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rosacea is a common skin disease characterized by transient or persistent central facial erythema , visible blood vessels , and frequently , papules and pustules .
since the 1950 's , tetracycline and erythromycin are the most commonly used oral antibiotics ( 1 - 3 ) . however , long - term treatment with antibiotics is not well tolerated because of side - effects including gastrointestinal intolerance , photosensitivity and candidiasis ( 3 ) . moreover , given the chronic nature of the disease , there is a possibility of developing bacterial resistance ( 1 ) .
azithromycin is a newly developed macrolide which offers some advantages compared to previously used antibiotics ( 4 ) .
fernandez - obregon ( 5 ) reported that all of ten patients who were not tolerated or controlled by conventional treatment demonstrated a significant improvement with the oral use of azithromycin .
after then , azithromycin has been found to be effective in the intractable rosacea in several clinical reports ( 1 , 6 , 7 ) .
we report a case of a 52-yr - old rosacea patient who was refractory and complicated by reactions to conventional topical and oral medications . after 10 weeks of oral azithromycin
, her lesions had mostly disappeared and the patient suffered no specific side - effects related to the medication .
our case showed that oral azithromycin could be a viable new treatment option for intractable rosacea cases .
a 52-yr - old postmenopausal woman complained of a 10-month history of multiple erythematous papules and some pustules on both cheeks on february 11 , 2008 ( fig .
physical examination revealed multiple pinhead to rice - sized erythematous papules and pustules on both cheeks .
laboratory studies including complete blood cell count ( cbc ) , blood chemistry , and anti - nuclear antibody ( ana ) were within normal limits .
more than ten demodex mites were observed on the demodex study . on the standard patch test ,
only nickel sulfate showed a positive response . on the basis of medical history and clinical findings
her skin lesions were not controlled by topical application of benzoyl peroxide , metronidazole twice a day or crotamiton once a day , or oral administration of doxycycline 200 mg for a month , metronidazole 500 mg for two weeks or isotretinoin 10 mg for a month . rather her rosacea was aggravated or complicated by these medications .
after taking conventional treatment of rosacea , she complained of diffuse facial erythema , swelling and aggravated papules ( fig .
we then prescribed oral azithromycin , which has both anti - inflammatory effects and leads to a reduction in reactive oxygen species .
two weeks after oral administration of 500 mg per day of azithromycin , facial erythema and swelling was reduced . since then , papular lesions which are presented on the cheek were begun to decrease .
after 10 weeks of oral azithromycin , the lesions had mostly disappeared , and no specific side - effects related to the medication were noted ( fig .
3 ) . also until 6 months after treatment , the patient had not experienced any recurrence or aggravation .
rosacea is a common cutaneous disorder which occurs most frequently in light - skinned middle aged women .
there are variable cutaneous signs of rosacea such as flushing , erythema , telangiectasia , edema , papules and pustules ( 2 ) . while the pathogenesis of rosacea remains unknown , several factors
recent reports suggest that the effects of reactive oxygen species can contribute to the development of rosacea ( 8) . conventional treatment of rosacea is based on a combination of systemic and topical antibiotics . since the 1950 's , tetracycline and erythromycin are the most commonly used oral antibiotics ( 1 - 3 ) .
the therapeutic activity of commonly used antimicrobials including tetracycline , doxycycline has been mainly attributed to their anti - inflammatory activities ( 9 , 10 ) .
these results indicate that antibiotics used in the treatment of rosacea affect various inflammatory processes such as the migration of neutrophils , production of pro - inflammatory cytokines including interleukin-1 , 6 , 8 , 10 , tumor necrosis factor- , leukotriene b4 , and oxidative burst in phagocytes ( 11 - 13 ) .
topical metronidazole and oral tetracyclines effectively treat about 80%-90% of rosacea patients ( 6 ) .
however , long - term treatment with antibiotics is not well tolerated due to requiring frequent administration , poor compliances and side - effects including gastrointestinal intolerance , photosensitivity and candidiasis ( 5 , 7 ) .
in addition , some patients do not respond to variable combination therapies and rather aggravated by their complications .
( 1 ) reported a rosacea patient who were developed tense bullae and hypopigmented scarring after taking oral doxycycline 100 mg .
oral azithromycin is a newly developed macrolide which offers some advantages over previously used antibiotics .
it has unique pharmacokinetics that allows it to penetrate into intracellular compartments rapidly and maintain prolonged tissue levels .
this allows for less frequent application and shorter duration of treatment which may increase compliance . with its high affinity for inflammatory tissues
, azithromycin can achieve steady state tissue levels in approximately 72 - 96 hr ( 14 ) .
moreover , after administration of oral azithromycin , tissue reactive oxygen species , an etiologic factor in the development of rosacea , were greatly decreased in some cases ( 7 ) .
fernandez - obregon ( 5 ) reported that all of ten patients who were not tolerated or controlled by conventional treatment of rosacea demonstrated a significant improvement with the oral use of azithromycin .
( 1 ) treated a 67-yr old man who had photosensitivity to the doxycycline and hyperpigmented dyschromia to the minocycline with an oral use of azithromycin in a dose of 250 mg 3 times weekly .
( 4 ) reported that treatment with oral azithromycin led to 75% decreases in the total number of lesions and an 89% decrease in inflammatory lesions compared with basal status .
another open - label study showed that azithromycin is as effective as standard dose of doxycycline and has a positive impact on the quality of life of patients compared with conventional treatment regimens ( 15 ) .
azithromycin may also be an acceptable agent for those using other medications , because it has no known major drug interactions .
additionally , azithromycin shows lower incidences of gastrointestinal discomfort compared with erythromycin ( 16 ) . according to one clinical study ,
only two of 32 patients complained of mild gastric discomfort and no one withdrew from the study due to the side - effects of aztithromycin ( 17 ) . in our case
, we report a case of a 52-yr - old woman who presented with intractable multiple , pinhead to rice - sized erythematous papules on her face , which were controlled by oral azithromycin .
our case shows that azithromycin could be a new treatment option for the treatment of intractable rosacea .
rosacea is a common chronic cutaneous disorder that primarily occurs on the convex surfaces of the central face and is often characterized by exacerbations and remissions . 
 a case of a 52-yr - old woman visited our clinic in february 2008 complaining typical features of rosacea including multiple pinhead to rice - sized erythematous papules . 
 we applied various conventional treatments including topical benzoyl peroxide and metronidazole as well as oral metronidazole , isotretinoin , and doxycycline . 
 the lesions were not controlled but were rather aggravated by complications from these treatments . 
 therefore , we prescribed oral azithromycin , which has anti - inflammatory effects and reduces reactive oxygen species . 
 ten weeks after the administration of oral azithromycin , 500 mg per day for 2 weeks , the lesions had mostly disappeared and no specific side effects related to the azithromycin were noted . 
 oral azithromycin dosing 500 mg / day for 2 weeks is effective for treatment of intractable rosacea .