Interventions for rosacea based on the phenotype approach: an updated systematic review includingGRADEassessments

Abstract

SummaryBackgroundRosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.ObjectivesTo update our systematic review on interventions for rosacea.MethodsWe searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk‐of‐bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence.ResultsWe included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light‐based treatment. We present the most current evidence for rosacea management based on a phenotype‐led approach.ConclusionsFor reducing temporarily persistent erythema there was high‐certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low‐to‐moderate‐certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high‐certainty evidence for topical azelaic acid and topical ivermectin; moderate‐to‐high‐certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate‐certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low‐certainty evidence for tetracycline and low‐dose minocycline. For ocular rosacea, there was moderate‐certainty evidence that oral omega‐3 fatty acids were effective and low‐certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.

Value of reflectance confocal microscopy for the monitoring of rosacea during treatment with topical ivermectin

“…This study confirmed the well-known efficacy of topical ivermectin to reduce inflammatory lesions in rosacea (36). To the best of our knowledge, this is the first study combining a broad spectrum of RCM and clinical variables to monitor rosacea during treatment.…”

“…It is hypothesized that clinical effects of rosacea treatment can be quantified and ideally also be predicted using RCM monitoring. Topical ivermectin, an antiparasitic preparation that has dual anti-inflammatory and acaricidal effects, has been widely studied as a safe, easy to use, and effective treatment to reduce papules and pustules in rosacea (36). This makes ivermectin a suitable intervention to monitor rosacea treatment effects.…”

Noninvasive objective skin measurement methods for rosacea assessment: a systematic review

“…Recently, the classification system was changed from subtype-based to phenotype-based to increase diagnostic and presentation accuracy, but as many trials predate the updated phenotype approach, the subtype-based system still dominates rosacea literature. 8,[10][11][12] To achieve optimal results, rosacea treatment is preferably adjusted to clinical symptoms and disease severity. 3,13,14 However, the variety of clinical manifestations among individual patients and presence of various classification systems make standardization and quantification of rosacea measurements challenging.…”

“…Initially, four rosacea subtypes were described: erythematotelangiectatic, papulopustular, phymatous and ocular. Recently, the classification system was changed from subtype‐based to phenotype‐based to increase diagnostic and presentation accuracy, but as many trials predate the updated phenotype approach, the subtype‐based system still dominates rosacea literature . To achieve optimal results, rosacea treatment is preferably adjusted to clinical symptoms and disease severity .…”

New evidence but still unmet medical needs in rosacea treatment

“…In this issue of the BJD , van Zuuren and colleagues have published the update of their systematic review of efficacy and tolerance of interventions for rosacea, a prevalent facial dermatosis that has a significant impact on quality of life . The number of included randomized controlled trials (RCTs) has increased from 22 in the first version in 2003 to 152 in this current update, illustrating the dynamism of contemporary therapeutic research.…”