What are the pharmacological treatments for rosacea?

From the Guidelines

The treatment of rosacea typically involves topical and oral medications based on the subtype and severity, with first-line treatment including topical metronidazole 0.75-1% applied once or twice daily, azelaic acid 15-20% applied twice daily, or ivermectin 1% cream applied once daily, as supported by recent studies 1. For mild to moderate papulopustular rosacea, these medications reduce inflammation and have antimicrobial properties.

• Topical metronidazole 0.75% and 1.0% formulations have been well studied in more than 500 patients, demonstrating superiority over vehicle and long-term efficacy and safety as monotherapy for control of inflammatory lesion associated with rosacea 1.
• Azelaic acid 15-20% applied twice daily is also effective in reducing inflammatory lesions and erythema.
• Ivermectin 1% cream applied once daily has been shown to be effective in reducing inflammatory lesions.

For erythematotelangiectatic rosacea, brimonidine 0.33% gel applied once daily can temporarily reduce redness through vasoconstriction.

• Brimonidine is a topical α-adrenergic that can reduce erythema by causing vasoconstriction 1.

When topical treatments are insufficient, oral antibiotics such as doxycycline (40-100mg daily) for 8-12 weeks are recommended, with the lower anti-inflammatory dose (40mg) preferred to minimize antibiotic resistance.

• Doxycycline 40 mg has been shown to be effective in reducing inflammatory lesions and is considered a viable treatment option for all severities of inflammatory papules/pustules, clinically inflamed phyma, and ocular features of rosacea 1.

For severe or refractory cases, oral isotretinoin (0.3-0.5mg/kg/day) may be considered for 12-16 weeks.

• Isotretinoin is a powerful oral retinoid that can be effective in reducing severe rosacea symptoms, but its use is limited due to potential side effects.

Ocular rosacea often responds to lid hygiene, artificial tears, and topical azithromycin or oral doxycycline.

• Lid hygiene and artificial tears are essential in managing ocular rosacea, and topical azithromycin or oral doxycycline can be added to reduce inflammation.

Treatment should be accompanied by trigger avoidance (sun exposure, spicy foods, alcohol, extreme temperatures) and gentle skincare using non-irritating cleansers and daily broad-spectrum sunscreen.

• Trigger avoidance and gentle skincare are crucial in managing rosacea, as they can help reduce symptoms and prevent flare-ups.

Patients should understand that rosacea is chronic and may require maintenance therapy after initial improvement to prevent relapse.

• Maintenance therapy is essential in managing rosacea, as it can help prevent relapse and reduce the risk of complications.

From the Research

Treatment Options for Rosacea

• Topical metronidazole, sulfacetamide/sulfur, and azelaic acid are generally effective for patients with mild rosacea 2
• For moderate papulopustular rosacea, combination therapy with oral tetracyclines and topical agents is the first-line choice 2
• Treatment with a topical agent, such as metronidazole, may help maintain remission 2
• Patients with ocular involvement may benefit from long-term oral antibiotics and metronidazole gel 2

Topical Treatments

• Topical metronidazole and azelaic acid have been shown to be effective in reducing inflammatory lesion counts and erythema in patients with rosacea 3, 4
• Topical ivermectin has been shown to be effective in reducing inflammatory lesion counts and improving quality of life in patients with papulopustular rosacea 4
• Topical brimonidine has been shown to be effective in reducing erythema in patients with rosacea 4

Systemic Treatments

• Oral doxycycline has been shown to be effective in reducing inflammatory lesion counts and improving quality of life in patients with papulopustular rosacea 4
• Low-dose isotretinoin has been shown to be effective in reducing inflammatory lesion counts and improving quality of life in patients with papulopustular rosacea 4
• Oral tetracycline has been shown to be effective in reducing inflammatory lesion counts, but the evidence is limited 4

Combination Therapies

• Combination therapy with topical metronidazole and oral doxycycline has been shown to be effective in reducing inflammatory lesion counts and improving quality of life in patients with papulopustular rosacea 5, 4
• Combination therapy with topical ivermectin and oral doxycycline has been shown to be effective in reducing inflammatory lesion counts and improving quality of life in patients with papulopustular rosacea 5