From the Guidelines
Rosacea treatment should prioritize topical metronidazole 0.75% or 1% cream applied twice daily as a first-line treatment, given its efficacy in reducing inflammatory lesions and perilesional erythema, as demonstrated in a 6-month double-blind placebo-controlled study 1.
Treatment Overview
Rosacea is a chronic inflammatory skin condition that primarily affects the face, causing redness, visible blood vessels, and sometimes small, red, pus-filled bumps. Treatment typically involves a combination of skincare practices and medications.
First-Line Treatments
For mild rosacea, gentle cleansers and moisturizers are recommended, along with daily broad-spectrum sunscreen (SPF 30+) as sun exposure can trigger flares.
- Topical medications like metronidazole (0.75% or 1% cream applied twice daily) are effective in reducing inflammatory lesions and perilesional erythema, as shown in a study where metronidazole produced a 65% decrease in inflammatory lesion counts compared with a 15% reduction for vehicle 1.
- Azelaic acid (15-20% applied twice daily) and ivermectin 1% cream (applied once daily) are also first-line treatments.
Moderate to Severe Cases
For moderate to severe cases, oral antibiotics such as doxycycline (40-100mg daily for 8-12 weeks) may be prescribed, with once-daily oral doxycycline 40 mg being an effective and safe option, as confirmed by two phase 3, randomized, double-blind, placebo-controlled trials 1.
Additional Treatments
Persistent facial redness can be treated with brimonidine gel 0.33% or oxymetazoline cream 1% applied once daily. Laser therapy may help reduce visible blood vessels. Patients should identify and avoid personal triggers, which commonly include spicy foods, alcohol, extreme temperatures, and certain skincare products.
Management and Prognosis
Rosacea cannot be cured but can be effectively managed with consistent treatment. The condition likely results from a combination of genetic predisposition, immune system abnormalities, and environmental factors that cause blood vessel dysfunction and inflammation in the skin.
From the Research
Treatment Options for Rosacea
- A range of treatment options are available for rosacea, including topical and oral medications 2, 3.
- Topical treatments include metronidazole, azelaic acid, and ivermectin, which have shown efficacy in reducing inflammatory lesions and erythema 4, 5, 6.
- Oral treatments, such as doxycycline and isotretinoin, may also be effective in treating papulopustular rosacea 6.
- Laser and light-based therapies, including pulsed dye laser and intense pulsed light therapy, may also be used to treat rosacea 6.
Efficacy of Treatment Options
- Topical metronidazole and azelaic acid have been shown to be more effective than placebo in reducing inflammatory lesions and erythema in papulopustular rosacea 4, 6.
- Topical ivermectin has been shown to be effective in reducing inflammatory lesions and improving quality of life in patients with papulopustular rosacea 6.
- Doxycycline has been shown to be effective in reducing inflammatory lesions and erythema in papulopustular rosacea, with a lower dose (40 mg) having fewer adverse effects than a higher dose (100 mg) 6.
- Isotretinoin has been shown to be effective in treating papulopustular rosacea, with low-dose isotretinoin being slightly more effective than doxycycline 6.
Triggers and Comorbidities
- Helicobacter pylori infection and small intestinal bacterial overgrowth may be triggers for rosacea, and adapted antibiotic protocols may be used to treat these conditions 2, 3.
- Demodex folliculorum infestation may also be a trigger for rosacea, and topical treatments such as crotamiton 10% or metronidazole may be used to treat this condition 2, 3.