3 in patients with rosacea,
Nasal sarcoidosis (lupus pernio) superficially resembles rhino-
and 7 in those with vitiligo. Severe QoL impairments (DLQI
phyma. However, sarcoidosis often affects the nasal septum
> 10), were less frequent (11!0%) than in vitiligo
(causing nasal obstruction). The surface of the thickened nose
(24!6%).45
in lupus pernio, although telangiectatic, is generally smooth,
lacking the rugose peau d’orange surface that characterizes rhino-
5.6. Natural history phyma. Patients with lupus pernio almost invariably have evi-
dence of multisystem disease.
Rosacea usually follows a fluctuating course. The eventual dura-
tion and outcomes are variable, and there is a paucity of pub-
lished data. In a survey of 92 patients ≥ 10 years after a diagnosis5.8. Complications
of rosacea, 48 responded and 25 still had active disease, while 23
Lymphoedema is a relatively rare complication of rosacea that
had cleared.46 In patients in whom the rosacea had resolved, the
can develop over the face and ears. In time, this may
duration of the disease had ranged from 1 to 25 years.
develop into a coarsening of the features known as leonine
Treatment of rosacea can effectively suppress the symptoms
facies. A characteristic pattern of lymphoedema of the upper
and signs of the disease, but there is no evidence that this is
half of the face developing as a complication of chronic
curative. In a follow-up study of 70 patients after 6 months of
rosacea has been termed chronic upper facial erythematous
treatment with tetracycline, two-thirds had relapsed after a
oedema or Morbihan disease. The orbital skin is often
mean follow-up period of 2!6 years.47
© 2021 British Association of Dermatologists British Journal of Dermatology (2021) 185, pp725–735
males and females approximately equally, argue against this
affected, resulting in severe eyelid swelling and sometimes
being a form of rosacea. It can be difficult to distinguish from
ectropion.
micropapular sarcoidosis.
Malignancy, most frequently basal cell carcinoma, may be
Granulomatous perioral dermatitis in children (facial Afro-Caribbean
seen as a complication of rhinophyma. This can be difficult to
childhood eruption [FACE], Gianotti-type perioral dermatitis, granulo-
diagnose owing to the phymatous distortion of normal skin
matous periorificial dermatitis and sarcoid-like granulomatous dermati-
contours, so it is important to be alert to this risk.
tis) is seen in prepubertal children and may represent a
juvenile form of perioral dermatitis or of acne agminata. It is
5.9. Facial dermatoses possibly related to rosacea considered relatively common in Afro-Caribbean children.52
This is a papular eruption generally confined to the face, with
Perioral dermatitis (periorificial dermatitis) is sometimes regarded as
lesions clustering around the mouth, eyes, nose and ears.53,54 In
a variant of rosacea. It presents as a persistent erythematous
contrast to perioral dermatitis it does not spare the narrow zone
eruption of tiny papules and papulopustules that appears
bordering the lips, and pustules are not seen. The histology has
abruptly in the nasolabial areas and spreads rapidly to the
been variously described as showing nonspecific inflammation
perioral zone, sparing the lip margins. Occasionally, it may
with hyperkeratosis or, more often, as granulomatous, with the
spread to the forehead, eyelids and glabella. Pruritus, burning
inflammatory changes often, but not invariably, being perifollic-
and soreness are prominent symptoms. The lesions consist of
ular. Blepharitis has occasionally been present.
monomorphic small papules and pustules occurring against a
Complete resolution usually occurs after a few months –
background of redness and variable scaling. The papules may
either spontaneously or in response to treatment. In some
occur in recurrent crops and are usually less substantial than
cases, small, pitted scars have been reported.
those of rosacea. A similar eruption involving the eyelids and
Pyoderma faciale (rosacea conglobata, rosacea fulminans) is a florid
periorbital skin has been termed periocular dermatitis. It
eruption of pustules and cystic swellings that may be intercon-
almost entirely affects young adult females, the age range
nected by sinuses, confined to the face, with an absence of
tending to be somewhat younger than that of rosacea, and
comedones.55,56The latter two features distinguish this entity
occurrence in childhood more frequent. Topical corticosteroid
from acne conglobata. However, it remains possible that this
therapy is known to be an important aetiological factor. Occa-
is an unusual variant of acne vulgaris. This is a distressing dis-
sionally, this can result from inadvertent transfer during topi-
ease, often followed by severe scarring. Pyoderma faciale
cal corticosteroid treatment to other regions such as the
mainly affects adults, and most frequently females (in contrast
hands. The use of inhaled corticosteroids for treating asthma,
to acne conglobata). There is often no preceding history of
particularly from nebulizers, may also cause perioral dermati-
acne or rosacea. It is usually a fulminant eruption (rosacea ful-
tis. Periocular dermatitis may be caused by corticosteroid eye
minans). Marked erythema and oedema are usually present.
ointment.48 A variety of primary irritant and allergic contact
Some cases have developed during pregnancy, suggesting that
factors and cosmetic products have been proposed to play a
hormonal factors may play a role. Occasional cases may arise
role, but this has not been substantiated.49 A high prevalence
as a side-effect of medication. Culture of the purulent dis-
of atopy has been reported in patients with perioral dermati-
charge or needle aspiration may be sterile or may yield a
tis.50 Perioral dermatitis tends to resolve if exposure to topical
growth of commensal organisms, including Staphylococcus epider-
corticosteroid stops, although this may take some weeks or
midis and Propionibacterium acnes. This investigation can be helpful
months. Less often, the condition may persist, continuously or
in excluding Gram-negative infection. Significant scarring
intermittently.
develops in many cases.
Acne agminata (lupus miliaris disseminatus faciei, acnitis and facial
Steroid rosacea is the term used for the induction of symp-
idiopathic granulomas with regressive evolution [FIGURE]) is seen
toms closely resembling erythematotelangiectatic rosacea
mainly in adolescents and young adults of either sex. It pre-
and/or inflammatory rosacea by the application of topical
sents as multiple, monomorphic, symmetrical, reddish-brown
corticosteroids.57 This is usually associated with the use of
papules on the chin, forehead, cheeks and eyelids.51 The
potent and very potent corticosteroids, although less potent
lesions may cluster around the mouth or on the eyelids or
compounds can occasionally cause similar problems. This
eyebrows so that the term ‘agminata’ is appropriate, although
entity is clearly associated with the use of topical corticos-
– paradoxically – in many cases, the lesions are widely dis-
teroids, and it is not clear whether there are mechanisms in
seminated around the face and the term ‘disseminatus’ seems
the pathogenesis shared with rosacea. Topical corticosteroids
more applicable. Diascopy of larger lesions often reveals an
may also induce features of acne vulgaris, and these may
apple jelly nodule-like appearance, indicating their granuloma-
coexist in the same patients.
tous histology. This eruption tends to be self-limiting, resolv-
Facial dysaesthesia is a clinical presentation in which sensory
ing completely over a few months or up to 2 years. In some
disturbance predominates and is often out of proportion to
cases, there is scarring. The clinical picture in classical cases is
any visible abnormality.58 The most common complaint is a
distinctive and does not closely resemble rosacea.
severe facial burning sensation, usually occurring intermit-
The aetiology remains unknown. It has been considered by
tently, and sometimes triggered by contact, temperature
some to be a variant of rosacea. While the distribution of
changes or particular foods. Facial hypersensitivity is often a
lesions is similar, the natural history and the tendency to affect
British Journal of Dermatology (2021) 185, pp725–735 © 2021 British Association of Dermatologists
BAD guidelines for the management of people with rosacea 2021, P.J. Hampton et al. 733
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British Journal of Dermatology (2021) 185, pp725–735 © 2021 British Association of Dermatologists
BAD guidelines for the management of people with rosacea 2021, P.J. Hampton et al. 735
© 2021 British Association of Dermatologists British Journal of Dermatology (2021) 185, pp725–735