Guidelines

Management

Conservative / General Management

• Avoid trigger factors if possible (e.g. smoking, alcohol, spicy food)
• Sun protection with high-factor sunscreen

General skin care measures:

• Regular use of non-oily emollients if skin is dry
• Use gentle soap-free OTC cleansers
• Cosmetics (yellow / green tinted) to camouflage skin erythema

Pharmacological Management

Choice of drugs depends on the clinical phenotype and severity

Persistent Erythema

1st line: topical brimonidine 0.5% gel once daily or PRN

• Advise that it only offers temporary relief of symptoms (may reduce erythema within 30 min, reaching peak action at 3-6 hours, but after erythema will return to baseline)

Papules and/or Pustules

Mild to moderate: topical ivermectin once daily for 8-12 weeks

• Pregnancy: topical metronidazole / azelaic acid

Moderate to severe (or if topical ivermectin not effective alone): topical ivermectin + oral doxycycline 40mg once daily for 8-12 weeks

• Pregnancy: topical metronidazole / azelaic acid + oral erythromycin

Clinically Inflamed Phymatous Disease

Consider oral doxycycline 40mg once daily for 6 weeks

Specialist Treatment Escalation

The following may be considered:

• Oral isotretinoin
  • Severe inflammatory papules and/or pustules, or persistent clinically inflamed phymatous disease
• Electrodessication or laser
  • persistent erythema and/or extensive telangiectasia

References

Original Guideline