This feature is extracted from a publication available from Wolters Kluwer Health. origin; more recent data have indicated an exacerbated immune response possibly caused by bacteria or an overproduction of inflammatory proteins.1 Traditional therapy has centered on reducing symptoms and facial redness through the use of oral tetracyclines and/or topical metronidazole which is effective in the majority of cases. However in patients who do not respond or who are unable to tolerate tetracyclines other oral antibiotics have been tried (eg macrolides).2 3 The use of vasoactive drugs including topical oxymetazoline may be beneficial for symptoms of flushing and erythema associated with rosacea. Patient Population Adult patients (age range 55 to 70 years) with acne rosacea accompanied by symptoms of erythema and flushing. Danusertib Dosage and Duration Intranasal oxymetazoline 0.05% solution applied topically once daily to affected facial areas for up to 17 months. Results The topical use of oxymetazoline 0.05% solution in the management of rosacea has been primarily limited to data from case series including fewer than 10 patients and demonstrating sustained improvements in both erythema and flushing. Alhough oxymetazoline is not recognized in national guidelines an international consensus statement recognizes the possible NF1 therapeutic role of oxymetazoline in the management of rosacea despite the limited evidence. Guidelines American Acne and Rosacea Society The American Acne and Rosacea guidelines provide an overview of the fundamental issues associated with the disease and outline the pharmacological and behavioral management. The conversation of pharmacological management is usually provided as a review of all therapies and does not suggest a tiered approach to therapy. Included in this guideline are the 3 US Food and Drug Administration (FDA)-approved topical products sulfacetamide/sulfur azelaic acid and metronidazole. Other topical agents resolved have varying levels of evidence including calcineurin inhibitors (eg tacrolimus and pimecrolimus) benzoyl peroxide/clindamycin and retinoids. Topical permethrin has also been noted as effective in case reports of refractory rosacea that were related to demodex folliculitis. Oral anti-inflammatory agents include low-dose controlled release doxycycline which is usually FDA approved. Doses greater than 50 mg of oral doxycycline are considered off-label as is the use of other oral antibiotics (eg tetracyclines minocycline and oral isotretinoin). It should be noted that there has been increased concern regarding the promotion of antibiotic resistance with the use of antibiotics in the management of rosacea. Thus these guidelines recommend that antibiotic Danusertib use be limited and directed Danusertib at a specific pathogen when present. Oral antibiotics should be reserved for cases that are poorly responsive or refractory to topical or anti-inflammatory therapies. Topical oxymetazoline is not pointed out in these guidelines.4 International Consensus (Rosacea International Expert Group) This international consensus statement notes that oral tetracyclines (tetracycline doxycycline and Danusertib minocycline) and topical agents are the mainstay of rosacea treatment with the 3 primary topical drugs having FDA approval (eg azelaic acid metronidazole and sodium sulfacetamide/sulphur). Other topical brokers with noted efficiacy include antibiotics (eg erythromycin clindamycin) and retinoids (eg adalapene tretinoin). This guideline also notes that other topical agents have been evaluated but are supported by variable evidence in the treatment of rosacea including permerthrin tacrolimus pimecrolimus and oxymetazoline. Oxymetazoline has resulted in improvement in erythema and erythematous flares with relief in stinging and burning. For symptoms of periodic flushing vasoactive drugs are also recommended including topical oxymetazoline and oral nadolol ondansetron or clonidine despite limited evidence. The FDA-approved topical therapies are suggested as first-line treatment for prolonged erythema or rosacea characterized by papules and pustules. The addition of oral antibiotics may be warranted. For nodular or plaque type rosacea first-line therapy consists of oral antibiotics oral isotretinoin intralesional corticosteroids or combined topical brokers with low-dose doxycycline. In refractory cases the addition of high-dose antibiotics may be combined with topical brokers. Topical antibiotics (fusidic acid and metronidazole) and oral antibiotics.