What is the most appropriate next treatment for a patient with rosacea who has not responded to metronidazole (1% cream)?

From the Guidelines

For a patient with rosacea who has not responded to metronidazole 1% cream, the most appropriate next treatment would be doxycycline oral, specifically a 40-mg dose, which has been shown to be effective in reducing inflammatory lesions and improving symptoms of rosacea. This recommendation is based on the most recent and highest quality study available, which demonstrated the efficacy and safety of once-daily doxycycline 40 mg in treating moderate-to-severe rosacea 1. The study found that doxycycline led to significant reductions in inflammatory lesions and improved symptoms, with a mean reduction of 11.8 lesions in one study and 9.5 lesions in another, compared to placebo-treated subjects.

The use of doxycycline 40 mg is supported by its anti-inflammatory properties, which are thought to be responsible for its effectiveness in treating rosacea, rather than its antimicrobial properties 1. This is important, as it reduces the risk of antibiotic resistance and makes it a more suitable option for long-term treatment. Additionally, the study found that doxycycline 40 mg was well-tolerated, with no serious adverse events or treatment-associated events reported 1.

Other treatment options, such as azelaic acid topical or ivermectin topical, may also be effective in treating rosacea, but the evidence supporting their use is not as strong as that for doxycycline 40 mg 1. Isotretinoin oral may be considered for severe or refractory cases, but it is typically reserved for patients who have not responded to other treatments due to its potential side effects.

Key points to consider when treating rosacea include:

• The importance of gentle skin care and sun protection
• Avoiding triggers like spicy foods, alcohol, and extreme temperatures
• The potential need for combination therapy to achieve optimal results
• The importance of periodic adjustment of treatment as rosacea is a chronic condition with fluctuating severity
• The use of doxycycline 40 mg as a first-line treatment option for patients with moderate-to-severe rosacea who have not responded to metronidazole 1% cream.

From the FDA Drug Label

PRECAUTIONS General: If sensitivity or severe irritation develop with the use of AZELEX® Cream, treatment should be discontinued and appropriate therapy instituted. The most appropriate next treatment for a patient with rosacea who has not responded to metronidazole (1% cream) is azelaic acid topical.

• This option is chosen because the patient has already tried metronidazole and it was not effective, and azelaic acid is another topical treatment option for rosacea.
• The patient has reported some skin dryness with metronidazole, but this is a common side effect of many topical rosacea treatments, and azelaic acid may have a similar side effect profile.
• There is no information in the provided drug label that would suggest azelaic acid is not a suitable option for this patient 2.

From the Research

Treatment Options for Rosacea

The patient has not responded to metronidazole 1% cream, so the next step is to consider alternative treatments. The following options are available:

• Azelaic acid topical: Azelaic acid has been shown to be effective in reducing inflammatory lesion counts and erythema in patients with rosacea 3, 4.
• Ivermectin topical: There is no evidence in the provided studies to support the use of ivermectin topical as a treatment for rosacea.
• Isotretinoin oral: Isotretinoin can be used in resistant cases of rosacea, but it is not typically considered a first-line treatment 3.
• Doxycycline oral: Doxycycline has been shown to be effective in reducing inflammatory lesion counts and erythema in patients with rosacea, particularly when used at subantibiotic doses 5, 6.

Recommended Treatment

Based on the evidence, azelaic acid topical or doxycycline oral may be considered as the next treatment option for this patient. Azelaic acid has been shown to be effective in reducing inflammatory lesion counts and erythema, and it can be used as a monotherapy or in combination with other treatments 4. Doxycycline, particularly at subantibiotic doses, has also been shown to be effective in reducing inflammatory lesion counts and erythema, and it can be used as a monotherapy or in combination with topical treatments 5, 6.

Key Considerations

When selecting a treatment, it is essential to consider the patient's individual needs and medical history. The patient's skin dryness since initiating metronidazole 1% cream should be taken into account, and the new treatment should be chosen based on its potential to minimize adverse effects and maximize efficacy 3, 5, 4.