What are the treatment options for rosacea?

Treatment Options for Rosacea

Phenotype-based treatment tailored to specific symptoms is the most effective approach for rosacea management, with topical therapy being the preferred initial treatment for most patients and combination therapy with systemic agents reserved for more severe cases. 1

First-Line Treatment Options

Topical Treatments

• Metronidazole (0.75% or 1%)

  • Effective for inflammatory lesions and perilesional erythema
  • Both 0.75% and 1% strengths are equally effective when used once daily 1
  • Well-studied in over 500 patients with demonstrated efficacy and safety 1
  • Provides 65% reduction in inflammatory lesion counts compared to 15% with vehicle 1
  • Excellent for maintenance therapy to prevent relapses 2

• Azelaic Acid (15% gel/foam)

  • Comparable efficacy to metronidazole
  • Requires twice-daily application compared to once-daily metronidazole 3
  • Effective for inflammatory lesions

• Ivermectin (1% cream)

  • Effective for papulopustular rosacea
  • Demonstrated efficacy in reducing inflammatory lesions 1

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

  • Newest FDA-approved topical agent (2022)
  • Uses microencapsulation technology to extend drug delivery time
  • Shows rapid onset of action (evident by week 2)
  • Demonstrates progressive clinical improvement for up to 52 weeks
  • Excellent tolerability profile 1

• Minocycline Foam (1.5%)

  • FDA approved in 2020
  • Effective for inflammatory lesions 1

Systemic Treatments

• Doxycycline (40mg modified release)
  • Effective at subantimicrobial doses for inflammatory lesions and erythema 2
  • Often used in combination with topical agents for moderate to severe cases 1

Treatment Algorithm Based on Rosacea Phenotype

Papulopustular Rosacea

1. Mild cases:

   • Start with topical therapy: metronidazole (0.75% or 1%), azelaic acid 15%, ivermectin 1%, or E-BPO 5%
   • Metronidazole 1% gel once daily is as effective as azelaic acid 15% gel twice daily 3

2. Moderate to severe cases:

   • Combination therapy: topical agent plus oral doxycycline 40mg
   • Metronidazole 0.75% lotion is more effective when combined with doxycycline 2

Erythematotelangiectatic Rosacea

• Brimonidine gel 0.33% or oxymetazoline HCl cream 1% for persistent erythema 1

Maintenance Therapy

• Topical metronidazole is effective for maintenance and decreases relapses 2
• Long-term management is crucial as up to two-thirds of patients relapse when therapy is discontinued 1

Important Considerations

Treatment Duration

• Initial treatment course typically 12-15 weeks
• Maintenance therapy often needed to prevent relapses

Common Pitfalls to Avoid

1. Inadequate treatment duration

   • Complete clearance should be the goal, not just improvement 1

2. Irritation from topical treatments

   • Up to 89% of patients who experience treatment-related irritation discontinue therapy within a month 1
   • E-BPO 5% and microencapsulated formulations may reduce irritation risk

3. Failure to address triggers

   • Long-term avoidance of triggers, gentle skincare, and adherence to pharmacologic treatment are fundamental for control 1

4. Monotherapy for severe disease

   • Severe cases often require combination therapy with topical and systemic agents 1

5. Overlooking maintenance therapy

   • Maintenance treatment with topical metronidazole decreases relapses 2

Special Considerations

• Ocular involvement may require long-term oral antibiotics and metronidazole gel 4
• Referral to specialists is necessary for ocular complications, severe/recalcitrant cases, or phymatous changes 4

Rosacea treatment should be guided by the specific signs and symptoms that are most troubling to the patient, with topical therapy as the preferred initial approach and combination therapy reserved for more severe cases or to gain more rapid control of symptoms.