Interventions for rosacea based on the phenotype approach: An updated systematic review including GRADE assessments:Evidence based treatments for rosacea based on phenotype approach

BackgroundRosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.ObjectivesUpdating our systematic review on interventions for rosacea. MethodsWe searched: CENTRAL in The Cochrane Library, MEDLINE, EMBASE, LILACS, Science Citation Index, and ongoing trials registers (March 2018) for randomised controlled trials. Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors. 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: 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 and isotretinoin; moderate certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg. 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.