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Management and treatment of Rosacea in the Primary Care Setting.

Author: Leonard E,APRN, NP-C, FNP-BC



Rosacea is a skin vascular disorder that develops later in life, usually between 30 to 50 years of age, and is most common in fair- skinned people; women are affected 3 times more often than men, but when men are affected they have typically more severe symptoms, including rhinophyma (fig 2)

Fig 2 . Rhinophyma is a skin disorder that causes the nose to enlarge and become red, bumpy, and bulbous. It is thought to result from untreated, severe rosacea, a chronic inflammatory skin condition that causes facial redness on the nose and cheeks.

What are the characteristics of the lesions ?

Distribution of lesions occurs on the center of the face (cheeks, chin, nose, or forehead), with inflammatory papules and pustules on an erythematous base

What are the trigger and aggravating factors ?

Many patients have flushing and blushing reactions to emotional or environmental triggers (before actual lesions occur). The following are the most common reported triggers of this condition:

  • Alcohol ingestion

  • Irritating cosmetics

  • Excessive washing of face

  • Emotional stress

  • Spicy foods, smoking, caffeine, or sun exposure

Clinical Manifestations

The more common Signs and symptoms of rosacea are:

  • Central facial flushing (transient)

  • Nontransient erythema or persistent redness of the face

  • This erythema Occurs bilaterally without comedones; there is very little to no scarring

  • Papules ( Small raised, tender bump on the skin) and pustules ( small, pus-filled sores , Pustules appear on the skin as small, raised, reddened areas that typically have a whitish center pus) in clusters

  • Telangiectasia ( Dilated small blood vessels on the skin or mucous membranes, anywhere in the body.)

  • Burning or stinging, which can occur with the use of sunscreens or moisturizers

  • Plaques and dryness with itchy, scaly skin (resembles xerosis)

  • Edema after prolonged flushing

  • Rhinophyma (usually in men) ( Rhinophyma is a skin disorder characterized by a large, red, bumpy or bulbous nose)

  • Ocular manifestations

Less common signs and symptoms are watery, bloodshot eyes; dryness with photophobia and Conjunctivitis and blepharitis


It is important to note that Antibiotics (either oral or topical) are not curative for Rosacea and may need to repeat dosing later with every flare-ups.

For Non-Severe Rosacea the use of Topical Antibiotics should be enough. The most common pharmacological treatment includes:

Topical pharmacologic treatment

  • Metronidazole 1% cream apply every day or metronidazole 0.75% gel twice at day

  • Clindamycin 1% lotion twice at day , erythromycin 2% solution twice at day, or sulfacetamide/sulfur 10% once at day or twice at day. treatment course may take up to 2 to 3 months

  • Azelaic acid (Azelac) 15% to 20% cream: apply bid up to 3 months (effective for papulopustular acne rosacea)

  • Ivermectin cream 1% (Soolantra) apply qd

Systemic (Oral Therapy) for Severe Cases.

if Rosacea is severe, may need to add an oral antibiotic (usually tetracycline) until remission. may take several weeks for the effects to be seen and the usual course of treatment is up to 2 months

Systemic therapy is used to treat hard-to-control rosacea with or without ocular manifestations; treatment therapy may take up to 3 to 6 months. The most common therapies include :

  • Tetracycline 250 to 500 mg q12h until improvement is seen; then decrease to daily

  • Doxycycline 100 mg bid until improvement is seen; then may need daily dosing

  • Minocycline 50 to 100 mg bid until improvement is seen; then may need daily dosing

  • Metronidazole 250 mg qd for 4 to 6 weeks

Patient Education

It is very important to educate the patient about the need of avoiding using steroids on the face. It should be emphasized and highlighted the use of daily facial moisturizers, sunscreens, and mild cleansers.

Referral considerations

If after receiving treatment in the primary care setting , there is not resolution or improvement . The best approach is to request a referral to an experience board certified dermatologist for specialized treatment.


Fenstermacher, K., & Hudson, B. T. (2015). Practice guidelines for family nurse practitioners. W B Saunders Company. Dunphy, L. M., Winland-Brown, J. E., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing. F A Davis Company.

Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient. Lww.

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