Rosacea

Our Approach in Rosacea

Shree Hospitals — Life-saving care

Rosacea is managed in two simultaneous tracks: reducing active inflammation and flushing in the short term, and eliminating rosacea trigger avoidance failures that perpetuate the disease in the long term. Our rosacea specialist dermatologist team in Mumbai, India addresses both tracks from the first visit  because a patient who receives the best topical therapy but continues to eat spicy food daily at lunch, use a hot water shower, and apply a fragrant moisturiser will experience no lasting improvement regardless of the prescription.

1. Diagnosis & Subtype Classification

The 2017 global rosacea consensus reclassified rosacea by phenotype rather than subtype.

• • Erythematotelangiectatic (ETR) phenotype  persistent centrofacial erythema, facial flushing and telangiectasia, burning and stinging; the vascular phenotype
  • Papulopustular (PPR) phenotype  inflammatory papules and pustules on a background of centrofacial erythema; the most commonly misdiagnosed as acne
  • Phymatous phenotype  progressive skin thickening, rhinophyma (nose), rarely chin or forehead; predominantly men
  • Ocular rosacea  blepharitis, conjunctival hyperaemia, recurrent chalazia, corneal involvement; present in 50% of rosacea patients; often unrecognised
  • Clinical differentiation from acne: rosacea has no comedones; triggers are identifiable; distribution is strictly central face; flushing and vascular component coexist with papulopustules
    

2. General Skin Care & Barrier Restoration

• Gentle cleanser  fragrance-free, low-pH, non-foaming; avoid physical exfoliants, scrubs, and spinning cleansing devices
• Moisturiser ceramide-containing, fragrance-free; reduces the transepidermal water loss and sensory reactivity that characterise rosacea skin
• Broad-spectrum SPF 50+  mineral sunscreen (zinc oxide, titanium dioxide) preferred; chemical UV filters can sting rosacea skin
• Avoid known irritants  witch hazel, alcohol-containing toners, vitamin C in acidic form, strong retinoids in early management

   

• 3.Rosacea Trigger Avoidance

   

  Rosacea trigger avoidance is the single most impactful modifiable element of rosacea management.

• UV exposure  the most universal trigger; mineral sunscreen essential even on cloudy days
• Heat  hot beverages, hot showers, steam rooms, saunas; switch to lukewarm water
• Spicy food and alcohol — particularly red wine; flushing triggers that increase vascular reactivity
• Exercise in heat  cold mist spray, cool room, avoiding peak heat hours; not avoiding exercise altogether
• Topical products containing fragrance, menthol, camphor, or alcohol
• Demodex infestation  Demodex folliculorum density is elevated in rosacea skin; contributes to inflammatory and papulopustular phenotype; treated with Ivermectin cream or oral Ivermectin

4. Topical Therapy

• Metronidazole for rosacea — 0.75% gel or 1% cream twice daily; anti-inflammatory; reduces papules, pustules, and erythema; most extensively studied topical for PPR rosacea
• Azelaic acid 15% gel — anti-inflammatory and antikeratinising; particularly effective for papulopustular rosacea and post-inflammatory erythema; safe in pregnancy
• Ivermectin 1% cream ;the most effective topical for papulopustular rosacea; superior to metronidazole in head-to-head trials; once daily; anti-Demodex and anti-inflammatory
• Brimonidine 0.33% gel  alpha-adrenergic agonist; vasoconstriction reduces persistent erythema within 30 minutes; effect lasts 8–12 hours; for ETR phenotype
• Oxymetazoline 1% cream  FDA-approved for persistent centrofacial erythema; alpha-1 agonist with longer duration than brimonidine; once-daily application

5.Systemic Therapy

• Sub-antimicrobial Doxycycline 40mg modified-release — approved dose for rosacea; anti-inflammatory without antibiotic activity; 16 weeks standard course; for moderate papulopustular rosacea
• Doxycycline 100mg daily  off-label but widely used for 12 weeks in moderate PPR; not for prolonged use
• Oral Ivermectin  for Demodex-driven or refractory papulopustular rosacea; single dose or 3-day course
• Isotretinoin low dose (10–20mg daily)  for phymatous rosacea and refractory papulopustular disease; reduces sebaceous hyperplasia and phymatous change

6. Laser & Light Therapies

• Pulsed Dye Laser (PDL) and Intense Pulsed Light (IPL) ; the primary treatments for facial flushing and telangiectasia and persistent vascular erythema; target oxyhaemoglobin in superficial dermal vessels; series of 3–6 sessions at 4–6 week intervals
• Nd:YAG 1064nm laser  for larger calibre visible telangiectasia and facial vessels
• CO2 laser and electrosurgery  for rhinophyma (phymatous rosacea); reshape and resurface the thickened nasal skin
• Post-procedure sun protection laser-treated rosacea skin requires meticulous SPF compliance for 4 weeks post-procedure