Rosacea treatment guideline for the Netherlands.

Dear Editor, The classification of rosacea has evolved from a subtyping into a phenotype approach,1, 2, 3 and an updated systematic review on interventions in rosacea using this approach was recently published.4 Therefore, we developed a new evidence‐based guideline for all physicians and skin therapists involved in the management of patients with rosacea. A patient information leaflet based on this guideline was produced. The working group (WG) consisted of four dermatologists, two general practitioners, one ophthalmologist, one plastic surgeon, two skin therapists, one patient and two staff members of the Dutch Society of Dermatology and Venereology. All affiliated organizations participated in external review. The Dutch Association for Hospital Pharmacists was invited to participate in the WG, but chose to participate only in the external review. The Association of Innovative Medicines, Dutch Health Insurers, the Dutch Association of Hospitals and the Dutch Federation of University Medical Centres were invited to participate in devising health questions and external review. Development of the guideline was independently funded by the Dutch Medical Specialists’ Quality Fund. Two WG members had received one‐off nonfinancial support from Galderma in 2016; the other members declared no conflicts of interest.

The updated systematic review ‘Interventions for rosacea based on the phenotype approach’ served as the basis for guideline development.4 This review conformed to the PRISMA statement and included GRADE certainty‐of‐evidence assessments for all prespecified outcomes (quality of life, participant‐assessed rosacea severity, adverse events, physician‐assessed rosacea severity, erythema and telangiectasia, lesion counts, time to improvement, and duration of remission).4, 5 The search up to March 2018 provided 152 randomized controlled trials.4 Study selection, data extraction, risk‐of‐bias assessment (Cochrane risk‐of‐bias tool) and analyses were carried out independently by two authors. The complete content of the review, encompassing 93 comparisons and including 25 summary‐of‐findings tables, is available in the appendix of that paper.4 Three of the authors of this systematic review were involved in the development of the guideline (E.J.v.Z., M.M.D.v.d.L. and B.W.M.A.).

The health questions covered in the guideline, as formulated by the WG and external stakeholders, were (i) which self‐care measures can be advised; (ii) what are the effectiveness and safety of the topical treatments brimonidine, oxymetazoline, ivermectin, metronidazole and azelaic acid, and how suitable are other topical treatments; (iii) what are the effectiveness and safety of tetracyclines and isotretinoin, and how suitable are other systemic treatments; (iv) what are the effectiveness and safety of intense pulsed light and laser‐based therapies; (v) what are the effectiveness and safety of combination treatments; (vi) which therapeutic options exist for phymas; (vii) which self‐care measures can be advised for ocular rosacea; (viii) what are the effectiveness and safety of treatment options for ocular rosacea; (ix) when do patients with ocular rosacea need to be referred to an ophthalmologist; (x) which therapeutic options are safe during pregnancy; (xi) which therapeutic options are safe for children; and (xii) what are the effectiveness and safety of maintenance treatments.

The guideline followed the GRADE Evidence to Recommendation Frameworks. In making recommendations the WG integrated estimates of effect for desirable and undesirable outcomes of interest and confidence in the estimates of effect (certainty of evidence), items available from the systematic review, with estimates of values and preferences, and resource use.6, 7 Recommendations are either strong or weak, and for or against a treatment.6 We used the wording ‘recommend’ for strong recommendations and ‘consider’ for weak recommendations. This guideline was developed for the Netherlands; however, its generalizability with respect to costs, availability and preferences may differ from country to country. To ensure completeness and transparency of reporting of the guideline the AGREE II checklist was used.8

Considering that rosacea has a negative impact on quality of life and that improvement of well‐being is important, a full chapter was dedicated to this topic. The WG recommended addressing quality of life (aspects most bothersome to the patient), treatment satisfaction, social and professional functioning, and psychological well‐being.

The most important recommendations have been reported in a treatment algorithm (Fig. 1). In addition to the recommendations provided in the treatment algorithm, the WG recommended against the use of topical clindamycin, solely or in combination with topical tretinoin. Due to inconsistent evidence regarding the effectiveness of benzoyl peroxide cream or gel and of permethrin cream, prescribing these warrants caution. The same holds true for oral azithromycin, although it could be a treatment option for those experiencing adverse events of doxycycline and minocycline, or in pregnant women. Topical oxymetazoline and minocycline foam are not yet available in the Netherlands, but were evaluated in the guideline (with the caveat of nonavailability). The full guideline is available at www.nvdv.nl.

Figure 1

Rosacea treatment algorithm. Consider = weak recommendation. Recommended = strong recommendation. b.i.d., twice daily; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; PDL, pulsed‐dye laser; q.d., once daily; UV, ultraviolet; YAG, yttrium aluminium garnet.

The WG will consider an annual update or revision based on recent developments and new evidence. An updating process will be launched when required.