From the Guidelines
The treatment of papulopustular rosacea should involve a combination of topical and oral medications, with first-line topical treatments including metronidazole 0.75% or 1% gel or cream applied twice daily, azelaic acid 15% gel or 20% cream applied twice daily, or ivermectin 1% cream applied once daily, as recommended by the most recent and highest quality study 1.
Key Treatment Options
- Topical metronidazole 0.75% or 1% gel or cream applied twice daily
- Azelaic acid 15% gel or 20% cream applied twice daily
- Ivermectin 1% cream applied once daily
- Oral doxycycline 40-100 mg daily for 4-12 weeks for moderate to severe cases
Rationale
The treatment of papulopustular rosacea aims to reduce inflammation, control Demodex mite populations, and decrease the abnormal immune response that characterizes the condition. Topical treatments such as metronidazole, azelaic acid, and ivermectin have been shown to be effective in reducing inflammatory lesions and perilesional erythema associated with rosacea 1. Oral antibiotics like doxycycline are often added for moderate to severe cases, with low-dose doxycycline (40 mg daily) being particularly effective in providing anti-inflammatory benefits without antibiotic effects, reducing the risk of bacterial resistance 1.
Additional Considerations
- Gentle skincare practices, including using mild cleansers, avoiding irritants like alcohol-based products, and applying daily broad-spectrum sunscreen
- Avoiding triggers such as spicy foods, alcohol, and extreme temperatures
- Maintenance therapy to prevent recurrence after treatment has induced remission
Evidence-Based Recommendations
The most recent and highest quality study 1 recommends the use of topical minocycline 1.5% foam as a treatment option for moderate-to-severe rosacea, with statistically significant greater reductions in inflammatory lesion counts compared to vehicle. However, the primary recommendation remains a combination of topical and oral medications, with first-line topical treatments including metronidazole, azelaic acid, and ivermectin, and oral doxycycline for moderate to severe cases.
From the Research
Treatment Options for Papulopustular Rosacea
- Topical metronidazole, azelaic acid, and oral doxycycline (40 mg) have some evidence to support their effectiveness in moderate to severe rosacea 2
- Oral metronidazole or oral tetracycline can be used to treat papulopustolar rosacea 2
- Systemic therapy, including tetracyclines, such as subantimicrobial-dose doxycycline, can be used to treat papulopustular rosacea 3
- Topical azelaic acid, ivermectin, metronidazole, minocycline, and oral doxycycline, tetracycline, and isotretinoin can be used to treat papules and pustules 4
Additional Therapies
- Brimonidine tartrate gel can be used to treat erythema 5
- Oral medication, such as beta blockers, or vascular laser and light-based therapy can be used to treat erythema 5
- Topical crotamiton 10% or metronidazole can be used to treat Demodex folliculorum infestation 2
- Light therapies, such as intense pulsed light and pulsed dye laser, can be used to treat the erythemato-telangiectatic type of rosacea 6