In a patient with chronic, treatment-refractory seborrhoeic dermatitis and rosacea on facial skin with impaired epidermal barrier, the most advanced specialist-level management should prioritise restoring barrier function while avoiding long-term topical corticosteroids, irritant vehicles, and cumulative barrier damage.
Topical therapies: Use of topical calcineurin inhibitors (e.g., tacrolimus) is recommended as a steroid-sparing option for seborrhoeic dermatitis, especially in cases with concerns about skin atrophy; these agents have anti-inflammatory and possible antifungal effects but require specialist initiation due to off-label use and potential risks 3. For rosacea, topical azelaic acid and ivermectin have high to moderate-certainty evidence for reducing inflammatory lesions and are generally well tolerated; however, azelaic acid may cause irritation, so formulations with improved tolerability or vehicle modifications should be considered 1,2,4. Emollients and barrier creams specifically designed for sensitive, reactive skin should be used liberally to support barrier repair and reduce irritation 5. Avoidance of irritant vehicles and fragrances is critical.
Systemic therapies: For severe, refractory rosacea with inflammatory papules and pustules, low-dose modified-release doxycycline is supported by moderate-to-high-certainty evidence and has a better safety profile than higher-dose tetracyclines or minocycline 1,8. Oral isotretinoin may be considered for severe inflammatory or phymatous rosacea unresponsive to other treatments, but requires specialist supervision due to side effects 1. Systemic anti-inflammatories may be indicated for widespread or refractory seborrhoeic dermatitis, warranting dermatology referral 3. Biologic therapies are not established for these conditions but may be considered in exceptional refractory cases within specialist settings.
Procedural interventions: For persistent erythema and telangiectasia in rosacea, laser therapies such as pulsed dye laser, Nd:YAG laser, intense pulsed light (IPL), or electrodessication can be effective adjuncts to medical therapy and help reduce vascular components without damaging the barrier 1. For phymatous changes, surgical options including excision or laser sculpting may be appropriate 1. Skin camouflage services can support psychosocial impact and improve quality of life 1.
Hierarchy and approach: Initial focus should be on optimising barrier repair with emollients and non-irritant topical agents (calcineurin inhibitors for seborrhoeic dermatitis, ivermectin or azelaic acid for rosacea), avoiding long-term steroids. If inadequate, escalate to systemic antibiotics (low-dose doxycycline) or isotretinoin for rosacea, and systemic anti-inflammatories for seborrhoeic dermatitis under specialist care. Procedural vascular laser treatments serve as adjuncts for persistent erythema and telangiectasia. Throughout, individualised treatment plans based on phenotype and tolerance are essential, with multidisciplinary input as needed 1,3,5.