Rosacea Treatment
Bumps and Pus-filled Lesions
Subtype: Papulopustular rosacea

This rosacea subtype tends to respond well to treatment, and there are many treatment options. To see clearing of the bumps, pus-filled lesions, and persistent redness, treatment often begins with combination therapy (the use of two or more treatments). Combination therapy tends to produce faster, more effective results. To maintain results, a patient may be switched to a single therapy.

The treatments prescribed for the bumps, pus-filled lesions, and redness include:

1. Topical Medications
   The following topical (applied to the skin) medications are often prescribed to treat this subtype of rosacea:

• Antibiotics (Topical antibiotics that may be prescribed include clindamycin, erythromycin, and metronidazole.)

• Azelaic acid

• Benzoyl peroxide

• Retinoid

• Sulfacetamide

• Sulfur lotions

Effectiveness: Several studies have shown that topical (applied to the skin) medications can be just as effective as oral (taken by mouth) medications for treating the bumps, pus-filled lesions, and redness of rosacea. The topical medications, however, tend to take longer to produce results. Many patients notice slight improvements within the first month; however, it usually takes about two months to notice more dramatic results.

Side effects: These tend to be mild. Side effects include burning, stinging, itching, or skin irritation when applying a topical medication. Some patients may experience dry skin. Others can see scaly skin or a rash.

After applying a topical retinoid, the skin may feel warm or sting. Sometimes redness increases temporarily. Peeling of the skin also can occur. When using a topical retinoid, it is important to apply sunscreen before going outdoors as topical retinoids tend to increase sensitivity to the sun. Some patients also experience increased sensitivity to wind and cold.

2. Oral Medications
   The following oral (taken by mouth) medications may be prescribed to treat papulopustular rosacea:

• Non-antibiotic Dosage Doxycycline
  Weighing in at only 40 milligrams of doxycycline per capsule, this dosage of doxycycline is not potent enough to kill bacteria. Since it cannot kill bacteria, it does not act as an antibiotic.

Effectiveness: Research shows that 40 milligrams can effectively stop inflammation. When inflammation decreases, patients tend to see fewer bumps and pus-filled lesions.

In clinical trials, this medication has proven safe and effective for treating the bumps, pus-filled lesions, and redness of rosacea. This led the U.S. Food and Drug Administration (FDA) to approve non-antibiotic dosage doxycycline for the treatment of the bumps and pus-filled lesions of rosacea in adults. The medication is meant for once daily use and can be taken long term.

Side Effects: While the antibiotic dosage of doxycycline can cause side effects, these side effects were not observed in the clinical trials for non-antibiotic dosage. Patients did not say they had an upset stomach or sun sensitivity. None of the women treated with the non-antibiotic dosage, also called the anti-inflammatory dosage, experienced a yeast infection. Since the anti-inflammatory dosage cannot kill bacteria, a patient would not be expected to develop antibiotic resistance. When a patient develops antibiotic resistance, the antibiotic becomes ineffective in killing or weakening the targeted bacteria. Antibiotic resistance is a global health concern.

• Oral Antibiotics
  Oral antibiotics tend to work faster than topical antibiotics, and dermatologists may prescribe one of the following oral antibiotics to treat the bumps and pus-filled lesions:

• Doxycycline

• Erythromycin

• Minocycline

• Tetracycline

If a patient cannot tolerate the above antibiotics, one of the following oral antibiotics may be prescribed. These have been shown to work faster and cause less gastrointestinal problems, but they are much more expensive:

• Azithromycin

• Clarithromycin

Effectiveness: The antibiotics listed above are highly effective in reducing the bumps and pus-filled lesions of rosacea. Most patients see results after 3 to 4 weeks of treatment. Once the rosacea is under control, many patients are switched to a topical therapy to keep the rosacea under control. Some patients require long-term use of an antibiotic or non-antibiotic dosage doxycycline to maintain control.

Side Effects: Antibiotic resistance is the primary concern when an antibiotic is prescribed. Antibiotic resistance develops when a person takes an antibiotic too frequently or for too long, which can cause the medication to no longer effectively kill or weaken the bacteria. This means that previously treatable diseases could become untreatable worldwide. Tuberculosis, gonorrhea, and malaria have become much more difficult to treat because the microorganisms that cause these diseases have mutated. This means that treatment that was previously effective no longer works.

Other side effects include yeast infections in women, upset stomach, light sensitivity, vertigo, and lupus-like symptoms.

3. Other Treatment Options
   In some cases, rosacea does not respond to the therapies described above. If you have been following the prescribed treatment plan and treatment fails, be sure to discuss this with your dermatologist. Less commonly used treatment may be an option.

References:
Baldwin HE. “Systemic Therapy for Rosacea.” Skin Therapy Letter.com March 2007; 12. Available at www.skintherapyletter.com/2007/12.2./1.html. Last accessed May 15, 2008.

Crawford GH, Pelle MT, James WD. “Rosacea: I. Etiology, pathogenesis, and subtype classification.” J Am Acad Dermatol 2004; 51: 327-41; quiz 42-4.

Del Rosso JQ. “Recently Approved Systemic Therapies for Acne Vulgaris and Rosacea.” Cutis 2007; 80: 113-20.

Pelle MT, Crawford GH, James WD. “Rosacea: II. Therapy.” J Am Acad Dermatol 2004; 51: 499-512; quiz 3-4.

Webster GF. “Rosacea and Related Disorders.” In: Bolognia JL, Jorizzo JL, Rapini RP et al, editors. Dermatology, Spain, Mosby Elsevier; 2008. p. 509-11.

All content solely developed by the American Academy of Dermatology