Rosacea is a common dermatologic condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and inflammatory papular or pustular eruptions resembling acne.  This guideline addresses the various forms of treatment utilized for this condition.

Medically Necessary:

Management of rosacea is considered medically necessary when any combination of the following conditions exists:

• Frequent and/or increased facial blushing;
• Complaints of easy irritation (redness, burning, stinging) and erythema of facial skin when using common skin care products;
• Erythema, which may be persistent or transitory, and may increase with flares;
• Facial telangiectasias (especially in paranasal region);
• Formation of facial papules and pustules;
• Development of ocular changes (such as conjunctivitis, blepharitis and/or keratitis);
• Development of edema;
• Rhinophyma

Note: Because several skin conditions share some of the clinical features of rosacea, differentiation of rosacea from other diseases/conditions may be required. Isolated telangectasia in the absence of other signs and symptoms is not diagnostic of rosacea.

The following treatment options are considered medically necessary.

Medical Management:

Initial medical management is based on severity of clinical presentation. This includes patient education to avoid triggers (sun exposure, stress, alcohol consumption, spicy foods, irritating facial care products) and medication therapy including any of the following:

Oral Antibiotics
Oral antibiotic therapy is generally continued until the inflammatory lesions have cleared and maintained, tapered or discontinued based on individual patient response.

Tetracycline:
Systemic tetracycline in doses ranging from 250 mg daily to 500 mg twice a day for 6-12 weeks is usually used in treating acneiform lesions, with improvement evident 2-4 weeks after commencement of therapy. The condition takes a chronic course in most individuals. Intermittent low dose therapy may prevent relapse. Ocular rosacea is usually well controlled with tetracycline.

Doxycycline:
50-100mg once or twice a day for 6-12 weeks.

Minocycline:
50-100mg twice a day or a sustained action formulation once daily for 6-12 weeks is an acceptable antibiotic alternative.

Erythromycin:
250mg once or twice daily for 6-12 weeks may be used as an alternative for tetracycline intolerant patients or pregnant or lactating women.

Metronidazole:
200mg once or twice daily for 4-6 weeks may be used for resistant cases.

Topical Agents

Topical metronidazole:
Available in a twice-daily application of 0.75% cream or gel and in a once-daily 1.0% formulation. Helpful for mild disease and as an adjuvant to systemic therapy.

Topical azelaic acid:
Available as a 20% cream or a 15% gel, this is a topical formulation with established efficacy comparable to topical metronidazole.

Isotretinoin:
May be helpful for recalcitrant disease, but recurrence is common. Low dose Isotretinoin may be helpful for selected patients. Appropriate monitoring is recommended. This drug is highly teratogenic.

Sodium Sulfacetamide (10%)/Sulfur (5%):
Available in cleanser, gel, suspension, lotion and cream formulations are helpful in reducing redness and inflammatory papules and pustules.

Surgical Management:

See ANC.00007 Cosmetic and Reconstructive Services: Skin Related.

Surgical management of acne rosacea is considered medically necessary when the criteria below are met.

• Laser and surgical treatment of rosacea is reserved for severe and refractory forms of rosacea, unresponsive to standard medical therapy. Standard medical therapy includes an adequate trial of topical agents and/or oral agents (antibiotics). Documentation that the patient has undergone and received inadequate results with conservative management as well as preoperative photos documenting the clinical skin changes that are to be treated are required.

• Severe permanent telangiectasia may be treated by electrosurgery, laser (pulsed dye V-beam, the 585 flash pump laser, KTP laser or intense pulsed light [IPL] therapy.
• Severe rhinophyma can be treated with a radiofrequency cutting current and a hockey puck adapter, carbon dioxide laser peel, or surgical shaving.

Not Medically Necessary:

Treatment of rosacea is considered not medically necessary when:

• One or more of the rosacea associated conditions listed above are not present;
• The treatment modality is not one of those included in the medically necessary criteria listed above;
• The use of lasers or other surgical treatments in the absence of failed or inadequate response to medical therapy.

Cosmetic/Not Medically Necessary:

The use of lasers or other surgical treatments for isolated telangiectasia or when the above criteria are not met is considered cosmetic/not medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

	No specific code for medical management of rosacea
17106-17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique) (includes codes 17106, 17107, 17108)
30120	Excision or surgical planing of skin of nose for rhinophyma
96920-96922	Laser treatment for inflammatory skin disease (psoriasis) (includes codes 96920, 96921, 96922)

ICD-9 Diagnosis

448.0	Hereditary hemorrhagic telangiectasia
695.3	Rosacea

According to the National Rosacea Society, an estimated 14 million Americans suffer from the facial redness and swelling of rosacea. Rosacea is more common in fair-skinned people and typically begins as a tendency to blush easily.  The condition can occur for extended periods of time and frequently progresses to a persistent redness of the face with pimples, visible blood vessels, and in its most severe form, enlarged oil glands which result in a thickening of the nose (rhinophyma).

The National Rosacea Society has developed a standard classification system that divides the clinical signs and symptoms of rosacea into four subtypes and one variant form.  A brief description of this classification system is provided below.

Rosacea Subtypes
Subtype 1: Erythematotelangiectatic rosacea
Characterized by flushing and persistent central facial erythema (reddening of the skin) with or without telangiectasia (spider veins). A history of flushing alone is common among patients presenting with this subtype.

Subtype 2: Papulopustular rosacea
Characterized by persistent central facial erythema with transient papules or pustules or both in a central facial distribution. However, papules and pustules also may occur around the mouth, nose and eyes. Resembles acne vulgaris, except that comedones are absent. This subtype is often seen after or in combination with subtype 1.

Subtype 3: Phymatous rosacea
Characterized by thickening skin, irregular surface nodularities, and enlargement. Rhinophyma is the most common presentation, but similar changes may occur in other locations, including the chin, forehead, cheeks, and ears. This subtype is frequently observed after or in combination with subtypes 1 or 2.

Subtype 4: Ocular rosacea
Characterized by the sensation of burning, stinging, dry, or itchy eye. Blurred vision or eye sensitivity to light may occur. Swelling around the eye or telangiectasia (spider veins) of the sclera may be visible.

Variant: Granulomatous rosacea
Characterized by noninflammatory; hard; brown, yellow, or red cutaneous papules; or nodules of uniform size.

Medical management of rosacea includes educating patients to avoid triggers such as sun exposure, stress, alcohol consumption, spicy foods, and irritating facial care products. Topical agents and oral antibiotics are also used to manage the condition. Surgical treatment includes the use of lasers, radiofrequency cutting, carbon dioxide laser peels and surgical shaving, but is reserved for severe and refractory forms of rosacea which are unresponsive to standard medical therapy.

1. American Academy of Dermatology “Advancing the Treatment of Skin Conditions at the Speed of Light”July21, 2005. Available at: http://www.aad.org/aad/Newsroom/Advancing+the+Treatment+of
   +Skin+Conditions+at+the+Speed+of+Light.htm Accessed on October 16, 2006.
2. American Academy of Dermatology “Rosacea Revealed” October 13th, 2004. Available at: http://www.aad.org/public/News/NewsReleases/rosacea_pelle.htm Accessed on October 16, 2006.
3. Blount DW. Rosacea: a common, yet commonly overlooked condition. American Family Physician. Aug 2002.
4. Cohen F, Tiemstra JD. Diagnosis and treatment of rosacea. J American Board of Family Practice. Vol 15, Issue 3 214-217.
5. Dahl MV, Jarratt M, Kaplan D, et al. Once-daily topical metronidazole cream formulations in the treatment of the papules and pustules of rosacea. J Am Acad Dermatol. 2001 Nov;45(5):723-30.
6. Dover JS, Arndt KA, Dinehart SM, et al. Guidelines of care for laser surgery. American Academy of Dermatology, Guidelines/Outcomes Committee. J Am Acad Dermatol. 1999;41 (3 Pt 1):484-495.
7. Liu RH, Smith MK, Basta SA, et al. Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Arch Dermatol. 2006 Aug;142(8):1047-52.
8. National Rosacea Society. Available at: http://www.rosacea.org/ Accessed on October 16, 2006.
9. Odom RB. The subtypes of rosacea: implications for treatment. Cutis. 2004 Jan;73(1 Suppl):9-14.
10. Pelle MT, Crawford GH, James WD. Rosacea: II. Therapy. J Am Acad Dermatol. 2004 Oct;51(4):499-512.
11. Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24;352(8):793-803.
12. Tan JK, Girard C, Krol A, et al.. Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea. J Cutan Med Surg. 2002 Nov-Dec;6(6):529-34. Epub 2002 May 13.
13. Thiboutot D, Thieroff-Ekerdt R, Graupe K. Efficacy and safety of azelaic acid (15%) gel as a new treatment for papulopustular rosacea: results from two vehicle-controlled, randomized phase III studies. J Am Acad Dermatol. 2003 Jun;48(6):836-45.
14. 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 Apr;46(4):584-7. Available at: http://www.rosacea.org/class/classystem.html Accessed on October 16, 2006.
15. Wolf JE Jr, Kerrouche N, Arsonnaud S. Efficacy and safety of once-daily metronidazole 1% gel compared with twice-daily azelaic acid 15% gel in the treatment of rosacea. Cutis. 2006 Apr;77(4 Suppl):3-11.

Management of Rosacea

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