What is the appropriate treatment for a 32-year-old female with intermittent facial flushing, visible blood vessels, and triggers including spicy food and sun exposure, who is taking levonorgestrel (levonorgestrel)/ethinyl estradiol (ethinyl estradiol) oral contraceptive?

From the Guidelines

The patient should continue her levonorgestrel/ethinyl estradiol oral contraceptive as it is unlikely to worsen rosacea symptoms, and instead, focus on topical and lifestyle interventions for managing rosacea. For a 32-year-old female with symptoms suggesting rosacea (intermittent facial flushing, visible blood vessels, and triggers like spicy food and sun exposure), the recommended treatment approach includes both topical and lifestyle interventions.

First-line Therapy

• Topical metronidazole 0.75% gel or cream applied twice daily,
• Azelaic acid 15-20% applied twice daily to affected areas, as suggested by the global rosacea consensus panel 1.

Lifestyle Modifications

• Avoid identified triggers (spicy foods, sun exposure),
• Use daily broad-spectrum sunscreen (SPF 30+),
• Adopt gentle skincare with mild non-soap cleansers,
• Avoid alcohol-containing products.

Additional Treatments

For more severe cases, oral antibiotics such as doxycycline 40-100 mg daily for 4-12 weeks may be beneficial 1. Laser therapy could be considered for persistent telangiectasias (visible blood vessels). These recommendations target the inflammatory and vascular components of rosacea while the lifestyle changes help prevent flare-ups. If symptoms don't improve within 4-6 weeks, the patient should follow up for possible treatment adjustment or dermatology referral. The use of combined oral contraceptives (COCs) like levonorgestrel/ethinyl estradiol has anti-androgenic properties and can be beneficial for acne treatment, but its direct impact on rosacea is less clear 1. However, given the patient's current contraceptive needs and the lack of strong evidence suggesting COCs exacerbate rosacea, continuing the oral contraceptive is reasonable.

From the Research

Treatment Options for Rosacea

The patient's symptoms of intermittent facial flushing, visible blood vessels, and triggers including spicy food and sun exposure are consistent with rosacea. The appropriate treatment for rosacea depends on the severity and subtype of the disease.

• Topical metronidazole and azelaic acid are commonly used to treat mild to moderate rosacea, as they have anti-inflammatory properties and can reduce the appearance of erythema and inflammatory lesions 2, 3, 4, 5.
• For moderate to severe papulopustular rosacea, combination therapy with oral antibiotics (such as doxycycline) and topical agents may be necessary 2, 4, 6.
• Brimonidine and ivermectin are also approved topical agents for the treatment of rosacea, with brimonidine specifically targeting erythema and ivermectin targeting inflammatory lesions 5.
• In some cases, oral isotretinoin may be used to treat resistant cases of rosacea, although this is typically reserved for severe cases 6.

Stopping Birth Control

There is no clear evidence to suggest that stopping levonorgestrel/ethinyl estradiol oral contraceptive would improve the patient's rosacea symptoms. However, hormonal fluctuations can exacerbate rosacea symptoms in some individuals. If the patient's symptoms are suspected to be related to her birth control, an alternative form of contraception may be considered, but this should be discussed with her healthcare provider.

Topical Calcipotriol

There is no evidence to suggest that topical calcipotriol is an effective treatment for rosacea. Topical calcipotriol is typically used to treat psoriasis, and its use in rosacea is not supported by current evidence 2, 3, 4, 5, 6.