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Clinical Policy Bulletin:
Number: 0547


Aetna considers medical treatment of rosacea medically necessary.  However, surgical treatment of disfigurement from rosacea (e.g., scarring and telangiectasias) is considered cosmetic.

Aetna considers excision or shaving of rhinophyma medically necessary for the treatment of bleeding or infection refractory to medical therapy (i.e., the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions), 

Aetna considers botulinum toxin for the treatment of rosacea experimental and investigational because its effectiveness for this condition has not been established.

See CPB 0559 - Pulsed Dye Laser Treatment.

Note: Cosmetic surgery is excluded from coverage under Aetna standard benefit plans.  Please check benefit plan descriptions for details.  See CPB 0031 - Cosmetic Surgery.


Rosacea is a multi-factorial skin disorder that usually affects middle-aged individuals and is characterized by persistent erythema, telangiectasias and acute episodes of edema, papules, and pustules.  Patients may have a tendency to flush easily.  Treatment is difficult and is dependent on the severity of disease.  Avoidance of excessive sunlight and extreme temperatures is typically recommended.  Medical management is aimed only at the inflammatory papules and pustules and the erythema that surrounds them.  Topical preparations of metronidazole, clindamycin and erythromycin have been shown to be helpful for mild cases.  Oral tetracycline and erythromycin are often prescribed for moderate cases, and Accutane (isotretinoin) has been found to be effective in severe refractory cases.  Oral metronidazole has also been used in severe refractory cases.

Accepted guidelines indicate that laser surgery and electrocautery are the only satisfactory treatments for the telangiectasias.  Treatment is directed toward obliteration of ectatic vessels.  Rhinophyma (soft tissue and sebaceous hyperplasia of the nose) is considered the culmination of acne rosacea.  Rhinophyma responds to electrosurgery, laser excision, and surgical debulking.  Because telangiectasias and rhinophyma do not cause functional limitations, their treatment is considered cosmetic. 

Goldberg (2005) stated that pharmacological agents remain the mainstay for initial and maintenance treatment of rosacea.  However, monochromatic (i.e., laser) and polychromatic light-based therapies are increasingly being used for the treatment of certain signs of rosacea.  The author noted that despite the increased use of lasers and other light-based therapies, few well-controlled studies have been conducted on their use for the treatment of rosacea.  Furthermore, a Cochrane review on interventions for rosacea (van Zuuren et al, 2005) concluded that the quality of studies evaluating rosacea treatments was generally poor.  There is evidence that topical metronidazole and azelaic acid are effective.  There is some evidence that oral metronidazole and tetracycline are effective.  There is insufficient evidence concerning the effectiveness of other treatments.  Good randomized controlled trials looking at these treatments are urgently needed.

Parodi et al (2011) stated that a range of treatment options are available in rosacea, which include several topical (mainly metronidazole, azelaic acid, other antibiotics, sulfur, retinoids) and oral drugs (mainly tetracyclines, metronidazole, macrolides).  In some cases, the first choice is a systemic therapy because patients may have sensitive skin and topical medications can be irritant.  Isotretinoin can be used in resistant cases of rosacea.  Unfortunately, the majority of studies on rosacea treatments are at high or unclear risk of bias.  A recent Cochrane review (van Zuuren et al, 2011) found that only topical metronidazole, azelaic acid, and oral doxycycline (40 mg) had some evidence to support their effectiveness in moderate-to-severe rosacea and concluded that further well-designed, adequately-powered randomized controlled trials are needed.  In the authors' practice, they evaluated their patients for the presence of 2 possible triggers, Helicobacter pylori infection and small intestinal bacterial over-growth.  When they are present, these clinicians use adapted antibiotic protocols.  If not, they use oral metronidazole or oral tetracycline to treat papulopustolar rosacea.  They also look for Demodex folliculorum infestation.  When Demodex concentration is higher than 5/cm(2), they use topical crotamiton 10 % or metronidazole.

Bamford et al (2012) noted that a 2006 article published in the International Journal of Dermatology reported that oral zinc sulfate 100 mg thrice-daily was associated with improvement in the severity of facial rosacea.  The current study was undertaken to further evaluate the role of zinc in the management of rosacea.  This was a randomized, double-blind trial of 220 mg of zinc sulfate twice-daily for 90 days in patients with moderately severe facial rosacea at baseline.  Subjects were recruited in the Upper Midwest USA between August 2006 and April 2008, and followed until July 2008.  A total of 44 subjects completed the trial (22 in each arm).  Rosacea improved in both groups.  There were no differences in magnitude of improvement based on rosacea severity scores between subjects receiving zinc sulfate and subjects receiving placebo (p = 0.284).  Serum zinc levels were higher in subjects receiving zinc (p < 0.001).  Oral zinc sulfate was not associated with greater improvement in rosacea severity compared with placebo in this study.  The authors stated that additional studies are needed to determine what role oral zinc may have in the management of rosacea.

Chang et al (2012) stated that papulopustular acne rosacea is a chronic inflammatory condition that can be difficult to treat.  Many patients are unwilling to use systemic medications, and single topical agents alone may not address all the symptoms of rosacea.  A combination topical clindamycin phosphate 1.2 % and tretinoin 0.025 % gel is efficacious for acne vulgaris, and may be helpful for rosacea, since acne vulgaris and rosacea shares many similar clinical and histologic features.  In a randomized, double-blind, placebo-controlled, 2-site pilot study, these investigators examined the safety and effectiveness of a combination gel consisting of clindamycin phosphate 1.2 % and tretinoin 0.025 % on papulopustular rosacea after 12 weeks of usage.  A total of 79 subjects with moderate-to-severe papulopustular acne rosacea using both physician and subjects' validated assessment tools wer included in this study.  Primary endpoint consisted of statistically significant reduction in absolute papule or pustule count after 12 weeks of usage.  There was no significant difference in papule/pustule count between placebo and treated groups after 12 weeks (p = 0.10).  However, there was nearly significant improvement in physicians' assessments of the telangiectasia component of rosacea (p = 0.06) and erythemato-telangiectatic rosacea subtype (p = 0.05) in treated versus placebo group after 12 weeks.  The only significant adverse event difference was facial scaling, which was significantly increased in treated group (p = 0.01), but this did not result in discontinuation of study drug.  The authors concluded that a combination gel of clindamycin phosphate 1.2 % and tretinoin 0.025 % may improve the telangiectatic component of rosacea and appears to better treat the erythemato-telangiectatic subtype of rosacea rather than papulopustular subtype.  They stated that these future studies with much larger sample size might confirm these preliminary findings.

Sadick et al (2011) rhinophyma is a benign dermatological disease of the nose that affects primarily Caucasian men in their 5h decade of life.  Its main characteristic is a slowly progressive hyperplasia of the sebaceous glands and the adjacent tissue with irregular thickening of the nasal skin and nodular deformation.  It is defined as the end stage of acne rosacea.  The main reasons for patients to seek medical help are cosmetic problems and functional impairments (e.g., nasal airway obstruction, difficulty in eating).  Surgery is indisputably the treatment of choice for rhinophyma.

Macdonald and Nguyen (2012) presented the case of a 42-year old man with a 10-year history of rosacea, and who exhibited impaired nasal breathing and a mass on the tip of his nose that began growing 9 months earlier.  Examination revealed a multi-lobulated sebaceous nodule (4 cm by 3 cm) protruding from the nasal tip.  The histopathological findings of marked sebaceous hyperplasia, follicular rupture, an absence of granulomas, and prominent fibrosis confirmed the clinical suspicion of rhinophyma.  A biopsy specimen was obtained, and staining did not reveal infectious organisms.  Phyma is the result of hyperplasia and fibrosis of the sebaceous glands in the presence of rosacea.  Although rhinophyma is by far the most common pattern in cases of phyma, metophyma (swelling of the forehead), otophyma (swelling of the ear), and gnathophyma (swelling of the chin) can also be observed.  The lesions can become large, causing significant social stigmatization and posing a challenge in the management of patient care.  Re-contouring with the use of electrosurgery or CO2 laser resurfacing is common.  This patient underwent staged procedures, with shave-debulking surgery followed by contouring with electrosurgery.  His breathing was restored to normal.

Little et al (2012) stated that rhinophyma is a cosmetically disfiguring disease of the external nose that most frequently affects elderly Caucasian males.  Frequently, there is associated derangement of nasal airway patency.  Although the true incidence of rhinophyma and its exact etiology remain unknown, it is widely believed to represent the final stage in a continuum of acne rosacea.  Medical therapy has not been effective in reversing the disease process, and surgery remains the most accepted method of treating rhinophyma.  A wide variety of surgical techniques have been developed and modified over the years in an effort to treat this disorder safely and without significant sequelae.  Despite many advances in fundamental understanding, surgical techniques, and related technologies, no single method has been universally embraced and employed as the "gold standard".  These investigators described the most commonly employed modern surgical techniques and methods used throughout the world to treat rhinophyma.  There was special emphasis on the authors' preferred method of excision and post-operative management (tumescent anesthesia, Weck blade excision, and argon beam coagulation), which has been demonstrated to be effective and expeditious.

Husein-Elahmed and Armijo-Lozano (2013) noted that early stages of rhinophyma can be managed with medical treatment using isotretinoin or oral antibiotics (metronidazole).  However, severe cases usually are refractory to medical approaches.  Surgical therapies to treat these severe refractory cases have been described.  These investigators described a simple, safe, efficient, and cost-effective approach to the treatment of severe rhinophyma using a scalpel and the electroscalpel, instruments readily available in every operating room.

An UpToDate review on “Management of rosacea” (Maier, 2013) states that “Tissue hypertrophy, dilated follicles, and irregular nodular overgrowths are characteristic features of the phymatous subtype of rosacea.  These changes most commonly affect the nose (rhinophyma), but may also affect other areas such as the chin, cheeks, and ears …. Laser ablation and surgical techniques can be used to debulk and recontour tissue distorted by phymatous changes.  Ablative carbon dioxide lasers and infrared diode lasers have been used for this purpose.  Surgical debulking can be performed through dermabrasion, scalpel excision, electrosurgery, or cryosurgery”.

Dayan and colleagues (2012) noted that there are many different treatment modalities for each of the physical findings associated with rosacea, and all have varying results.  As the use of onabotulinumtoxinA rises, its benefit in the treatment of a growing number of medical diseases increases.  The authors reported anecdotal evidence of patients with rosacea experiencing improved symptoms of erythema and flushing after treatment with intradermal, microdroplets of onabotulinumtoxinA.  There were no adverse events reported for any of the treatments.  The mechanism of action through a likely neurogenic component to vascular dysfunction, inflammation, and hyper-sebaceous activity was reviewed.  The effectiveness of onabotulinumtoxinA in the treatment of rosacea needs to be examined in well-designed studies.

CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
CPT codes not covered for indications listed in the CPB:
+ 17003
HCPCS codes not covered for indications listed in the CPB:
J0585 Injection, onabotulinumtoxinA, 1 unit
J0586 Injection, abobotulinumtoxinA, 5 units
J0587 Injection, rimabotulinumtoxinB, 100 units
J0588 Injection, incobotulinumtoxinA, 1 unit
ICD-9 codes covered if selection criteria are met:
695.3 Rosacea
ICD-9 codes not covered for indications listed in the CPB:
448.0 - 448.9 Disease of capillaries [telangiectasias and scarring from rosacea]
709.2 Scar conditions and fibrosis of skin [from rosacea]

The above policy is based on the following references:
  1. Litt JZ. Rosacea: How to recognize and treat an age-related skin disease. Geriatrics. 1997;52:39-40, 42, 45-47.
  2. 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.
  3. Laughlin SA, Dudley DK. Laser therapy in the management of rosacea. J Cutan Med Surg. 1998;2 Suppl 4:S4-24-9.
  4. Cuevas T. Identifying and treating rosacea. Nurse Pract.  2001;26(6):13-15, 19-23; quiz 24-25.
  5. Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.
  6. Cohen AF, Tiemstra JD. Diagnosis and treatment of rosacea. J Am Board Fam Pract.  2002;15(3):214-217.
  7. Gessert CE, Bamford JT. Measuring the severity of rosacea: A review. Int J Dermatol. 2003;42(6):444-448.
  8. Stone DU, Chodosh J. Oral tetracyclines for ocular rosacea: An evidence-based review of the literature. Cornea. 2004;23(1):106-109.
  9. Odom RB. The subtypes of rosacea: Implications for treatment. Cutis. 2004;73(1 Suppl):9-14.
  10. Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.
  11. Zakhary K, Ellis DA. Applications of aminolevulinic acid-based photodynamic therapy in cosmetic facial plastic practices. Facial Plast Surg. 2005;21(2):110-116.
  12. Goldberg DJ. Lasers and light sources for rosacea. Cutis. 2005;75(3 Suppl):22-26; discussion 33-36.
  13. van Zuuren EJ, Graber MA, Hollis S, Interventions for rosacea. Cochrane Database Syst Rev. 2005;(3):CD003262.
  14. van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol. 2007;56(1):107-115.
  15. Thomas K, Yelverton CB, Yentzer BA. The cost-effectiveness of rosacea treatments. J Dermatolog Treat. 2009;20(2):72-75.
  16. Mostafa FF, El Harras MA, Gomaa SM, et al. Comparative study of some treatment modalities of rosacea. J Eur Acad Dermatol Venereol. 2009;23(1):22-28.
  17. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg. 2009;35(6):920-928.
  18. Korting H, Schöllmann C. Current topical and systemic approaches to treatment of rosacea. J Eur Acad Dermatol Venereol. 2009;23(8):876-882.
  19. Scheinfeld N, Berk T. A review of the diagnosis and treatment of rosacea. Postgrad Med. 2010;122(1):139-143.
  20. Gallo R, Drago F, Paolino S, Parodi A. Rosacea treatments: What's new and what's on the horizon? Am J Clin Dermatol. 2010;11(5):299-303.
  21. Gollnick H, Blume-Peytavi U, Szabó EL, et al. Systemic isotretinoin in the treatment of rosacea - doxycycline- and placebo-controlled, randomized clinical study. J Dtsch Dermatol Ges. 2010;8(7):505-515.
  22. van Zuuren EJ, Kramer S, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2011;3:CD003262.
  23. van Zuuren EJ, Kramer SF, Carter BR, et al. Effective and evidence-based management strategies for rosacea: Summary of a Cochrane systematic review. Br J Dermatol. 2011;165(4):760-781.
  24. Parodi A, Drago F, Paolino S, Treatment of rosacea. Ann Dermatol Venereol. 2011;138 Suppl 3:S211-S214.
  25. Bamford JT, Gessert CE, Haller IV, et al. Randomized, double-blind trial of 220 mg zinc sulfate twice daily in the treatment of rosacea. Int J Dermatol. 2012;51(4):459-462.
  26. Chang AL, Alora-Palli M, Lima XT, et al. A randomized, double-blind, placebo-controlled, pilot study to assess the efficacy and safety of clindamycin 1.2% and tretinoin 0.025% combination gel for the treatment of acne rosacea over 12 weeks. J Drugs Dermatol. 2012;11(3):333-339.
  27. Sadick H, Riedel F, Bran G. Rhinophyma in rosacea. What does surgery achieve? Hautarzt. 2011;62(11):834-841.
  28. Macdonald JB, Nguyen XH. Images in clinical medicine: Rhinophyma. N Engl J Med. 2012;367(19):1838.
  29. Little SC, Stucker FJ, Compton A, Park SS. Nuances in the management of rhinophyma. Facial Plast Surg. 2012;28(2):231-237.
  30. Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: OnabotulinumtoxinA. J Drugs Dermatol. 2012;11(12):e76-e79.
  31. Maier LE. Management of rosacea. Last reviewed April 2013. UpToDate Inc. Waltham, MA.
  32. Husein-Elahmed H, Armijo-Lozano R. Management of severe rhinophyma with sculpting surgical decortication. Aesthetic Plast Surg. 2013;37(3):572-575.
  33. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: A status report on systemic therapies. Cutis. 2014;93(1):18-28.
  34. Tuzun Y, Wolf R, Kutlubay Z, et al. Rosacea and rhinophyma. Clin Dermatol. 2014;32(1):35-46.

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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