symptoms, a symptom-based algorithm
is most useful. An algorithm for rosacea
treatment is provided in Figure 2.
2,40
Use of Physical Modalities and
Devices
Telangiectases, persistent redness, and
phyma may not respond well to the drug
therapies described earlier. A detailed
description of laser- and light-based sys-
tems is beyond the scope of this article,
but a brief mention is warranted. Pulsed
dye laser and intense pulsed light devices
have been successful in treatment of per-
sistent erythema and telangiectases, but
with these methods, tanned- or dark-skin
types may be difficult to treat. Surgeries
and dermabrasion are common tech-
niques used in treatment of phyma.
41
Treatment of Phymatous
Rosacea
Improvements in phymatous changes
early in the course of disease are pos-
sible with oral doses of isotretinoin
(0.3–1 mg/kg/day) for 12 to 28 weeks.
More advanced disease requires use of
laser or surgical techniques to decrease
bulk and change the contour of tissue.
Hypopigmentation and scarring may
occur particularly in patients with deep
skin pigmentation. These procedures
may also be painful.
41,42
Treatment of Ocular Rosacea
Although ocular rosacea is classified as
subtype 4, it often occurs in conjunction
with other rosacea subtypes. Because the
symptoms of watery, burning, dry, itchy,
and light-sensitive eyes are not distinc-
tive to rosacea, it is frequently misdiag-
nosed or underdiagnosed. It is estimated
that more than half of patients with
rosacea may have ocular involvement.
15
Eyelids should be cleaned twice daily
with warm water and gentle cleanser;
this should be done every day regard-
less of whether there are symptoms of a
flare-up.
42
Contact lenses should not be
worn during flare-ups. Artificial tears
may relieve eye dryness, and warm
compresses may assist in meibomian
gland function. These glands located
at the eyelid margin secrete oil and
may become blocked, exacerbating dry
eyes and eyelid inflammation. Drug
therapy may include ophthalmic anti-
biotics (erythromycin, metronidazole)
to relieve lid inflammation. Moderate
to severe disease may require use of
oral tetracycline, metronidazole, or a
macrolide antibiotic, and dietary sup-
plementation with omega-3 fatty acids
may improve meibomian gland secre-
tion.
15
Patients with moderate to severe
symptoms may require a referral to
an ophthalmologist for evaluation and
treatment.
Role of the Community
Pharmacist
A survey in March 2015, which consist-
ed of 535 patients with rosacea and 309
dermatologists, found that almost half
of the patients surveyed mistook their
rosacea symptoms for acne prior to their
diagnosis.
43
Thirty percent reported they
do not use any treatment for their condi-
tion, and one-fourth of the patients used
makeup instead of drug therapy to treat
flare-ups; the majority of patients were
unaware of common rosacea triggers. A
2008 analysis of prescribing patterns and
insurance claims found that only 10%
of patients affected by rosacea sought
conventional medical treatment.
44
These
results highlight the need for patient edu-
cation about rosacea, its causes, and the
treatments available.
It is essential that patients who appear
to have signs and symptoms of rosa-
cea be referred to an appropriate health
care provider, usually a dermatologist
or ophthalmologist, for evaluation and
diagnosis. Failing to get appropriate care
for rosacea in the early stages may result
in progression to more severe disease.
Since many patients delay seek-
ing treatment for rosacea, how
can you assist patients in becom-
ing proactive in managing their
disease?
As highly accessible health care pro-
viders, community pharmacists are ide-
ally positioned for educating patients
exhibiting possible signs of rosacea
and referring them for evaluation.
Pharmacists can educate patients about
triggers that may cause flare-ups and
assist them in choosing appropriate skin
care products to protect and moisturize
the skin.
Patients also need to learn about
the variety of medications available
for the treatment of various rosacea
symptoms, including the efficacy and
potential AEs of each. Education on
the proper application of topical prod-
ucts in combination with the skin care
regimen, including avoidance of the
eyes, lips, and mucous membranes, is
important. Patients need to be advised
to wash their hands immediately fol-
lowing application of topical medica-
tion. Differentiating mild skin irritation
that may occur early in treatment from
excessive irritation or allergic reactions
should also be discussed.
Manufacturers of rosacea products
provide several resources and support for
patients, which include telephone access
to health care providers who are rosa-
cea experts, videos and written patient
education materials, online management
tools, and offers for savings on medica-
tions. Pharmacists may assist patients
in accessing these resources, some of
which are listed in Table 3.
16
Patients with rosacea must not only
adhere to a regimen of topical and/or
oral medications but also make life-
style changes and learn how to handle
potential embarrassment, anxiety, stress,
stigma, and social isolation, which are
associated with this disease. Awareness
of the psychosocial aspects of rosacea
is important in managing the treatment
of patients.
Although rosacea is a noncurable
chronic condition, with appropriate edu-
cation and the support of a health care
team, patients may achieve optimal out-
comes and improve their quality of life.
STAR
TABLE 3: RESOURCES TO LEARN MORE ABOUT ROSACEA
National Rosacea Society (rosacea.org)
American Academy of Dermatology (aad.org/dermatology-a-to-z/diseases-and-treatments/q---t/
rosacea)
National Institute of Arthritis and Musculoskeletal and Skin Diseases (niams.nih.gov/Health_Info/
Rosacea/default.asp)
116 PharmacyTimes.org December 2015
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