From the Guidelines
Treatment for rosacea should prioritize topical metronidazole (0.75% or 1% gel or cream applied once or twice daily) as a first-line option, given its efficacy in reducing inflammatory lesions and perilesional erythema, as demonstrated in studies such as 1.
Key Treatment Options
- Topical treatments: metronidazole (0.75% or 1% gel or cream applied once or twice daily), azelaic acid (15-20% applied twice daily), ivermectin (1% cream applied once daily), and brimonidine (0.33% gel for temporary reduction of redness)
- Oral antibiotics: doxycycline (40-100mg daily for 8-12 weeks) or minocycline (50-100mg daily), with low-dose doxycycline (40mg) being effective for reducing inflammation without antibiotic effects, as shown in 1
- Lifestyle modifications: avoiding triggers like spicy foods, alcohol, extreme temperatures, sun exposure, and harsh skincare products, and using gentle cleansers, moisturizers, and broad-spectrum sunscreen (SPF 30+)
Considerations for Treatment
- Treatment effectiveness varies by individual and often requires a combination approach tailored to the specific subtype of rosacea (erythematotelangiectatic, papulopustular, phymatous, or ocular)
- The ROSCO panel recommends a phenotype-led treatment algorithm, considering each feature and its severity individually, as outlined in 1 and 1
- General skincare and eye care underlie the treatment approach to managing cutaneous and ocular features, respectively
- Oral doxycycline, a tetracycline antibiotic, is a viable treatment option for all severities of inflammatory papules/pustules, clinically inflamed phyma, and ocular features of rosacea, with a 40-mg modified-release dose considered to have anti-inflammatory but not antibiotic activity, as discussed in 1 and 1
From the Research
Treatment Options for Rosacea
The treatment options for rosacea include a range of topical and oral medications. Some of the commonly used topical treatments are:
- Metronidazole 2, 3, 4, 5
- Azelaic acid 2, 3, 5, 6
- Other antibiotics such as sulfur and retinoids 2
- Oral drugs like tetracyclines, metronidazole, and macrolides 2, 3
Topical Metronidazole
Topical metronidazole has been shown to be effective in treating rosacea, with studies demonstrating its efficacy in reducing inflammatory lesion counts and erythema 3, 4, 5. It can be used as a monotherapy or in combination with oral antibiotics 3. Maintenance treatment with topical metronidazole has also been shown to decrease relapses and allow for longer intervals between flares 4.
Combination Therapy
Combination therapy with oral antibiotics and topical treatments may be necessary for severe cases of rosacea 2, 3, 6. This approach can help to reduce the risk of relapse and improve treatment outcomes.
Other Treatment Options
Other treatment options for rosacea include:
- Isotretinoin for resistant cases 2
- Brimonidine, an alpha-2-adrenoreceptor agonist, for the treatment of erythema in rosacea 6
- Avoiding triggers such as Helicobacter pylori infection and small intestinal bacterial overgrowth 2
- Treating Demodex folliculorum infestation with topical crotamiton or metronidazole 2