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December 2015 PharmacyTimes.org 113 subtypes 1 and 2 can be self-treated, par- ticularly in the early stages. Pharmacists may recommend nonprescription thera- py, refer to a physician as needed, and reinforce the need for treatment to delay or prevent progression of the disease. Management and Treatment Goals Rosacea has a wide diversity of clinical presentations; therefore, treatment must be individualized and guided by the clinical signs and symptoms most both- ersome to the patient. A combination of lifestyle and medical treatment strategies may be necessary to achieve desired outcomes. Goals of therapy include maintaining optimum skin condition, delaying or preventing progression from milder to more severe stages of the dis- ease, facilitating remission and avoiding exacerbations, improving patient quality of life, and alleviating signs and symp- toms of disease, such as erythema, skin irritation, papules, and pustules. 2 Self-Care Strategies Avoid Triggers A number of triggers that cause flare- ups of rosacea have been identified and are specific to each patient. It is impor- tant for patients to learn what worsens their rosacea and avoid what causes flare-ups when possible. Keeping a jour- nal is helpful to identify patterns of triggers. The National Rosacea Society has compiled a list of common triggers from patient histories and surveys (Table 2 16 ). 16 Other potential causes of flare-ups include hot food, dairy products, beans, chocolate, some fresh and dried fruits, menopause, chronic cough, and caffeine withdrawal. 17 A thorough medication history can reveal flare-up triggers. Common medi- cations that exacerbate rosacea include niacin, vasodilators (ie nitrates, hydrala- zine, erectile dysfunction agents), and topical steroids. 16,18 When discussing the occur- rence of flare-ups with patients, how can a pharmacist assist the patient in identifying the life- style issues that lead to these flares? *S = Stop; T = Think; A = Assess; R = Review Skin Care Attention to appropriate skin care has been shown to significantly improve skin hydration, decrease skin sensitivity, and improve overall skin health. 19 The key to appropriate skin care is to use gentle products that avoid stinging, burning, and irritation. Pharmacists should rec- ommend products labeled "for sensitive skin" that do not contain alcohol, witch- hazel, menthol, peppermint, eucalyptus oil, other astringents, exfoliators, and fragrances. Appropriate skin cleans- ers should be lipid-free, nonalkaline or synthetic detergent bars for sensitive skin. 20 Products that contain emulsifiers may strip moisture and protective fac- tors from the skin surface and should be avoided. 20 Patients should be counseled that any new skin products should first be tested on a site other than the face to be sure they do not cause irritation, and the number of products used on the face should be limited. 21 Gentle regular cleansing is an impor- tant first step. Pharmacists should instruct patients to avoid abrasive cloths and/or sponges, use lukewarm water to rinse, blot skin dry, and wait until skin is completely dry (up to 30 minutes) before applying topical products. Because facial moisturizers provide a moisture bar- rier and prevent redness due to irritation, daily use of moisturizer is essential, and it should contain color neutralizers to correct for skin redness. Ceramide-, hyaluronic acid-, or silicone-based prod- ucts are preferred. Proper use of makeup can also reduce the appearance of rosa- cea and improve a patient's self-image. A green-tinted primer can even out skin tone and correct for redness, and oil-free foundations and matte-finish makeup should be recommended to patients with rosacea. 22 UV radiation is a trigger for flare-ups and may cause photodamage leading to greater erythema and telangiectasia; therefore, use of a broad-spectrum sun- screen is essential. A sun protection factor (SPF) greater than 30 is favored. 23 Shaving can be a challenge for men with rosacea. An electric razor can cause less skin irritation than other razors. Pharmacists should advise patients to avoid lotions that sting or burn and to choose an aftershave product that mois- turizes and soothes the skin. 24 Topical Therapy A number of topical treatments are approved by the FDA for the treatment of rosacea. Selection of therapy should be individualized and based on the type and severity of rosacea experienced by the patient. Metronidazole Topical metronidazole, a first-line agent, has been used to treat PPR for more than 50 years. Its mechanism of action is thought to be decreased ROS—both production and inactivation of existing species. 18 Both 0.75% and 1% metroni- dazole cream, applied daily, have been shown to be effective in reducing red- ness, papules, and pustules in trials and have reduced relapse up to 6 months following termination of treatment. 18,25 Common adverse effects (AEs) include itching, skin irritation, and dryness. 18 Azelaic Acid Another first-line agent is azelaic acid. As a 15% gel or foam and a 20% cream, azelaic acid has been shown to produce marked improvement or complete remis- sion in 70% to 80% of patients with PPR in trials 26 and is well tolerated, with initial burning, itching, and sting- ing being the primary AEs. Symptoms TABLE 2: COMMON ROSACEA TRIGGERS 16 Trigger Factor Percentage Affected Sun exposure 81% Emotional stress 79% Hot weather 75% Wind 57% Heavy exercise 56% Alcohol consumption 52% Hot baths 51% Cold weather 46% Spicy foods 45% Humidity 44% Indoor heat 41% Certain skin-care products 41% Heated beverages 36% Reprinted with permission from the National Rosacea Society. STAR*