A.

PENATALAKSANAAN
Tetracyclines, prescribed as for acne (p. 154), are the traditional treatment and are
usually effective. Erythromycin is the antibiotic of second choice. Courses should last for at
least 10 weeks and, after gaining control with 500–1000 mg daily, the dosage can be cut to
250 mg daily. The condition recurs in about half of the patients within 2 years, but repeated
antibiotic courses, rather than prolonged maintenance ones, are generally recommended.
Topical 0.75% metronidazole gel (Formulary 1, p. 336), applied sparingly once daily, is
nearly as effective as oral tetracycline and often prolongs remission. It can be tried before
systemic treatment and is especially useful in treating ‘stuttering’ recurrent lesions that do not
then need repeated systemic courses of antibiotics. Rarely systemic metronidazole or
isotretinoin (p. 154) is needed for stubborn rosacea. Rosacea and topical steroids go badly
together (Fig. 12.15); if possible patients should use traditional applications such as 2%
sulphur in aqueous cream or 1% ichthammol inzinc cream. Sunscreens may help if sun
exposure is an aggravating factor, but changes in diet or drinking habits are seldom of value.1

Topically, metronidazole gel (Metrogel, Rozex) twice daily may be helpful. If this is
ineffective, the usual oral treatment is tetracycline, initially 1 g daily, reducing to 250 mg
daily after a few weeks and continued for 2 to 3 months. Erythromycin is an alternative.
Repeated treatment is often needed. Isotretinoin can be used but is less effective than in acne.
Plastic surgery is required for rhinophyma.2
The most important first step in the treatment of rosacea is the avoidance of triggers.
Triggers are both exposures and situations that can cause a flare-up of the flushing and skin
changes in rosacea. Principal among these is sun exposure. Rosacea patients must be advised
always to apply a nonirritating facial sun block when outdoors. Stress, through autonomic
activation, can also increase the flushing. Alcohol consumption, while not a cause in itself,
can aggravate this condition through peripheral vasodilation. Spicy foods can also aggravate
the symptoms of rosacea through autonomic stimulation. Finally, care must be taken to use
only those facial cleansers, lotions, and cosmetics that are nonirritating, hypoallergenic, and
noncomedogenic. Rosacea should be treated at its earliest manifestations to mitigate
progression to the stages of edema and irreversible fibrosis. Antibiotics have traditionally
been considered the first line of therapy, although their success is considered to be primarily
due to anti-inflammatory effects rather than antimicrobial ones.4 Topical metronidazole,
which is effective for stage I and stage II rosacea and avoids the toxicity of systemic

1
treatment, is considered first-line therapy.11 Metronidazole is available in a twice-daily
application of 0.75% cream or gel and in a newer once-daily 1.0% formulation.4 No
significant difference in efficacy has been found between the once-daily 1.0% medicine and
the twice-daily 0.75% medicine.12 Sulfacetamide lotion can also be used in place of
metronidazole. In certain patients, sulfacetamide might be less irritating than metronidazole.4
Rosacea responds well to oral antibiotics. Starting treatment with simultaneous oral
and topical therapy reduces initial prominent symptoms, prevents relapse when oral therapy
is discontinued, and maintains long-term control.6 Oral therapy is generally continued until
inflammatory lesions clear or for 12 weeks, whichever comes first.12 Tetracycline is the
primary oral antibiotic prescribed for rosacea therapy, at a dosage of 1.0 to 1.5 g/d divided
into 2 to 4 daily doses. Minocycline at 100 mg two times a day is an acceptable alternative.
13 Doxycycline is another acceptable alternative, although the monohydrate formulation, in a
dosage of 100 mg once daily, is more consistently effective and has fewer gastrointestinal
side effects than the hyclate form.13,14 Clarithromycin, 250 mg to 500 mg twice daily, has
been found to be as effective as doxycycline but with a more benign side effect profile.15
New Therapies
Azelaic acid is a naturally occurring, dicarboxylic acid possessing antibacterial
activity. It is available as a 20% cream and is generally used as an alternative treatment for
acne vulgaris. In 1999 Maddin16 compared once-daily applications of azelaic acid with
topical metronidazole 0.75% cream for treatment of papulopustular rosacea. Maddin
concluded that both medicines were equally effective in reducing the number of
inflammatory lesions and the associated signs and symptoms of rosacea. When the study
physicians’ rating of the overall improvement was considered, however, the azelaic acid was
considered to be considerably more effective. The patients involved in the study also
preferred the azelaic acid.16 Topical retinoic acid has been shown to have a beneficial effect
on the vascular component of rosacea. 17 The drawbacks of retinoic acid therapy include
delayed onset of effectiveness, dry skin, erythema, burning, and stinging.17 Retinaldehyde is
intermediate in the natural metabolism of retinoids, between retinal and retinoic acid, and is
generally well tolerated while retaining most of the therapeutic activity of retinoic acid.17
Daily application of a 0.05% retinaldehyde cream for 6 months was found to yield positive
and statistically significant outcomes in 75% of those patients undergoing treatment.17
Specifically, improvements were found in erythema and telangiectasias, the vascular
components of rosacea. Topical vitamin C preparations have recently been studied in the
reduction of the erythema of rosacea.18 Daily use of an over-the-counter cosmetic 5.0%

2
vitamin C (L-ascorbic acid) preparation was used in an observer-blinded and
placebocontrolled study. Nine of the 12 participants experienced both objective and
subjective improvement in their erythema.18 It was suggested that free-radical production
might play a role in the inflammatory reaction of rosacea, and that the antioxidant effect of L-
ascorbic acid might be responsible for its effect. These promising preliminary results still
need to be confirmed in larger, longterm studies.
Treatment of Advanced Disease
Recalcitrant rosacea can respond to oral isotretinoin therapy. In a recent study of 22
patients with mild to moderate rosacea, major reductions in erythema, papules, and
telangiectasias were noted by the ninth week of treatment.19 Isotretinoin reduces the size of
sebaceous glands and alters keratinization. Recalcitrant cases of rosacea have been
successfully treated with 0.5 mg/kg/d of isotretinoin.12 Isotretinoin, of course, has serious
side-effects,most notably its teratogenic potential. Female patients of childbearing age must
be strongly advised to use effective birth control. Stage IV of rosacea, involving irreversible
fibrotic changes, such as rhinophyma, does not respond well to medical therapy. At that
point, the patient should be referred for cosmetic surgery, such as cryosurgery and laser
therapy.
In the aging US population, rosacea is an increasingly common disorder. Although
rosacea causes only limited physical effects, the prominent visibility of these changes often
yields intense psychosocial distress. Although the exact cause of rosacea is unknown, its
progression, signs, and symptoms can be readily alleviated by the primary care physician.
The treatment of rosacea is with long term courses of oxytetracycline, which may
need to be repeated. Topical treatment along the lines of that for acne is also helpful. Topical
steroids should not be used as they have minimal effect and cause a severe rebound erythema,
which is difficult to clear. Avoiding hot and spicy foods may help. Recent reports indicate
that synthetic retinoids are also effective.4

Rosacea can be a difficult disease to treat, at least in part because the predisposing
vasodilation is largely unresponsive to topical or systemic therapy (with the exception of
corticosteroids, which should be avoided). Avoidance of obvious vasodilators and irritants is
clearly helpful, but is rarely sufficient. Since effective rosacea treatments have been in
existence for over 40 years, there are relatively few recent large-scale studies. Although some
would relegate all but the most rigorous studies to the realm of medical folklore, in the case

3
of rosacea, the currently available data are based primarily on smaller prospective trials as
well as retrospective series (Table 38.3).
Table 38.3 -- Therapeutic ladder for the medical treatment of rosacea.
THERAPEUTIC LADDER FOR THE MEDICAL TREATMENT OF ROSACEA
Drug Dosage/Frequency Level of evidence
Topical
Metronidazole 0.75% and 1% qd to bid [cream, gel or lotion] 1
Sodium sulfacetamide (with or without sulfur and/or urea) 10% qd to bid [cream,
foam, lotion, suspension or wash] 1 (with sulfur) or 2
Azelaic acid 15% and 20% bid [cream or gel] 1
Benzoyl peroxide/clindamycin 5%/1% qd [gel] 1
Tretinoin 0.01% to 0.1 % qd [cream or gel] 3
Oral
Tetracycline 250–500 mg qd to bid[*] 1
Doxycycline 50–100 mg qd to bid[*] 20 mg bid, 40 mg qd 2
Minocycline 50, 75, 100 mg qd to bid[*]; 40, 90, 135 mg (1 mg/kg) qd 1 or 2
Erythromycin[†] 200, 250, 333, 400, 500 mg (30–50 mg/kg/daily) [bid to qid,
depending on dose] 3
Azithromycin 250–500 mg (5–10 mg/kg) 3 times/week 2
Isotretinoin 10 to 40 mg qd[‡] 2
For telangiectasias and rhinophyma, the 585 nm pulsed dye laser and electrosurgery
can be used, respectively. Key to evidence-based support: (1) prospective controlled trial; (2)
retrospective study or large case series; (3) small case series or individual case reports.
* Then tapered.
† Especially for children with perioral dermatitis.
‡ Higher doses have been used anecdotally.

Topical Therapy
Metronidazole is a major topical therapy for rosacea[42–44]. Applied once or twice
daily, it is most active against inflammatory lesions and may have some effect on erythema
due to inflammation (as opposed to fixed telangiectasias). The response is not immediate and
sometimes several weeks are required before any benefit is seen.
Azelaic acid cream is useful in patients with rosacea, and it appears to be about as
effective as topical metronidazole[45]. Benzoyl peroxide preparations that are not irritating

4
are also useful in treating the inflammatory forms of rosacea[46]. Topical erythromycin,
clindamycin and tetracycline appear to have little effect on rosacea. However, sodium
sulfacetamide is an older medication that can be helpful for treating mild rosacea and as an
adjunct for more severe disease. Hydrocortisone 1% cream may be compounded with 0.5-1%
precipitated sulfur and applied twice daily to treat mild rosacea.
Topical tretinoin–perhaps counter-intuitively, because of the absence of comedones in
rosacea–has been reported to be helpful over the long term in treating rosacea patients[47].
Clinical improvement is not thought to be related to its effect on follicular keratinization, but
may be due to its effect on the elastolysis seen in chronic rosacea.

Oral Therapy
Tetracyclines are the most commonly prescribed oral medications for the treatment of
rosacea[48–50]. Their mechanism of action in this disease is primarily anti-inflammatory,
given that a bacterial stimulus for this disease has not been proven. The anti-inflammatory
activity of the tetracyclines is well documented[51–53]. Tetracyclines decrease the
chemotactic response of neutrophils, inhibit MMPs (see above), inhibit granuloma formation,
and inhibit protein kinase C. Interestingly, the relative potency of the tetracyclines’ inhibition
of granuloma formation parallels their clinical activity. Tetracycline is weakest, and
doxycycline and minocycline are approximately equipotent.
Typically, treatment is started at a higher dose (see Table 38.3) that is then lowered
once the disease is under control. At this point, tetracyclines can be given in surprisingly
small dosages (e.g. 250 mg of tetracycline or 50 mg of doxycycline daily or every other day).
However, there is justifiable concern about the overuse of antibiotics and the spread of
resistant organisms. Dermatologists should take care to avoid the use of unnecessary long-
term oral antibiotics in rosacea patients by repeatedly attempting to taper the medication. The
initial use of sub-antimicrobial doses of doxycycline (e.g. 40 mg [extended release] once
daily[54]) or lower doses of minocycline (1 mg/kg/day) has been advocated by some
clinicians. Comparison studies of the effects on resistance patterns of short courses of higher
doses of tetracyclines followed by similar low doses versus initial low doses are needed.
Other oral antibiotics are occasionally useful for treating patients with rosacea.
Trimethoprim–sulfamethoxazole and ciprofloxacin both can improve inflammatory
rosacea[50], but they are rarely used, because of concerns regarding the generation of
resistant bacterial populations and hypersensitivity reactions with the former. Erythromycin is
used for pediatric patients with granulomatous periorificial dermatitis, because of concerns

5
with staining of teeth with tetracyclines. In general, penicillins and cephalosporins are of little
use in the treatment of rosacea.
Isotretinoin
The most severe forms of rosacea may require oral isotretinoin therapy[47,55].
Inflammatory lesions and particularly refractory nodules typically respond well to 0.5 to 1
mg/kg/day, but lower doses may be effective. Unfortunately, a lasting response, such as is
seen in acne treated with recommended cumulative doses, does not occur as frequently, and
patients may require long-term maintenance therapy with oral tetracyclines. Isotretinoin is
also helpful in treating early rhinophyma. Results are best if treatment is initiated before
significant fibrosis has developed.
Surgical Treatments
Telangiectasias and persistent erythema are effectively treated with intense pulsed
light or pulsed dye lasers[56,57]. Lasting remissions of vascular rosacea are sometimes
achieved. Electrocoagulation of telangiectasias is also effective, but it carries a greater risk of
scarring. Recontouring via electrosurgery or the CO2 laser is the only established method of
improving fibrotic rhinophyma (see Ch. 140).

B. PENCEGAHAN

C. KOMPLIKASI
The cheeks, nose, centre of forehead, and chin are most commonly affected; the peri-

orbital and peri-oral areas are spared (Fig. 12.12). Intermittent flushing is followed by

a fixed erythema and telangiectases. Discrete domed inflamed papules,

papulopustules and, rarely, nodules develop later. Rosacea, unlike acne, has no

comedones or seborrhoea. It is usually symmetrical. Its course is prolonged, with

exacerbations and remissions. Complications include blepharitis, conjunctivitis and,

occasionally, keratitis. Rhinophyma, caused by hyperplasia of the sebaceous glands

and connective tissue on the nose, is a striking complication (Fig. 12.13) that is more

common in males. Lymphoedema, below the eyes and on the forehead, is a tiresome

feature in a few cases. Some patients treated with potent topical steroids develop a

6
rebound flare of pustules, worse than the original rosacea, when this treatment is

stopped.1

Typical rosacea with papules and pustules on a

background of erythema. Note he also has a patch of scaly
seborrhoeic eczema on his brow.1

Marked rhinophyma1

7
 A perioral dermatitis following withdrawal of
the potent topical steroid that had been wrongly used to
treat seborrhoeic eczema.1

Rosacea with rhinophyma in a

woman. Rhinophyma usually affects men.2

D. PROGNOSIS

REFERENCES

8
1. J.A.A. Hunter. J.V.Savin, M.V.Dahl, Clinical Dermatology. 3rd Edition.
Australia, Blackwell Publishing company, 2002, 156-158
2. J. Gawkrodger, David, Dermatology An Illustrated colourtext, 61
3. Cohen, f, Aron. Tiemstra, Jeffrey D. Clinical Review Diagnosis
and Treatment of Rosacea. J Am Board Fam Pract May–June 2002
Vol. 15 No. 3, 2-4
4. Buxton,Paul K. ABC OF DERMATOLOGY Fourth Edition. BMJ
Bookshop London, 2003. 59
5.