Guidelines exist for most known diseases. Physicians can align their therapy efforts with this, as a guideline is drawn up according to the latest findings and experience by several experienced colleagues and is also updated at shorter intervals. Patients can also use the guidelines as a basis for discussion with their dermatologist. It also becomes clear from this that there must not be comments from dermatologists such as: “You can’t do anything about it” or “You have to live with that”, “Others have worse to endure”. You should also report such a medical oath of disclosure by specialists to the Association of Statutory Health Insurance Physicians in your federal state or inform your health insurance company.
6.1 General measures (Klövekorn)
Individual provocation factors, as far as they are recognizable by the course of the disease, should be avoided. If cosmetic products are used, they should be low in fat and well tolerated [49]. In particular, appropriate protection against UVA and UVB radiation must be ensured. Some experts consider physical sunblocks (titanium dioxide, zinc oxide) to be particularly compatible. Detergents should be soap-free. The patient should avoid toner or other preparations containing menthol, camphor, sodium lauryl sulfate or astringents. Waterproof cosmetics should preferably not be used. Although no special rosacea diet can be recommended, factors leading to vasodilation and flushing symptoms on the face should be avoided, such as alcohol, spicy foods and hot drinks. Due to the increased sensitivity of the skin in rosacea patients, aggressive cleansing substances should be avoided. Soaps should be avoided as they are alkaline and increase the pH of the skin. An increase in pH can lead to irritation of the skin [50]. The use of covering foundation/make-up did not worsen rosacea [51]. The use of decorative cosmetics (covering) also has a positive impact on the quality of life of patients.
6.2 Topical therapy (Schöfer)
Topical therapy is sufficient for rosacea erythematosa-teangiectatica and rosaceapapulopustulosa in many cases. In severe cases, it is combined with systemic treatment (see Chapter 6.3). In Germany, drugs containing 0.75% metronidazole in various bases and 15% azelaic acid in gel form are approved for topical rosacea treatment. Other topicals are used in rosacea as part of an off-label use. The various bases (gels, emulsions, etc.) of topicals play an important role for tolerability and effectiveness in the usually particularly sensitive skin of rosacea patients in addition to the active ingredients.
Metronidazole is the most commonly used and internationally widely used topical rosacea drug. The mechanism of action is not yet fully understood. It is likely that an anti-inflammatory or immunosuppressive effect is responsible for therapeutic success. The efficacy was demonstrated in several placebo-controlled studies and summarized in a Cochrane review [52]. Once daily use also showed an effect on erythema, papules and pustules in both 0.75% and 1% preparations [53]. In Germany, topicals with 0.75% metronidazole are available (cream, gel, lotio, emulsion). They do not differ significantly in their effect [54]. Metronidazole was equally effective in direct comparative studies with topical azelaic acid [55-57]. Small differences in the assessment of efficacy by patients or physicians were not considered clinically relevant [56].
In Germany, a 15% gel, but not the corresponding 20% cream, is approved for the treatment of rosacea (rosacea papulopustulosa). The effectiveness is attributed to an anti-inflammatory effect and to a normalization of keratinization. There is evidence of comparable or better efficacy in papules and pustules response when comparing azelaic acid with metronidazole[52, 58].
Alternatively, a 5% permethrin cream [25, 59], and 1% clindamycin preparations [59, 60] are used. The comparison of 5% permethrin cream with 0.75% metronidazole gel showed a similar effect on the reduction of papules and pustules [25]. Clindamycin reduces the number of papules, pustules and nodules when used externally (1%) [61], but like the other systemically applied antibiotics erythromycin and tetracycline should preferably not be used topically to avoid the development of resistance and sensitization. Also worth mentioning are topical retinoids, especially adapalene. Compared to metronidazole, adapalene had a better effect on inflammatory lesions, but showed a worse effect on reducing erythema [62], possibly with delayed onset [63]. In contrast, the results of a study with retinaldehyde indicated a favorable treatment influence on the vascular component. Erythema and telangiectasias were reduced here [64]. Topical application of the calcineurin inhibitors tacrolimus 0.03 or 0.1% ointment [65, 66] and pimecrolimus 1% cream [22, 67-70] showed good efficacy in the treatment of steroid-induced rosacea. The use of tacrolimus in papulopustular rosacea caused a reduction in erythema but had no effect on papulopustular lesions [65]. Benzoyl peroxide can lead to an improvement in the appearance of the skin in insensitive patients, but it shows the opposite effect on sensitive skin [66]. Combination preparations with clindamycin and erythromycin for rosacea therapy have also been tested [71].
As a chronic inflammatory facial dermatosis, rosacea has a tendency to recur after discontinuation of treatment. Improvements in skin condition achieved by intensive systemic or topical/systemic combination therapy can be maintained over a longer period of time [72] showed that successful maintenance therapy can be carried out with topical metronidazole preparations.
Outlook for topical therapy
For the treatment of erythema that has so far been difficult to influence topically (e.g. in rosacea erythematosa and rosacea telangiectatica or in vascularly mediated erythema in other degrees of severity of rosacea), brimonidine 1% is a symptomatically effective highly selective alpha-2-adrenoreceptor agonist before approval, which leads to effective long-lasting vasoconstriction after once daily use. Neither tachyphylaxis nor rebound phenomena of erythema were observed [73]. A better influence on rosacea-associated telangiectasias and erythema has also been described by the application of metronidazole in a novel w / o microemulsion (split-face study [74])Brimonidine gel and metronidazole in a microemulsion are under clinical investigation at the time of preparation of this guideline and have not yet been approved.