Treatment for Rosacea Fulminans
Rosacea fulminans should be treated with a combination of isotretinoin and corticosteroids (both topical and systemic), as this regimen produces superior and more rapid response compared to oral antibiotics alone. 1
Understanding Rosacea Fulminans
Rosacea fulminans is a rare and severe inflammatory dermatosis characterized by:
- Sudden onset of painful papules, pustules, cysts, and nodules on the face
- Predominantly affects women of childbearing age, though rare cases in men have been reported
- Lesions typically cover most of the facial surface with innumerable fluctuant inflammatory nodules
- Often preceded by seborrhea
Treatment Algorithm
First-Line Therapy
- Combination therapy with:
- Oral isotretinoin
- Systemic corticosteroids (short course)
- Topical corticosteroids
This combination approach is considered the gold standard for rosacea fulminans and is the only indication for corticosteroids in rosacea treatment 2, 1.
Dosing and Administration
- Isotretinoin: Start at lower doses and gradually increase
- Systemic corticosteroids: Short course (typically 2-4 weeks) with tapering to minimize side effects
- Topical corticosteroids: Applied to affected areas for rapid reduction of inflammation
Alternative Treatments
For patients who cannot tolerate standard therapy:
- Subantimicrobial-dose doxycycline (40mg) has shown success in treating rosacea fulminans, including in elderly patients with extrafacial lesions 3
Special Populations
Pregnant Women
Treatment options are limited during pregnancy:
- 5% permethrin cream has been reported as an effective and safe alternative 4
- Other options include:
- Topical erythromycin
- Oral erythromycin
- Topical metronidazole (with caution)
- Topical zinc oxide
Treatment Duration and Monitoring
- Allow sufficient treatment time (6-12 weeks) before considering a change in therapy 2, 5
- Monitor for improvement of inflammatory lesions
- Scarring is often minimal when appropriate treatment is initiated promptly 1
- Recurrence is rare after successful treatment 1
Common Pitfalls to Avoid
- Misdiagnosis: Rosacea fulminans is not a pyoderma, infection, or variant of acne conglobata 1
- Inadequate treatment duration: Treatments should be given sufficient time (at least 8 weeks) to demonstrate efficacy 2
- Monotherapy: Single treatments are rarely effective for this severe condition 5
- Overuse of corticosteroids: While necessary for treatment, prolonged use should be avoided to prevent side effects
Follow-up Care
- Regular follow-up to monitor treatment response and adjust therapy as needed
- Gradual tapering of medications once improvement is seen
- Maintenance therapy may be considered based on individual response
The phenotype-based approach recommended by the British Journal of Dermatology is particularly important in managing this severe form of rosacea, as multiple features often coexist and require simultaneous treatment with multiple agents 5.