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.
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:
ICD-9 codes covered if selection criteria are met:
ICD-9 codes not covered for indications listed in the CPB:
448.0 - 448.9
Disease of capillaries [telangiectasias, rhinophyma, and scarring from rosacea]
Scar conditions and fibrosis of skin [from rosacea]
The above policy is based on the following references:
Litt JZ. Rosacea: How to recognize and treat an age-related skin disease. Geriatrics. 1997;52:39-40, 42, 45-47.
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.
Laughlin SA, Dudley DK. Laser therapy in the management of rosacea. J Cutan Med Surg. 1998;2 Suppl 4:S4-24-9.
Cuevas T. Identifying and treating rosacea. Nurse Pract. 2001;26(6):13-15, 19-23; quiz 24-25.
Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.
Cohen AF, Tiemstra JD. Diagnosis and treatment of rosacea. J Am Board Fam Pract. 2002;15(3):214-217.
Gessert CE, Bamford JT. Measuring the severity of rosacea: A review. Int J Dermatol. 2003;42(6):444-448.
Stone DU, Chodosh J. Oral tetracyclines for ocular rosacea: An evidence-based review of the literature. Cornea. 2004;23(1):106-109.
Odom RB. The subtypes of rosacea: Implications for treatment. Cutis. 2004;73(1 Suppl):9-14.
Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.
Zakhary K, Ellis DA. Applications of aminolevulinic acid-based photodynamic therapy in cosmetic facial plastic practices. Facial Plast Surg. 2005;21(2):110-116.
Goldberg DJ. Lasers and light sources for rosacea. Cutis. 2005;75(3 Suppl):22-26; discussion 33-36.
van Zuuren EJ, Graber MA, Hollis S, Interventions for rosacea. Cochrane Database Syst Rev. 2005;(3):CD003262.
van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol. 2007;56(1):107-115.
Thomas K, Yelverton CB, Yentzer BA. The cost-effectiveness of rosacea treatments. J Dermatolog Treat. 2009;20(2):72-75.
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.
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.
Korting H, Schöllmann C. Current topical and systemic approaches to treatment of rosacea. J Eur Acad Dermatol Venereol. 2009;23(8):876-882.
Scheinfeld N, Berk T. A review of the diagnosis and treatment of rosacea. Postgrad Med. 2010;122(1):139-143.
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.
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.
van Zuuren EJ, Kramer S, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2011;3:CD003262.
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.
Parodi A, Drago F, Paolino S, Treatment of rosacea. Ann Dermatol Venereol. 2011;138 Suppl 3:S211-S214.
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.
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.
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