What are the treatment options for rosacea?

Treatment Options for Rosacea

Encapsulated benzoyl peroxide 5% (E-BPO 5%) is the newest FDA-approved topical treatment for rosacea that demonstrates rapid onset of action, excellent tolerability, and progressive clinical improvement for up to 52 weeks. 1

First-Line Treatment Options Based on Rosacea Phenotype

For Inflammatory Papules/Pustules

• Mild:

  • Azelaic acid 15% (topical)
  • Ivermectin 1% cream (topical)
  • Metronidazole 0.75% or 1% (topical) 1

• Moderate:

  • Azelaic acid 15% (topical)
  • Ivermectin 1% cream (topical)
  • Doxycycline 40mg (oral, anti-inflammatory dose) 1

• Severe:

  • Ivermectin 1% cream (topical)
  • Doxycycline 40mg (oral)
  • Isotretinoin (oral) for resistant cases 1

For Persistent Erythema

• Brimonidine 0.33% gel (topical)
• Oxymetazoline HCl 1% cream (topical)
• Intense pulsed light (IPL) therapy
• Metronidazole (topical) 1

For Telangiectasia

• Electrodessication
• Intense pulsed light (IPL)
• Lasers (pulsed-dye laser) 1

For Phymatous Changes

• Clinically inflamed: Doxycycline (oral)
• Clinically noninflamed: Physical modalities 1

Newer Treatment Options

Encapsulated Benzoyl Peroxide 5% (E-BPO 5%)

• FDA-approved in 2022
• Uses sol-gel microencapsulation technology to reduce irritation
• Demonstrated rapid improvement by week 2 of treatment
• Shows progressive clinical improvement for up to 52 weeks
• 44-50% of subjects achieved clear or almost clear skin (IGA scores)
• No therapeutic plateau observed at 12 weeks
• Excellent tolerability profile comparable to vehicle 1

Minocycline Foam 1.5%

• FDA-approved in 2020
• Another newer topical option for inflammatory lesions 1

Comparative Efficacy

• Metronidazole 1% gel (once daily) is as effective as azelaic acid 15% gel (twice daily) with similar reductions in inflammatory lesion counts (77% vs 80%) 2
• Topical metronidazole has been shown to be as effective as 250mg tetracycline twice daily 3
• Maintenance treatment with topical metronidazole decreases relapses and allows for longer intervals between flares 3, 4

Treatment Approach

1. Initial Assessment: Identify the predominant phenotype(s) - inflammatory papules/pustules, persistent erythema, telangiectasia, or phymatous changes

2. Basic Management for All Patients:

   • General skincare (SPF 30+, gentle cleansers, moisturizers)
   • Trigger avoidance (sun exposure, spicy foods, alcohol, extreme temperatures)

3. Treatment Selection:

   • For mild to moderate papulopustular rosacea: Start with topical therapy (metronidazole, azelaic acid, ivermectin, or E-BPO 5%)
   • For moderate to severe papulopustular rosacea: Consider combination therapy with topical agent plus oral anti-inflammatory dose doxycycline (40mg)
   • For persistent erythema: Add brimonidine or oxymetazoline
   • For telangiectasia: Consider procedural interventions

4. Maintenance Therapy:

   • Use minimum treatment needed to maintain control
   • Topical metronidazole has been proven effective for maintenance therapy 4

Important Considerations and Pitfalls

• Skin Irritation: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month 1. E-BPO 5% and newer formulations may help address this issue.

• Treatment Duration: Treatments should be used for a sufficient duration before switching to alternatives. The definition of "sufficient duration" varies by treatment 1.

• Combination Therapy: For moderate and severe presentations, combination treatments are often required. If first-line treatment fails, either consider an alternative first-line option or add an additional first-line agent 1.

• Relapse Prevention: When therapy is discontinued, up to two-thirds of subjects will eventually relapse 1. Maintenance therapy is often necessary.

• Ocular Rosacea: Consider referral to an ophthalmologist for cases that cannot be controlled with lid hygiene. For mild ocular symptoms, artificial tear substitutes may be prescribed 1.

The phenotype-based approach to rosacea management allows for tailored treatment that addresses the specific signs and symptoms most troubling to the patient, with the goal of achieving clear or almost clear skin to improve quality of life and reduce the stigmatization associated with this visible facial condition.