Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee

Published:February 06, 2020DOI:https://doi.org/10.1016/j.jaad.2020.01.077
      In 2017, a National Rosacea Society Expert Committee developed and published an updated classification of rosacea to reflect current insights into rosacea pathogenesis, pathophysiology, and management. These developments suggest that a multivariate disease process underlies the various clinical manifestations of the disorder. The new system is consequently based on phenotypes that link to this process, providing clear parameters for research and diagnosis as well as encouraging clinicians to assess and treat the disorder as it may occur in each individual. Meanwhile, a range of therapies has become available for rosacea, and their roles have been increasingly defined in clinical practice as the disorder has become more widely recognized. This update is intended to provide a comprehensive summary of management options, including expert evaluations, to serve as a guide for tailoring treatment and care on an individual basis to achieve optimal patient outcomes.

      Key words

      Abbreviation used:

      NRS ( National Rosacea Society)
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      References

        • Gallo R.L.
        • Granstein R.D.
        • Kang S.
        • et al.
        Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee.
        J Am Acad Dermatol. 2018; 78: 148-155
        • Alexis A.F.
        • Callender V.D.
        • Baldwin H.E.
        • Desai S.R.
        • Rendon M.I.
        • Taylor S.C.
        Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and clinical practice experience.
        J Am Acad Dermatol. 2019; 80: 1722-1729.e7
        • Gether L.
        • Overgaard L.K.
        • Egeberg A.
        • Thyssen J.P.
        Incidence and prevalence of rosacea: a systematic review and meta-analysis.
        Br J Dermatol. 2018; 179: 282-289
        • Forton F.M.N.
        • De Maertelaer V.
        Rosacea and demodicosis: little-known diagnostic signs and symptoms.
        Acta Derm Venereol. 2019; 99: 47-52
        • National Rosacea Society
        Survey Shows Controlling Stress Can Reduce Flare-up Frequency. Rosacea Review. Fall 2011 issue.
        (Available at:)
        • National Rosacea Society
        Rosacea Patients Feel Effects of Their Condition in Patient Setting. Rosacea Review. Fall 2012 issue.
        (Available at:)
        • National Rosacea Society
        Rosacea Can Affect Workplace Interactions, Survey Reveals. Rosacea Review. Fall 2015 issue.
        (Available at:)
        • Aksoy B.
        • Altaykan-Hapa A.
        • Egeman D.
        • et al.
        The impact of rosacea on quality of life: effects of demographic and clinical characteristics and various treatment modalities.
        Br J Dermatol. 2010; 163: 719-725
        • Su D.
        • Drummond P.D.
        Blushing propensity and psychological distress in people with rosacea.
        Clin Psychol Psychother. 2012; 19: 488-495
        • Dirschka T.
        • Micali G.
        • Papadopoulos L.
        • et al.
        Perceptions on the psychological impact of facial erythema associated with rosacea: results of international survey.
        Dermatol Ther (Heidelb). 2015; 5: 117-127
        • Van der Linden M.M.D.
        • van Rappard D.C.
        • Daams J.G.
        • et al.
        Health-related quality of life in patients with cutaneous rosacea: a systematic review.
        Acta Derm Venereol. 2015; 95: 395-400
        • Elewski B.E.
        Results of a national rosacea patient survey: common issues that concern rosacea sufferers.
        J Drugs Dermatol. 2009; 8: 120-123
        • Bewley A.
        • Fowler J.
        • Schöfer H.
        • et al.
        Erythema of rosacea impairs health-related quality of life: results of a meta-analysis.
        Dermatol Ther. 2016; 6: 237-247
        • Haliou B.
        • Cribier B.
        • Frey M.
        • et al.
        Feelings of stigmatization in patients with rosacea.
        J Eur Acad Dermatol Venereol. 2017; 31: 163-168
        • Browning D.J.
        • Proia A.D.
        Ocular rosacea.
        Surv Ophthalmol. 1986; 31: 145-158
        • Vieira A.C.
        • Höfling-Lima A.L.
        • Mannis M.J.
        Ocular rosacea – a review.
        Arq Bras Oftalmol. 2012; 75: 363-369
        • Hua T.C.
        • Chung P.I.
        • Chen Y.J.
        • et al.
        Cardiovascular comorbidities in patients with rosacea: a nationwide case-control study from Taiwan.
        J Am Acad Dermatol. 2015; 73: 249-254
        • Duman N.
        • Ersoy Evans S.
        • Atakan N.
        Rosacea and cardiovascular risk factors: a case control study.
        J Eur Acad Dermatol Venereol. 2014; 28: 1165-1169
        • Egeberg A.
        • Hansen P.R.
        • Gislason G.H.
        • et al.
        Assessment of the risk of cardiovascular disease in patients with rosacea.
        J Am Acad Dermatol. 2016; 75: 336-339
        • Egeberg A.
        • Weinstock L.B.
        • Thyssen E.P.
        • et al.
        Rosacea and gastrointestinal disorders: a population-based cohort study.
        Br J Dermatol. 2017; 176: 100-106
        • Egeberg A.
        • Fowler Jr., J.F.
        • Gislason G.H.
        • et al.
        Nationwide assessment of cause-specific mortality in patients with rosacea: a cohort study in Denmark.
        Am J Clin Dermatol. 2016; 17: 673-679
        • Spoendlin J.
        • Karatas G.
        • Furlano R.
        • Jick S.S.
        • Meier C.R.
        Rosacea in patients with ulcerative colitis and Crohn's disease: a population-based case control study.
        Inflamm Bowel Dis. 2016; 22: 680-687
        • Kim M.
        • Choi K.H.
        • Hwang S.W.
        • et al.
        Inflammatory bowel disease is associated with an increased risk of inflammatory skin diseases: a population-based cross-sectional study.
        J Am Acad Dermatol. 2017; 76: 40-48
        • Rainer B.M.
        • Fischer A.H.
        • Luz Felipe da Silva D.
        • et al.
        Rosacea is associated with chronic systemic diseases in a skin severity-dependent manner: results of a case-control study.
        J Am Acad Dermatol. 2015; 73: 604-608
        • Egeberg A.
        • Hansen P.R.
        • Gislason G.H.
        • et al.
        Exploring the association between rosacea and Parkinson disease: a Danish nationwide cohort study.
        JAMA Neurol. 2016; 73: 529-534
        • Lyon S.
        • Majewski S.
        • Guide N.
        • et al.
        LB766 Parkinson's disease association with rosacea: a large, single center, retrospective study.
        J Invest Dermatol. 2016; 136: B3
        • Egeberg M.D.
        • Hansen P.R.
        • Gislason G.H.
        • et al.
        Patients with rosacea have increased risk of dementia.
        Ann Neurol. 2016; 79: 921-928
        • Egeberg A.
        • Hansen P.R.
        • Gislason G.H.
        • et al.
        Clustering of autoimmune diseases in patients with rosacea.
        J Am Acad Dermatol. 2016; 74: 667-672
        • Akin Belli A.
        • Ozbas Gok S.
        • Akbaba G.
        • et al.
        The relationship between rosacea and insulin resistance and metabolic syndrome.
        Eur J Dermatol. 2016; 26: 260-264
        • Egeberg A.
        • Ashina M.
        • Gaist D.
        • et al.
        Prevalence and risk of migraine in patients with rosacea: a population-based cohort study.
        J Am Acad Dermatol. 2017; 76: 454-458
        • Li W.Q.
        • Zhang M.
        • Danby F.W.
        • et al.
        Personal history of rosacea and risk of incident cancer among women in the US.
        Br J Cancer. 2015; 113: 520-523
        • Egeberg A.
        • Hansen P.R.
        • Gislason G.H.
        • et al.
        Association of rosacea with risk for glioma in a Danish nationwide cohort study.
        JAMA Dermatol. 2016; 152: 541-545
        • Wilkin J.
        • Dahl M.
        • Detmar M.
        • et al.
        Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.
        J Am Acad Dermatol. 2002; 46: 584-587
        • Wilkin J.
        • Dahl M.
        • Detmar M.
        • et al.
        • National Rosacea Society Expert Committee
        Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea.
        J Am Acad Dermatol. 2004; 50: 907-912
        • Webster G.
        • Schaller M.
        • Tan J.
        • et al.
        Defining treatment success in rosacea as ‘clear’ may provide multiple patient benefits: results of a pooled analysis.
        J Dermatolog Treat. 2017; 28: 469-474
        • van Zuuren E.J.
        • Fedorowicz Z.
        • Carter B.
        • et al.
        Interventions for rosacea.
        Cochrane Database Syst Rev. 2015; : CD003262
        • Fowler Jr., J.
        • Jackson M.
        • Moore A.
        • et al.
        Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies.
        J Drugs Dermatol. 2013; 12: 650-656
      1. Rhofade cream prescribing information. Allergan, Irvine, CA2017 (Available at:)
        • Elewski B.E.
        • Draelos Z.
        • Dréno B.
        • et al.
        Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group.
        J Eur Acad Dermatol Venereol. 2011; 25: 188-200
        • Schaller M.
        • Almeida L.M.
        • Bewley A.
        • et al.
        Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel.
        Br J Dermatol. 2017; 176: 465-471
        • Powell F.C.
        Clinical practice. Rosacea.
        N Engl J Med. 2005; 352: 793-803
        • Reinholz M.
        • Tietze J.K.
        • Kilian K.
        • et al.
        Rosacea – S1 guideline.
        J Dtsch Dermatol Ges. 2013; 11: 768-780
        • Asai Y.
        • Tan J.
        • Baobergenova A.
        • et al.
        Canadian clinical practice guidelines for rosacea.
        J Cutan Med Surg. 2016; 20: 432-435
        • Stein L.
        • Kircik L.
        • Fowler J.
        • et al.
        Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies.
        J Drugs Dermatol. 2014; 13: 316-323
        • Stein Gold L.
        • Kircik L.
        • Fowler J.
        • et al.
        Long-term safety of ivermectin 1% cream vs azelaic acid 15% gel in treating inflammatory lesions of rosacea: results of two 40-week controlled, investigator-blinded trials.
        J Drugs Dermatol. 2014; 13: 1380-1386
        • Taieb A.
        • Khemis A.
        • Ruzicka T.
        • et al.
        Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-233k extension of the ATTRACT randomized study.
        J Eur Acad Dermatol Venereol. 2016; 30: 829-836
        • Taieb A.
        • Ortonne J.P.
        • Ruzicka T.
        • et al.
        Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial.
        Br J Dermatol. 2015; 172: 1103-1110
        • Schaller M.
        • Kemeny L.
        • Havlickova B.
        • et al.
        A randomized phase 3b/4 study to evaluate concomitant use of topical ivermectin 1% cream and doxycycline 40 mg modified-release capsules versus topical ivermectin 1% cream and placebo in the treatment of severe rosacea.
        J Am Acad Dermatol. 2020; 82: 336-343
        • Draelos Z.D.
        • Elewski B.
        • Staedtler G.
        • et al.
        Azelaic acid foam 15% in the treatment of papulopustular rosacea: a randomized, double-blind, vehicle-controlled study.
        Cutis. 2013; 92: 306-317
        • Beutner K.
        • Calvarese B.
        A multi-center, investigator-blind clinical trial to assess the safety and efficacy of metronidazole gel 1% as compared to metronidazole gel vehicle and metronidazole cream 1% in the treatment of rosacea.
        J Am Acad Dermatol. 2005; 52 (Suppl 10. abstract)
        • Bitar A.
        • Bourgouin J.
        • Doré N.
        • et al.
        A double-blind randomized study of metronidazole (Flagyl) 1% cream in the treatment of acne rosacea.
        Drug Invest. 1990; 2: 242-248
        • Bjerke J.R.
        • Nyfors A.
        • Austad J.
        • et al.
        Metronidazole (Elyzol) 1% cream v. placebo cream in the treatment of rosacea.
        Clin Trials J. 1989; 26: 187-194
        • Bleicher P.A.
        • Charles J.H.
        • Sober A.J.
        Topical metronidazole therapy for rosacea.
        Arch Dermatol. 1987; 123: 609-614
        • Breneman D.L.
        • Stewart D.
        • Hevia O.
        • et al.
        A double-blind, multicenter clinical trial comparing efficacy of once-daily metronidazole 1 percent cream to vehicle in patients with rosacea.
        Cutis. 1998; 61: 44-47
        • Dahl M.V.
        • Katz H.I.
        • Krueger G.G.
        • et al.
        Topical metronidazole maintains remissions of rosacea.
        Arch Dermatol. 1998; 134: 679-683
        • Koçak M.
        • Yağli S.
        • Vahapoğlu G.
        • et al.
        Permethrin 5% cream versus metronidazole 0.75% gel for the treatment of papulopustular rosacea: a randomized double-blind placebo-controlled study.
        Dermatology. 2002; 205: 265-270
        • Nielsen P.G.
        Treatment of rosacea with 1% metronidazole cream: a double-blind study.
        Br J Dermatol. 1983; 108: 327-332
        • van Zuuren E.J.
        • Fedorowicz Z.
        • Tan J.
        • et al.
        Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments.
        Br J Dermatol. 2019; 181: 65-79
        • Stein Gold L.
        • Papp K.
        • Lynde C.
        • et al.
        Treatment of rosacea with concomitant use of topical ivermectin 1% cream and brimonidine 0.33% gel: a randomized, vehicle-controlled study.
        J Drugs Dermatol. 2017; 16: 909-916
        • Del Rosso J.Q.
        • Webster G.F.
        • Jackson M.
        • et al.
        Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea.
        J Am Acad Dermatol. 2007; 56: 791-802
        • Del Rosso J.Q.
        • Schlessinger J.
        • Werschler P.
        Comparison of anti-inflammatory dose doxycycline versus doxycycline 100 mg in the treatment of rosacea.
        J Drugs Dermatol. 2008; 7: 573-576
        • Gollnick H.
        • Blume-Peytavi U.
        • Szabó E.L.
        • et al.
        Systemic isotretinoin in the treatment of rosacea – doxycycline- and placebo-controlled, randomized clinical study.
        J Dtsch Dermatol Ges. 2010; 8: 505-515
        • Sbidian E.
        • Vicaut É.
        • Chidiack H.
        • et al.
        A randomized-controlled trial of oral low-dose isotretinoin for difficult-to-treat papulopustular rosacea.
        J Invest Dermatol. 2016; 136: 1124-1129
        • Marks R.
        • Ellis J.
        Comparative effectiveness of tetracycline and ampicillin in rosacea: a controlled trial.
        Lancet. 1971; 2: 1049-1052
        • Sneddon I.B.
        A clinical trial of tetracycline in rosacea.
        Br J Dermatol. 1966; 78: 649-652
        • Two A.M.
        • Wu W.
        • Gallo R.L.
        • et al.
        Rosacea: Part II. Topical and systemic therapies in the treatment of rosacea.
        J Am Acad Dermatol. 2015; 72: 761-770
        • Opitz D.L.
        • Tyler K.F.
        Efficacy of azithromycin 1% ophthalmic solution for treatment of ocular surface disease from posterior blepharitis.
        Clin Exp Optom. 2011; 94: 200-206
        • Foulks G.N.
        • Borchman D.
        • Yappert M.
        • et al.
        Topical azithromycin and oral doxycycline therapy of meibomian gland dysfunction: a comparative clinical and spectroscopic pilot study.
        Cornea. 2013; 32: 44-53
        • Yildiz E.
        • Yeneral N.M.
        • Turan-Yardimci A.
        • et al.
        Comparison of the clinical efficacy of topical and systemic azithromycin treatment for posterior blepharitis.
        J Ocul Pharmacol Ther. 2018; 34: 365-372
        • Zandian M.
        • Rahimian N.
        • Soheilifar S.
        Comparison of therapeutic effects of topical azithromycin solution and systemic doxycycline on posterior blepharitis.
        Int J Ophthalmol. 2016; 9: 1016-1019
        • Shah S.A.
        • Spencer S.K.
        • Tharmarajah B.
        • et al.
        Meibomian gland dysfunction: azithromycin and objective improvement in outcomes in posterior blepharitis.
        Clin Exp Ophthalmol. 2016; 44: 866
        • Sobolewska B.
        • Doycheva D.
        • Deuter C.
        • et al.
        Treatment of ocular rosacea with once-daily low-dose doxycycline.
        Cornea. 2014; 33: 257-260
        • Quarterman M.J.
        • Johnson D.W.
        • Abele D.C.
        • et al.
        Ocular rosacea: signs, symptoms, and tear studies before and after treatment with doxycycline.
        Arch Dermatol. 1997; 133: 49-54
        • Wladis E.J.
        • Bradley E.A.
        • Bilyk J.R.
        • et al.
        Oral antibiotics for meibomian gland-related ocular surface disease: a report by the American Academy of Ophthalmology.
        Ophthalmology. 2016; 123: 492-496
        • Odom R.
        • Dahl M.
        • Dover J.
        • et al.
        Standard management options for rosacea, part 2: options according to subtype.
        Cutis. 2009; 84: 97-104
        • van Zuuren E.J.
        Rosacea.
        N Engl J Med. 2017; 377: 1754-1764
        • Schwab V.D.
        • Sulk M.
        • Seeliger S.
        • et al.
        Neurovascular and neuroimmune aspects in the pathophysiology of rosacea.
        J Invest Dermatol Symp Proc. 2011; 15: 53-62
        • Seeliger S.
        • Buddenkotte J.
        • Schmidt-Choudhury A.
        • et al.
        Pituitary adenylate cyclase activating polypeptide: an important vascular regulator in human skin in vivo.
        Am J Pathol. 2010; 177: 2563-2575
        • Sulk M.
        • Seeliger S.
        • Aubert J.
        • et al.
        Distribution and expression of non-neuronal transient receptor potential (TRPV) ion channels in rosacea.
        J Invest Dermatol. 2012; 132: 1253-1262
        • Wladis E.J.
        • Iglesias B.V.
        • Adam A.P.
        • et al.
        Molecular biologic assessment of cutaneous specimens of ocular rosacea.
        Ophthal Plast Reconstr Surg. 2012; 28: 246-250
        • Tan J.
        • Blume-Peytavi U.
        • Ortonne J.P.
        • et al.
        An observational cross-sectional survey of rosacea: clinical associations and progression between subtypes.
        Br J Dermatol. 2013; 169: 555-562
        • Holmes A.D.
        • Steinhoff M.
        Integrative concepts of rosacea pathophysiology, clinical presentation and new therapeutics.
        Exp Dermatol. 2017; 26: 659-667
        • Steinhoff M.
        • Buddenkotte J.
        • Aubert J.
        • et al.
        Clinical, cellular, and molecular aspects in the pathophysiology of rosacea.
        J Invest Dermatol Symp Proc. 2011; 15: 2-11
        • Trivedi N.R.
        • Gilliland K.L.
        • Zhao W.
        • et al.
        Gene array expression profiling in acne lesions reveals marked upregulation of genes involved in inflammation and matrix remodeling.
        J Invest Dermatol. 2006; 126: 1071-1079
        • Buhl T.
        • Sulk M.
        • Nowak P.
        • et al.
        Molecular and morphological characterization of inflammatory infiltrate in rosacea reveals activation of Th1/Th17 pathways.
        J Invest Dermatol. 2015; 135: 2198-2208
        • Aubdool A.A.
        • Brain S.D.
        Neurovascular aspects of skin neurogenic inflammation.
        J Invest Dermatol Symp Proc. 2011; 15: 33-39
        • Lonne-Rahm S.-B.
        • Fischer T.
        • Berg M.
        Stinging and rosacea.
        Acta Derm Venereol. 1999; 79: 460-461
        • Steinhoff M.
        • von Mentzer B.
        • Geppetti P.
        • et al.
        Tachykinins and their receptors: contributions to physiological control and the mechanisms of disease.
        Physiol Rev. 2014; 94: 265-301
        • Gao Y.Y.
        • Di Pascuale M.A.
        • Li W.
        • et al.
        High prevalence of Demodex in eyelashes with cylindrical dandruff.
        Invest Ophthalmol Vis Sci. 2005; 46: 3089-3094
        • Muto Y.
        • Wang Z.
        • Vanderberghe M.
        • et al.
        Mast cells are key mediators of cathelicidin-initiated skin inflammation in rosacea.
        J Invest Dermatol. 2014; 134: 2728-2736
        • Yamasaki K.
        • Kanada K.
        • Macleod D.T.
        • et al.
        TLR2 expression is increased in rosacea and stimulates enhanced serine protease production by keratinocytes.
        J Invest Dermatol. 2011; 131: 688-697
        • Schauber J.
        • Gallo R.L.
        The vitamin D pathway: a new target for control of the skin's immune response?.
        Exp Dermatol. 2008; 17: 633-639
        • Yamasaki K.
        • Di Nardo A.
        • Bardan A.
        • et al.
        Increased serine protease activity and cathelicidins promotes skin inflammation in rosacea.
        Nat Med. 2007; 13: 975-980
        • Preshaw P.M.
        • Hefti A.F.
        • Jepsen S.
        • et al.
        Subantimicrobial dose doxycycline as adjunctive treatment for periodontitis: a review.
        J Clin Periodontol. 2004; 31: 697-707
        • Thiboutot D.M.
        • Fleischer A.B.
        • Del Rosso J.Q.
        • et al.
        A multicenter study of topical azelaic acid 15% gel in combination with oral doxycycline as initial therapy and azelaic acid 15% gel as maintenance monotherapy.
        J Drugs Dermatol. 2009; 8: 639-648
        • Shim T.N.
        • Abdullah A.
        The effect of pulsed dye laser on the dermatology life quality index in erythematotelangiectatic rosacea patients.
        J Clin Aesth Dermatol. 2013; 4: 30-32
        • Tan S.R.
        • Tope W.D.
        Pulsed dye laser treatment of rosacea improves erythema, symptomatology, and quality of life.
        J Am Acad Dermatol. 2004; 51: 592-599
        • Arita R.
        • Fukuoka S.
        • Morishige N.
        Therapeutic efficacy of intense pulsed light in patients with refractory meibomian gland dysfunction.
        Ocul Surf. 2019; 17: 104-110
        • Zhang X.
        • Song N.
        • Gong L.
        Therapeutic effect of intense pulsed light on ocular demodicosis.
        Curr Eye Res. 2019; 44: 250-256
        • Kassir R.
        • Kolluru A.
        • Kassir M.
        Intense pulsed light for the treatment of rosacea and telangiectasias.
        J Cosmet Laser Ther. 2011; 13: 216-222
        • Vora G.K.
        • Gupta P.K.
        Intense pulsed light therapy for the treatment of evaporative dry eye disease.
        Curr Opin Ophthalmol. 2015; 26: 314-318
        • Toyos R.
        • McGill W.
        • Briscoe D.
        Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study.
        Photomed Laser Surg. 2015; 33: 41-46
        • Finis D.
        • Hayajneh J.
        • König C.
        • et al.
        Evaluation of an automated thermodynamic treatment (LipiFlow®) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial.
        Ocul Surf. 2014; 12: 146-154
        • Gupta P.K.
        • Vora G.K.
        • Matossian C.
        • et al.
        Outcomes of intense pulsed light therapy for treatment of evaporative dry eye disease.
        Can J Ophthalmol. 2016; 51: 249-253
        • Hagen K.B.
        • Bedi R.
        • Blackie C.A.
        • et al.
        Comparison of a single-dose vectored thermal pulsation procedure with a 3-month course of daily oral doxycycline for moderate-to-severe meibomian gland dysfunction.
        Clin Ophthalmol. 2018; 17: 161-168
        • Yin Y.
        • Liu N.
        • Gong L.
        • et al.
        Changes in the meibomian gland after exposure to intense pulsed light in meibomian gland dysfunction (MGD) patients.
        Curr Eye Res. 2019; 43: 308-313
        • Rong B.
        • Tang Y.
        • Tu P.
        • et al.
        Intense pulsed light applied directly on eyelids combined with meibomian gland expression to treat meibomian gland dysfunction.
        Photo Med Laser Surg. 2018; 36: 326-332
        • Blackie C.A.
        • Coleman C.A.
        • Nichols K.K.
        • et al.
        A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day.
        Clin Ophthalmol. 2018; 12: 169-183
        • National Rosacea Society
        Rosacea Triggers Survey.
        (Available at:)
        • Cole C.
        • Shyr T.
        • Ou-Yang H.
        Metal oxide sunscreens protect skin by absorption, not by reflection or scattering.
        Photodermatol Photoimmunol Photomed. 2016; 32: 5-10
        • National Rosacea Society
        Skin Care & Cosmetics.
        (Available at:)