DERMATOLOGY NURSING

Medical Management of Rosacea: Role of Proper Skin Care and Treatment Selection
James Q. Del Rosso

Rosacea is a common chronic facial dermatosis affecting adults. The pathophysiology appears to be multifactorial; however, epidermal barrier dysfunction, inflammation, and dermal matrix degradation are components of the disease. Medical management is dependent on clinical presentation, and warrants a three-pronged approach inclusive of patient education, proper skin care, and use of topical and/or systemic agents.

OBJECTIVES
This continuing nursing educational (CNE) activity is designed for nurses and other health care providers who care for and educate patients and their families regarding rosacea. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to: 1. Discuss the characteristics and pathophysiology of rosacea. 2. Summarize the medical treatment options for rosacea. 3. Describe skin care management techniques for rosacea. 4. List key points of patient education for rosacea.

James Q. Del Rosso, DO, FAOCD, is Dermatology Residency Director, Valley Hospital Medical Center, Las Vegas, NV.

Complimentary CNE for this Supplement is available on page 15 and at www.dermatologynursing.net

This article and the CNE answer/ evaluation form are also available online at www.dermatologynursing.net

osacea is a chronic disorder characterized by varying combinations of central facial erythema, telangiectasia, inflammatory lesions (papules and/or pustules), edema, and flushing, as well as intermittent periods of exacerbation and remission. Associated symptoms often include stinging, burning, pruritus, and scaling (Del Rosso, 2006; Millikan, 2003). Rosacea has been classified into several well-defined subtypes based on morphologic characteristics (Del Rosso, 2006). These classifications are designated as subtypes rather than stages. There is no predictable progression from one subtype to another, and any given patient may present with clinical features of more than one subtype. Regardless of subtype, the severity of signs and symptoms is variable (Del Rosso, 2006). The pathophysiology of rosacea remains elusive with several pathophysiologic associations described. Vascular and inflammatory components appear to be operative. Dermal matrix degradation and chronic alteration of superficial cutaneous vasculature have been described as features of rosacea (Millikan, 2004; Murphy, 2004; Yamasaki et al., 2007). Chronic photodamage (ultraviolet [UV] light

exposure) contributes to the progression of dermal matrix degradation. This is a consequence of the production of reactive oxygen species and up-regulation of matrix metalloprotease enzymes which contribute to the degradation of dermal collagen and elastic tissue (Del Rosso, 2006; Millikan, 2004; Murphy, 2004). Additionally, high levels of cathelicidin and serine protease have been detected in the skin of patients with rosacea as compared to normal skin of subjects without rosacea (Yamasaki et al., 2007). These findings suggest that chronic cutaneous inflammation contributes to the pathogenesis of rosacea (Yamasaki et al., 2007). Genetic factors appear to contribute to the intrinsic predisposition of an individual to develop rosacea, and extrinsically, a variety of environmental triggers influence the tendency to flare (Millikan, 2003). Commonly identified triggers include sunlight, heat, cold, wind, ambient hot temperature, consumption of spicy food, alcohol, and emotional stress. Epidermal barrier dysfunction, characterized by increased transepidermal water loss predominantly involving the central facial region, is an innate component of both inflammatory (papulopustular) and erythema-

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totelangiectatic rosacea (Del Rosso & Baum, 2008; Dirschka, Tronnier, & Folster-Holst, 2004; Draelos, 2004). Increased loss of water from the epidermis increases dryness and fine fissuring of the skin, and explains the commonly recognized clinical feature of sensitive facial skin in rosacea. The symptoms and signs that are commonly reported by the patient with rosacea parallel those which have been documented at baseline in rosacea studies before initiation of topical therapy. This supports the clinical observation that signs and symptoms, such as dryness, scaling, stinging, burning, and itching are inherent to rosacea, and are reported by approximately 30% to 50% of patients (Del Rosso & Baum, 2008; Elewski, Fleischer, & Pariser, 2003). Many externally applied irritants, which may be included in multiple skin care and cosmetic products that are poorly selected for individuals with rosacea (non-gentle cleansers, astringents, etc.), can exacerbate signs and symptoms of the disorder (Del Rosso, 2006). A three-pronged approach is optimal for managing rosacea in many patients (Del Rosso & Baum, 2008). Patient education provides a more comprehensive understanding of the disease state itself, teaches patients on proper use of skin care products and medications, emphasizes the importance of compliance, and sets realistic patient expectations regarding the anticipated magnitude of improvement and the time course of response. Appropriate skin care management can help repair and maintain skin barrier integrity, reduce symptoms and signs of the disease, and augment the therapeutic benefit of medication. Although treatment of rosacea is not curative, medical therapies can effectively reduce signs and symptoms of the disease. In patients with inflammatory rosacea, both appropriately selected topical and/or systemic agents can markedly reduce inflammatory lesions, erythema, and

Figure 1. Sulfacetamide 10%/Sulfur 5% plus SPF 18 Cream for Rosacea

Sulfacetamide 10%/Sulfur 5% + SPF 18 Cream for Rosacea
SS with Sunscreens Cream (SPF 18) versus Metronidazole Cream 0.075% % Reduction in Lesion Count
Week 3 40 Week 6 Week 9 Week 12

46
45 50 55 60 65 70
P < .05

50 63 66 68

68
75 80 85 SS with Sunscreens Cream Metro Cream

74 82

Shalita AR et al. Skin Aging. 2003;11(10 suppl):17-22.

associated symptoms. Importantly, a proper skin care regimen serves to reduce signs and symptoms of rosacea by helping to repair the epidermal barrier, and also serves to augment the therapeutic benefits of treatment. The dermatology practice will be most time efficient and outcomes will be more successful if the nursing staff are integrally involved in educating patients regarding the details of the management plan.

Medical Treatment Options

Currently available medical treatment options for rosacea include both topical and systemic agents. Available data show that these agents are capable of reducing the number of inflammatory lesions and the intensity of erythema (Del Rosso, 2006; Del Rosso & Baum, 2008). Topical agents. The three topical therapies with an indication for rosacea from the U.S. Food and Drug Administration (FDA) for rosacea are sulfacetamide 10%-sulfur 5% (sulfacetamide-sulfur), metronidazole, and azelaic acid (15% gel) (Del Rosso & Baum, 2008). Topical antibiotics (clindamycin, erythromycin) and topical calcineurin inhibitors (tacrolimus, pimecrolimus) have been used to

treat rosacea; however, they are not approved for this indication and data supporting their use are limited (Del Rosso, 2006; Del Rosso & Baum, 2008). Sulfacetamide-sulfur (1956). Sulfacetamide-sulfur is available in a variety of vehicles including a cleanser, lotion, topical suspension, and cream (with and without sunscreen)(Del Rosso, 2006; Del Rosso & Baum, 2008). The mechanism of action of sulfacetamide-sulfur is not known. Sulfacetamide-sulfur has been shown to reduce inflammatory lesions and perilesional erythema in patients with inflammatory rosacea and assists in reducing associated facial seborrheic dermatitis (see Figure 1). Topical metronidazole (1989). First introduced in 1989 as a 0.75% gel, topical metronidazole was the first agent approved by the FDA for treating rosacea. Currently, it is available as a 0.75% gel, lotion, and cream, and a 1% cream and gel (Del Rosso, 2006; Del Rosso & Baum, 2008). The antiinflammatory mechanism of action of topical metronidazole for rosacea relates at least partially to decreased release of reactive oxygen species from neutrophils. Topical metronidazole has been shown in several studies

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Figure 2. Phase III Pivotal Studies: Percent Change in Inflammatory Lesion Count
Phase III Pivotal Studies: Percent Change in Inflammatory Lesion Count
Continuous and significant reductions noted
0 Mean reduction from baseline, % 0 10 20 30 40 50 60 70 61.3% 42.6% Weeks 4 8 12
AzA gel (n=333) Vehicle (n=331)

Figure 3. Phase III Pivotal Studies: Change in Erythema Severity Rating

Phase III Pivotal Studies: Change in Erythema Severity Rating
Continuous improvement* with AzA gel
60 50% Patients improved, % 50 40 30 20 10 P=.001 0 0 4 Weeks
*Decrease of at least 1 point in the erythema rating.
Thiboutot et al. J Am Acad Dermatol. 2003;48:836845.

AzA gel (n=333) Vehicle (n=331)

30%

P<.0001 8 12

Thiboutot et al. J Am Acad Dermatol. 2003;48:836845.

Figure 4. Phase III Comparative Study: Percent Change in Inflammatory Lesion Count
Phase III Comparative Study: Percent Change in Inflammatory Lesion Count
Significantly greater reductions over 15 weeks
0 0 10 20 30 40 50 60 70 80 75.7% P=.002 61.3% 4 Weeks 8 12 15
AzA gel (n=124) Metronidazole 0.75% gel (n=127)

Figure 5. Phase III Comparative Study: Change in Erythema Severity Rating

Phase III Comparative Study: Change in Erythema Severity Rating
Continuous improvement* with AzA gel over 15 weeks
70 60 Patients improved, % 50 40 30 20 10 0 0 4 8 Weeks
*Decrease of at least 1 point in the erythema rating.
Elewski et al. Arch Dermatol. 2003;139:1444-1450.

61%
AzA gel (n=124) Metronidazole 0.75% gel (n=127)

Mean reduction from baseline, %

45%

P=.017

12

15

Elewski et al. Arch Dermatol. 2003;139:1444-1450.

to decrease inflammatory lesions and perilesional erythema in patients with inflammatory rosacea (Del Rosso, 2004; Del Rosso, 2006; Del Rosso & Baum, 2008; Elewski et al., 2003). Azelaic acid (2002). Azelaic acid 15% is available as an aqueous gel and is the most recently FDA approved topical therapy for rosacea (Del Rosso, 2004; Del Rosso, 2006; Del Rosso & Baum, 2008; Elewski et al., 2003). The mechanism of action

of azelaic acid in rosacea is believed to be anti-inflammatory and anti-oxidant, with a reduction in the release of reactive oxygen species from neutrophils reported (Del Rosso, 2004, 2006; Elewski et al., 2003). Although the 15% gel formulation contains a 5% lower concentration of azelaic acid than the 20% cream formulation that is approved for acne vulgaris, the 15% gel formulation provides markedly greater percutaneous drug

delivery of the active ingredient (Del Rosso & Baum, 2008; Draelos, 2006). Azelaic acid is approved for treating inflammatory lesions and erythema in patients with inflammatory rosacea, with several studies supporting its efficacy (Del Rosso, 2004, 2006; Draelos, 2006; Elewski et al., 2003; Thiboutot, Thieroff-Ekerdt, & Graupe, 2003) (see Figures 2-5). Systemic (oral) agents. Anti-inflammatory dose doxycycline (40

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Figure 6. Skin Care Considerations: Cleansers, Moisturizers, and Sunscreens

Skin Care Considerations: Cleansers, Moisturizers, and Sunscreens
Cleansers
Remove sebum and environmental dirt, not intercellular lipids1,2
Use foaming face washes or lipid-free cleansers Wash face gently with fingertips

Moisturizers
Combine occlusive agents, preventing evaporation, with humectant agents that attract water3,4
Products used should have minimal irritation potential

Sunscreens UVA/UVB photoprotection may prevent worsening of rosacea5

Use sunblock daily
1. Bikowski J et al. 2007;4:60-63; 2. Bikowski J. Cutis. 2001;68:12-19; 3. Bikowski J. Cutis. 2001;68:3-11; 4. Del Rosso JQ. Cutis. 2005:75(suppl 3): 17-21; 5. Murphy G. Cutis. 2004(suppl 3):13-16.

mg delayed release capsule formulation administered once daily) is the only oral agent approved by the FDA for treating rosacea (Del Rosso et al., 2007). It has proven effective in rosacea as doxycycline 100 mg daily, with a similar onset of therapeutic action and significantly fewer adverse events, especially gastrointestinal side effects (Del Rosso, Schlessinger, & Werschler, 2008). Unlike oral antibiotic doses of tetracycline agents (tetracycline, minocycline, doxycycline), anti-inflammatory dose doxycycline (administered once daily) is not categorized by the FDA as an antibiotic as it exhibits only anti-inflammatory activity without antibiotic effects (Del Rosso et al., 2007). Several oral antibiotics have been used off-label for rosacea based on a small collection of studies and widespread anecdotal experience (Pelle, Crawford, & James, 2004). The effectiveness of antiinflammatory dose doxycycline, or oral antibiotics such as tetracyclines, in reducing signs and symptoms of rosacea is believed to be due to their anti-inflammatory properties (Del Rosso & Baum, 2008; Del Rosso et al., 2007).

Skin Care Management

Proper skin care can help repair and maintain the function of the epidermal barrier and can reduce signs and symptoms of the disease (Del Rosso, 2004; Del Rosso & Baum, 2008) (see Figure 6). As an integral part of optimal treatment, the recommended total skin care regimen for patients with rosacea utilizes products containing synthetic detergent surfactants and optimized admixtures of occlusive and humectant components to minimize skin barrier dysfunction and to reduce skin irritation (Del Rosso, 2004; Del Rosso & Baum, 2008; Draelos, 2001; Draelos, Green, & Edison, 2006). It is also recommended that all patients with rosacea routinely use a high-SPF (15) product to protect against UV-light-induced epidermal and dermal abnormalities that further worsen rosacea (Del Rosso, 2004; Draelos, 2001; Pelle et al., 2004). Cosmetic camouflage may be used to conceal erythema and telangiectases (Draelos, 2001). Selection of skin cleansers. Soapbased cleansers are not appropriate for patients with rosacea as they have an alkaline pH and produce more damage to the skin barrier (Del

Rosso, 2003; Del Rosso & Baum, 2008; Draelos, 2000). Synthetic detergents (syndets) produce less epidermal damage with decreased irritation and dryness, and have a pH more compatible with natural skin acidity. Gentle foaming face washes and lipidfree cleansers are also appropriate for use in rosacea patients (Del Rosso, 2003; Draelos, 2000). Selection of moisturizers. Treatment of rosacea requires use of an appropriately selected skin care program including everyday use of moisturizers. Moisturizers incorporating humectant and occlusive agents replenish depleted lipids within the impaired epidermal barrier and restore its ability to retain moisture (Del Rosso, 2003; Draelos, 2000). Humectants (e.g., glycerin) attract and hold moisture within the epidermis, increasing hydration and allowing for enhanced penetration of topical pharmacologic agents (Del Rosso, 2003; Draelos, 2000). Occlusives, such as petrolatum and silicates, minimize desiccation by preventing cutaneous water loss (Del Rosso, 2003). The beneficial effect of suitable moisturizers on epidermal barrier function may result in perceptible improvement in signs and symptoms in patients with rosacea (Del Rosso & Baum, 2008; Subramanyan, 2004). Use of photoprotectants. Chronic photodamage has been suggested as a pathogenetic factor in rosacea (Del Rosso, 2004, 2006; Del Rosso & Baum, 2008; Millikan, 2003). It is recommended that patients with rosacea consistently use a photoprotectant (SPF 15) to avoid the dermal matrix degradation attributed, at least in part, to UV exposure (Del Rosso, 2004; Del Rosso & Baum, 2008). Recommended photoprotectants are those with broad-spectrum formulations capable of filtering both UVA and UVB wavelengths. Cosmetic selection. When selecting cosmetic and skin care products, patients with rosacea are advised to avoid potential irritants (Del Rosso &

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Baum, 2008; Draelos, 2001). The following ingredients are most likely to cause exacerbation of rosacea: alcohol, witch hazel, fragrance, menthol, peppermint, and eucalyptus oil (Draelos, 2001).

Patient Education
Managing expectations of patients with rosacea through diseasestate awareness establishes realistic outcomes and encourages compliance with treatment. Patients need to be informed regarding the chronicity of rosacea and its tendency to wax and wane. Education regarding potential flare factors is also important. The goals of initial improvement and long-term maintenance are important points to be explained to patients with rosacea. Key points on which patients will need to be counseled follow. Compliance with topical therapy. Patients need to understand the importance of continuing topical therapy after signs and symptoms of rosacea have resolved in order to maintain remission and prevent recurrence. After discontinuation of therapy, relapse occurs in one-quarter of patients after 1 month and in twothirds of patients after 6 months (Del Rosso & Baum, 2008). Avoiding UV exposure. It is important for patients with rosacea to limit the amount of time spent outdoors during maximum sunlight exposure (Del Rosso, 2005; Del Rosso & Baum, 2008; Pelle et al., 2004). A moisturizing sun protectant should be used when outdoors during daylight hours. Avoiding other known triggers. If patients are unsure of what causes their rosacea flares, they are encouraged to maintain a diary to help identify their own individual flare factors, and then to do their best to avoid them as much as possible. Use of skin care products and cosmetics recommended by their dermatologist/ professional staff. Patients should avoid soap-based facial cleansers. Cleansers containing synthetic detergents, as

well as foaming face washes and lipidfree cleansers are recommended; moisturizers should also be used regularly basis (Del Rosso, 2005; Del Rosso & Baum, 2008; Subramanyan, 2004). Use of proper skin cleansing technique. Patients should be taught to avoid vigorous scrubbing of the face (Del Rosso & Baum, 2008). Washing should be done gently, with only the fingertips. Water at room temperature (lukewarm) should be used during facial cleansing, as hot or cold temperature may trigger a flare of erythema and flushing.

References
Del Rosso, J.Q. (2003). Understanding skin cleansers and moisturizers: The correlation of formulation science with the art of clinical use. Cosmetic Dermatology, 16, 19-31. Del Rosso, J.Q. (2004). Medical treatment of rosacea with emphasis on topical therapies. Expert Opinions in Pharmacotherapy, 5, 5-13. Del Rosso, J.Q. (2005). Adjunctive skin care in the management of rosacea: cleansers, moisturizers, and photoprotectants. Cutis, 75, 17-21. Del Rosso, J.Q. (2006). Update on rosacea pathogenesis and correlation with medical therapeutic agents. Cutis, 78, 97-100. Del Rosso, J.Q., & Baum, E.W. (2008). Comprehensive medical management of rosacea: An interim study report and literature review. Journal of Clinical and Aesthetic Dermatology, 1, 20-25. Del Rosso, J.Q., Schlessinger, J., & Werschler, P. (2008). Comparison of anti-inflammatory dose doxycycline versus doxycycline 100 mg in the treatment of rosacea. Journal of Drugs in Dermatology, 7, 573-576. Del Rosso, J.Q., Webster, G.F., Jackson, M., Rendon, M., Rich, P., Torok, H., et al. (2007). Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. Journal of the American Academy of Dermatology, 56, 791802. Dirschka, T., Tronnier, H., & Folster-Holst, R. (2004). Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. British Journal of Dermatology, 150(6), 1136-1141. Draelos, Z.D. (2000). Therapeutic moisturizers. Dermatology Clinics, 18, 597-607. Draelos, Z.D. (2001). Cosmetics in acne and rosacea. Seminars in Cutaneous Medicine and Surgery, 20, 209-214. Draelos, Z.D. (2004). Treating beyond the histology of rosacea. Cutis, 74(Suppl. 3), 28-31. Draelos, Z.D. (2006). The rationale for advancing the formulation of azelaic acid vehicles. Cutis, 77(Suppl. 2), 7-11. Draelos, Z.D., Green, B.A., & Edison, B.L. (2006). An evaluation of a polyhydroxy acid skin care regimen in combination with azelaic acid 15% gel in rosacea patients. Journal of Cosmetic Dermatology, 5, 23-29. Elewski, B.E., Fleischer, A.B.,& Pariser, D.M. (2003). A comparison of 15% azelaic acid gel and 0.75% metronidazole gel in the topical treatment of papulopustular rosacea. Archives in Dermatology, 139, 1444-1450.

Conclusion
Rosacea is a common chronic facial dermatosis affecting adults. The pathophysiology appears to be multifactorial; however, epidermal barrier dysfunction, inflammation, and dermal matrix degradation are components of the disease. Medical management is dependent on clinical presentation, and warrants a three-pronged approach inclusive of patient education, proper skin care, and use of topical and/or systemic agents. A major impediment to proper patient education about rosacea is the limited time to provide counseling during a busy day at a dermatology practice. Nevertheless, patients both want and appreciate thorough counseling about the disease and its management. Although it is important for the dermatologist to explain diagnosis and treatment to patients, the nursing staff plays a vital role in patient education and is best equipped to explain details regarding disease-state fundamentals, skin care product selection and use, proper application of medications, and importance of compliance. Handout materials serve as an important supplement to verbal education. Patient education pamphlets are available from the National Rosacea Society, the American Academy of Dermatology, and as non-branded materials provided by pharmaceutical companies.

continued on page 14
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Rosacea Management Why It Matters: Nursing Implications and Patient Education

Michelle L. Barton

Rosacea is a chronic inflammatory process that affects over 13 million people. Patients with rosacea often feel embarrassed, frustrated, or experience low self-esteem. Patients who understand their diagnosis and treatment options are more likely to have positive outcomes; therefore, education is paramount to quality rosacea care.

OBJECTIVES
This continuing nursing educational (CNE) activity is designed for nurses and other health care providers who care for and educate patients and their families regarding rosacea. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to: 1. Summarize important points for understanding and managing rosacea. 2. List key trigger factors of rosacea. 3. Describe the importance of patient education in successful treatment outcomes.

Michelle L. Barton, MSN, CANP, CPNP, is a Nurse Practitioner, Affiliated Dermatologists of Green Hills, Nashville, TN.

Complimentary CNE for this Supplement is available on page 15 and at www.dermatologynursing.net

This article and the CNE answer/ evaluation form are also available online at www.dermatologynursing.net

osacea is a chronic inflammatory process affecting over 13 million people. Although rosacea affects mostly lightskinned females between 30 to 50 years of age, it can be seen in men, patients with darker complexions, and even the pediatric population. Topical and oral pharmacologic treatments are effective; however, relapse is common with over 60% of patients relapsing within 6 months. Pharmacologic therapy and managing trigger factors are essential for controlling rosacea. Nursing education plays a vital role in helping guide patients to effective, lifelong therapy. Nurses are educators and patient advocates. We know that helping patients understand their disease and therapy options is essential to better outcomes (Lacz & Schwartz, 2004; Wilkin et al., 2002; Wolf, 2005). Although the process of rosacea is not completely understood, chronic erythema and flushing often result in edema and telangiectasias. Papules and pustules form and lead to chronic inflammation. It has been proposed that Demodex mites contribute to papule and pustule formation as well as inflammation. Although not common, phymatous rosacea described

as skin thickening, enlarged follicles, irregular surface, generally involving the nose but may affect the forehead, cheeks, or chin may be caused by the profibrotic mediator, Factor XIII, a plasma substance (Dahl, 2001). Persistent central facial erythema, sparing the periocular area, for at least 3 months is the sole diagnostic criterion for rosacea. Other clinical features such as telangiectasias, papules, pustules, ocular erythema, and irritation, and rarely phymas, are supportive clinical signs (Crawford, Pelle, & James, 2004).

Differential Diagnosis
Inflammatory acne, seborrhea, lupus, dermatomyositis, and topical steroid misuse should be considered when evaluating patients with facial redness (Wolff, Johnson, & Suurmond, 2005).

Subtypes
In 2002, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea defined diagnostic criteria and four subtypes of rosacea: erythematotelangiectactic, papulopustular, phymatous, and ocular (Abelson, 1999; Wilkin et al., 2002). A breakdown of

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characteristics representative of those subtypes follows. Erythematotelangiectactic subtype characteristics Flushing Persistent central facial erythema Telangiectasias Burning or stinging sensation May be sensitive to topical products Minimal or no inflammatory lesions Papulopustular subtype characteristics Persistent central facial erythema Transient papules or pustules or both Edema may or may not be present Telangiectasias may be present Phymatous subtype characteristics Irregular surface nodularities Thickening of the skin Enlargement of the central face, nose, and/or forehead, ears, and eyelids Ocular subtype characteristics Common in 50% of patients with rosacea Foreign body sensation, burning, stinging, dryness, itching, photosensitivity, and blurred vision involving the eyes Blepharitis or conjunctivitis

Table 1. Selection of Theapy (Topical/Oral)

Topical Monotherapy for mild-to-moderate rosacea Slower onset than oral Fewer safety/tolerability issues Effective for maintenance of remission Source: Del Rosso, 2002. Oral Severe cases, ocular rosacea More rapid onset Adverse events Concerns re: antibiotic resistance from long-term use Lower dose to maintain remission

Understanding and Managing Rosacea

Genetic links. Patients of Celtic, northern European ancestry are most at risk. Treatment regimens. Oral and topical medications, combined with controlling environmental triggers, diet, stress management, and alternative treatments are the most effective treatment approaches. Length of therapy Lifelong. Rosacea cannot be cured, but it can be controlled effectively. After initiating therapy, a followup visit should be scheduled at 4 weeks to assess effectiveness and patient tolerability of the treat-

ment. After achieving good control, patients should followup every 6 months for re-evaluation and ongoing management. During followup visits, nurses can help patients by reinforcing treatment regiments, identifying trigger factors, and suggesting alternative behaviors, and coping skills. Examples include exercising indoors under airconditioning to avoid heat-related flairups, wearing a broad-brimmed hat to protect from the sun, and using moisturizers with sunscreen to protect against dryness and sun exposure. Psychosocial aspects. Teach patients how to manage stress. Anger, anxiety, frustration, and worry may cause rosacea flares (National Rosacea Society, 2001). Nurses can help patients manage these feelings by educating them about stress management techniques. Examples include deepbreathing exercises, visualization techniques, yoga, talk therapy, meditation, and support groups.

Treatment Considerations and Nursing Implications

Approaches to effective therapies. Treatment options should be selected based on the patients subtype, clinical features, and patient history and most importantly, patient preference (See Table 1). A 2002 National Rosacea Society survey found that 81% of patients with rosacea identified sun exposure as worsening their rosacea, but only 5% of patients with rosacea consistently wore sunscreen (Del Rosso, 2005). All patients with rosacea should use a UVA/UVB sun-

screen. Because skin sensitivity to many topical agents is common, products containing silicone, zinc oxide, or titanium dioxide are usually better tolerated (Mackley & Thiboutot, 2005). Topical agents: First-line therapy. For patients with mild-to-moderate rosacea, the choice of a topical therapy should be considered. Topical therapy may be used as both a rescue and maintenance medication. First-tier agents include azelaic acid, metronidazole, or sulfacetamide. Second-tier agents include erythromycin and clindamycin. These agents are relatively safe, have fewer side effects compared to oral therapy, and are aimed at reducing redness and inflammatory lesions. However, topical treatments may take longer to achieve improvement (Del Rosso, 2000). Although not approved by the U.S. Food and Drug Administration, other topical agents have been used to help manage rosacea. Tacrolimus and pimicrolimus may help reduce inflammation and itching. Tretinoin can reduce inflammation and rosacea lesions (Mackley & Thiboutot, 2005; Nghiem, Pearson, & Langley, 2002). Oral therapy. Tetracycline, doxycycline, and minocycline are commonly used as first-line oral therapies to reduce inflammation, papules, and pustules (Del Rosso, 2000). Recommended dosing for these medications is tetracycline 250 mg to 500 mg QDBID; doxycycline 50 mg to 100 mg QD-BID; and subantimicrobial doxycycline 20 mg BID or 40 mg QD.

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Photosensitivity with doxycycline use, and vertigo, hyperpigmentation, and lupus-like syndrome with minocyline use should be considered when choosing therapy. Subantimicrobial doxycycline (Periostat) (40 mg a day) has the benefit of fewer side effects, less antibiotic resistance, and is helpful in reducing inflammation and lesions (Mackley & Thiboutot, 2005). Tetracyclines should not be used in patients who are pregnant. In patients who cannot tolerate or are allergic to tetracyclines, erythromycin, clarithromycin, azithromycin, and metronidazole are effective choices. Laser therapy. Blood vessel formation is not treatable with topical or oral therapies. However, laser therapy is very effective to reduce both redness and blood vessels (Bikowski, 2003; Mackley & Thiboutot, 2005; Wolf, 2005).

Figure 1. Rosacea Flare Factors

Rosacea Flare Factors
HEAT Inside (eg, exercise, hot baths, overdressing) Outside (eg, radiant heat) Hot food/beverages EXERTION Exercise, chronic cough, lifting EMOTIONS Anger, stress Embarassment WEATHER Hot, cold, strong winds Spring season FOOD Cayenne pepper Hot coffee / tea Chocolate Tomatoes Citrus fruits Black pepper Cheese Cured meats ALCOHOL Red wine Liquor Beer DRUGS Vasodilators, nicotinic acid, calcium channel blockers, cholinergic agents, cyclosporin A, opiates, tamoxifen, erectile disfunction drugs DISEASE Carcinoid syndrome Mastocytosis, tumors Migraine headaches Hot flashes TOPICAL PRODUCTS Astringents Irritants Some cosmetics

Survey of 1,066 rosacea patients by National Rosacea Society, 1999.

27

Homeopathic/Alternative Treatments
Patients are increasingly looking for natural treatments for rosacea. Anti-inflammatory diets, vitamins, creams with natural ingredients, and identifying food intolerances are some examples. Unfortunately, clinical trials for these treatments are limited. Patients should be informed of this and told that some natural therapies may have adverse side effects, especially in combination with prescription medications. That said, here are some suggestions that may be helpful: Chrysanthellum indicum cream reduces redness Green tea reduces red bumps and pustules Niacinamide improves skin barrier and reduces redness; can be used as a cream or taken orally Licorice cream improves redness Aloe reduces irritation Chamomile reduces inflammation Diet and nutritional therapies

may also be helpful. Encourage patients to keep a diary to help elucidate foods that worsen rosacea. Foods that are known to cause inflammation include caffeine, alcoholic beverages, fast foods, high-fat meats, processed foods, high-sugar foods, tomatoes, candy (except dark chocolate), gluten additives, and refined carbohydrates. B vitamins, ginger, tumeric, omega 3 fatty acids, and olive oil are just a few of the anti-inflammatory diet and nutritional examples patients can choose from to control and improve inflammation (National Center for Complementary and Alternative Medicine, 2008; Wong, 2007).

Managing Trigger Factors

There are many rosacea trigger factors that affect patients in varying degrees (see Figure 1). Managing rosacea triggers is key for improving patients quality of life. Dermatology nurses are vital in providing the proper patient education necessary to achieve that goal. Strategies for managing trigger factors follow. Managing trigger factors Avoid sun exposure, heat, and humidity. Use fans and facial water spritzers. Avoid saunas, hot tubs, and hot water. Carry a small battery-operated fan

or water spritzer when traveling. Use UVA/UVB sunscreen. Cover the face on windy or cold days. Moisturize daily and more often in dry climates and cold weather. Control/manage stress with lowintensity exercise, yoga, deep breathing, meditation. Employ strategies to stay healthy: maintain a healthy diet and avoid inflammatory foods, get a good nights sleep, practice preventative care see your primary care provider annually, keep blood pressure under control, manage menopause hot flashes, get your flu shot, stop smoking (another pro-inflammatory behavior). Avoid food and beverage triggers, such as caffeine (try decaf coffee or fruit teas), chili powder (substitute cumin), and curry powder (use tumeric). Cleanse the face morning and evening with mild, non-fragrant products (such as Purpose or CeraVe). Avoid harsh cleansing with wash cloths, sponges, astringents, and toners, which may irritate the skin and cause redness and inflammation. Use make-up suited to skin type. For example:

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Figure 2. Education Resource Survey: Appearance

Education Resource Survey

Figure 3. Education Resource Survey: Social Situations

Education Resource Survey

Overall, do you feel better about your appearance since using rosacea treatment regularly?

Do you feel more confident or self-assured in social situations, given an improved appearance?
Yes 78.2% 21.8%

Always Most of the time Often Sometimes Not at all

24.1% No 44.8% 10.3% 13.8% 6.9%

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Figure 4. Education Resource Survey: Education Sources

Education Resource Survey

Figure 5. Patient Education Resources for Rosacea

Patient Education Resources for Rosacea
The National Rosacea Society
www.rosacea.org 1-800-NO-BLUSH

What have you learned most about from educational sources of information?

Dermatology Nurses Association

Common trigger factors Rosacea-friendly skin care products Daily skin care routine Chronic nature of rosacea 44.2% 47.7% 55.8% 67.4%

www.dnanurse.org

American Academy of Dermatology

www.aad.org

Rosacea Infocenter
www.rosaceainfocenter.com

RosaceaNet
www.skincarephysicians.com/rosaceanet
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* For oily skin, try Neutrogena Skin Clearing oil-free make-up. * For normal skin, try Neutrogena Healthy Glow SPF 30 make-up. * For dry skin, try LOreal Ideal Balance Foundation. * To camouflage, try Dermablend or Covermark (green tinted make-up is a good concealer for redness and lesions) (National Rosacea Society, 2008a, 2008b).

The Importance of Patient Teaching

A patient survey conducted in

2000 by the National Rosacea Society showed that 75% of rosacea patients experienced low self-esteem, 70% described feeling embarrassed, 69% said they were frustrated, and 56% felt robbed of pleasure and happiness (National Rosacea Society, 2000). With effective therapy, 70% of patients with rosacea reported improved well-being, while 60% experienced improved professional interactions, and 57% related an improved social life (National Rosacea Society, 2000). The Finacea Patient Survey (Intendis, 2007) reported that 77% of

patients said that learning about lifestyle changes helped identify their trigger factors. Over 60% of patients said that learning about their rosacea helped them manage their expectations of treatment. Eighty-seven percent of patients said they were more compliant with their therapy after learning about rosacea. The majority of patients also chose and used appropriate skin care products after learning about rosacea. With effective therapy, over 78% of patients surveyed said they felt more confident and selfassured (see Figures 2-4). The practice of nursing includes

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Table 2. Rosacea Patient Counseling Summary

Often genetic Lifelong treatment/management Treatment counseling should include: Helping patients manage environmental and emotional factors Educating patients about their treatment regimen and guiding their choice for therapy Teaching essential skin care mild cleansers, daily moisturizers, sunscreen Providing resource material/rosacea handouts/medication instructions Encouraging regular followup - re-evaluate and adjust treatment regiment based on patient history changes, response to therapy, and improving outcome and compliance - reinforce treatment/management strategies, educate patient on new therapies.

educating our patients. We can define it as nurturing, enlightening, coaching, directing, and informing, but why is it important? Why does it matter? (see Table 2.) It matters because there is so much information available to patients. A Google search of rosacea gives 3,790,000 results. Dermatology nurses must be able to help patients navigate through the overwhelming data. We must be able to give accurate and current information to help patients understand and manage their health concerns, and provide avenues for patient support (see Figure 5). We often have little time to spend with patients, so every minute is important and must be used efficiently and effectively. Because patients with rosacea often feel embarrassed, frustrated, or experience low self-esteem, education is paramount to quality care. Their personal and professional lives are affected by their disease. Patients who understand their diagnosis and treatment options are more likely to have positive outcomes. And thats why nurses are essential in helping patients with rosacea reach better outcomes by understanding and managing this lifelong disease process.
References
Abelson, M. (1999). An ophthalmologists view of ocular rosacea. Skin & Aging, 32, 50-54.

Bikowski, J. (2003). Subantimicrobial dose doxycycline for acne and rosacea. SKINmed, 2, 234-245. Crawford, G., Pelle, M., & James, W. (2004). Rosacea: 1. Etiology, pathogenesis, and subtype classification. Journal of the American Academy of Dermatology, 51, 327-341. Dahl, M. (2001). Pathogenesis of rosacea. Advances in Dermatology, 17, 29-45. Del Rosso, J.Q. (2000). Systemic therapy for rosacea: Focus on oral antibiotic therapy and safety. Cutis, 66(4, Suppl.), 7-13. Del Rosso, J.Q. (2002). A status report on the management of rosacea: Focus on topical therapies. Cutis, 20(5), 271-275. Del Rosso, J.Q. (2005). Adjunctive skin care in the management of rosacea: Cleansers, moisturizers, and photoprotectants. Cutis, 75(Suppl. 3), 17-21. Intendis. (2007). Finacea patient survey [unpublished data]. Berlin, Germany. Lacz, N.L., & Schwartz, R.A. (2004). Rosacea in the pediatric population. Cutis, 74(2), 99-103. Mackley, C., & Thiboutot, D. (2005). Diagnosing and managing the patient with rosacea. Cutis, 75, 25-29. National Center for Complementary and Alternative Medicine. (2008). Herbs at a glance: Horse chestnut. Retrieved July 30, 2008, from http://www.nccam.nih.gov/ health/horsechestnut National Rosacea Society. (2000). Survey shows rosacea disrupts work for patients with severe symptoms. Retrieved August 11, 2008, from http://www.rosacea. org/rr/2000/fall/article_3.php National Rosacea Society. (2001). Stress control cuts rosacea symptoms. Retrieved August 11, 2008, from http://www. rosacea.org/rr/2001/summer/article_ 3.php National Rosacea Society. (2008a). Rosacea triggers. Retrieved October 28, 2008,

from http://www.rosacea.org/patients/ materials/triggersindex.php National Rosacea Society. (2008b). Coping with rosacea. Retrieved October 28, 2008, from http://www.rosacea.org/ patients/materials/coping/intro.php Nghiem, P., Pearson, G., & Langley, R. (2002). Tacrolimus and pimecrolimus: From clever prokaryotes to inhibiting calcineurin and treating atopic dermatitis. Journal of the American Academy of Dermatology, 46, 228-241. Wilkin, J., Dahl, M., Detmar, M., Drake, L., Feinstein, A., Odom, R., et al. (2002). Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. Journal of the American Academy of Dermatology, 46(4), 584-587. Wolf, J. (2005). Present and future rosacea therapy. Cutis, 75, 4-7. Wolff, K., Johnson, R., & Suurmond, D. (Eds.). (2005). Rosacea. In Fitzpatricks color atlas and synopsis of clinical dermatology (5th ed., pp. 8-11). New York: McGraw-Hill. Wong, C. (2007). Alternative medicine: Natural treatments for rosacea. Retrieved July 29, 2008, from http://altmedicine.about. com/cs/treatments/a/Rosacea.htm

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Millikan, L. (2003). The proposed inflammatory pathophysiology of rosacea: Implications for treatment. SKINmed: Dermatology for the Clinician, 2, 43-47. Millikan, L.E. (2004). Rosacea as an inflammatory disorder: A unifying theory? Cutis, 73(Suppl. 1), 5-8. Murphy, G. (2004). Ultraviolet light and rosacea. Cutis, 74(Suppl. 3), 13-16. Pelle, M.T., Crawford, G.H., & James, W.D. (2004). Rosacea II: Therapy. Journal of the American Academy of Dermatology, 51, 449-512. Subramanyan, K. (2004). Role of mild cleansing in the management of patient skin. Dermatologic Therapy, 17(Suppl. 1), 26-34. Thiboutot, D., Thieroff-Ekerdt, R., & Graupe, K. (2003). Efficacy and safety of azelaic acid 15% gel as a new treatment for papulopustular rosacea: Results from two vehicle-controlled, randomized phase III studies. Journal of the American Academy of Dermatology, 48, 836-845. Yamasaki, K., Di Nardo, A., Bardan, A., Murakami, M., Ohtake, T., Coda, A., et al. (2007). Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea. Nature Medicine, 13(8), 975-980.

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