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aftershave), witch hazel, menthol, peppermint or eucalyptus. Patients should be warned that ocular symptoms need to be followed-up.

(B) TOPICAL THERAPY

For mild erythema and inflammatory lesions, use:
~ metronidazole 0.75% gel or cream topically, twice daily OR
~ clindamycin 1% solution topically, twice daily OR
~ erythromycin 2% gel topically, twice daily.

A non-alcohol-based gel is often cooling and soothing, but some patients prefer the more emollient cream base. Topical treatments need to be trialled for 6 to 12 weeks, as benefits are often delayed.

Although safety with long-term use has not been studied, long-term maintenance with topical metronidazole is often used to control rosacea and prolong remissions.

(C) SYSTEMIC THERAPY

Consider systemic treatment in more severe cases or when topical therapy alone is unsuccessful. Initial treatment is:
~ doxycycline 50 to 100 mg orally, daily OR
~ tetracycline 500 to 1000 mg orally, daily or in two divided doses.

If there is inadequate response in 4 weeks, other antibiotics can be considered:
~ erythromycin 250 mg orally, twice daily OR
~ minocycline 50 to 100 mg orally, daily.

Lack of success with one antibiotic does not infer that others will not be useful. An 8-week course is often used and repeated as required. Occasionally a lower suppressive dose is used longer term.

The safety of long-term antibiotic therapies is controversial because of the increasing evidence of antibiotic resistance in organisms worldwide. Bacteria have never been shown to play a significant role in the pathogenesis of rosacea, and the beneficial effects of antibiotics in rosacea are presumably due to nonantimicrobial actions.

Where antibiotics have failed or proven inadequate, "low-dose" oral isotretinoin (eg. 10 mg three times a week) has been effective.

For ocular rosacea, systemic antibiotic therapy effectively controls ocular symptoms in most cases. Artificial tears may provide symptomatic relief. In severe cases, opthalmological review may be needed.

(D) LASER THERAPY

Vascular laser therapy (eg. with pulsed dye lasers) is effective for erythrotelangiectatic changes. Several treatment sessions may be required depending on severity and patient expectations. This treatment has minimal complications in experienced hands.

Anecdotal reports suggest that vascular laser treatment may have a beneficial effect on flushing and inflammatory changes. Controlled studies are required to verify these claims.

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