What are the treatment options for rosacea?

Rosacea Treatment: A Phenotype-Based Approach

Treatment for rosacea should follow a phenotype-based approach targeting specific features rather than subtypes, with combination therapy often necessary to address multiple symptoms simultaneously. 1

General Measures (Foundation for All Treatments)

• Skincare fundamentals:
  • Sun protection (SPF 30+)
  • Gentle cleansers
  • Moisturizers
  • Trigger avoidance (individualized)

Treatment Algorithm by Phenotype

1. Transient Erythema (Flushing)

• First-line options:
  • Topical α-adrenergics (brimonidine)
  • Oral beta blockers
  • Pulsed-dye laser (PDL)

2. Persistent Erythema

• First-line options:
  • Topical brimonidine
  • Intense pulsed light (IPL)
  • Pulsed-dye laser (PDL)
  • Oral doxycycline

3. Inflammatory Papules/Pustules

• Mild:
  • Topical azelaic acid
  • Topical ivermectin
  • Topical metronidazole
• Moderate:
  • Topical azelaic acid
  • Topical ivermectin
  • Oral doxycycline
• Severe:
  • Topical ivermectin
  • Oral doxycycline
  • Oral isotretinoin

4. Telangiectasia

• First-line options:
  • Electrodessication
  • Intense pulsed light (IPL)
  • Lasers

5. Phymatous Changes

• Clinically inflamed:
  • Oral doxycycline
• Clinically non-inflamed:
  • Physical modalities (laser, surgical)

6. Ocular Rosacea

• Mild symptoms:
  • Lid hygiene
  • Artificial tears
• Moderate to severe:
  • Ophthalmological referral
  • Oral doxycycline
  • Topical medications as directed by ophthalmologist

Combination Therapy Approach

Multiple features of rosacea often coexist and require simultaneous treatment with multiple agents 1. If first-line treatment fails after an adequate trial period (typically 6-12 weeks), either:

1. Try an alternative first-line option from the same category, or
2. Add another first-line agent to create a combination therapy

Maintenance Therapy

The minimum treatment necessary to maintain control should be used, with the approach depending on:

• Treatment modality
• Patient preference for ongoing therapy
• Disease severity

Special Considerations

• Doxycycline options: 40mg modified-release formulation (anti-inflammatory, not antibiotic) is preferred where available to reduce antibiotic resistance concerns 1
• Treatment duration: Allow sufficient time (6-12 weeks) before considering a treatment failure 1
• Ocular involvement: All but the mildest ocular features warrant ophthalmological referral 1, 2

Treatment Pitfalls to Avoid

• Subtype-based treatment: This approach fails to address the full spectrum of presenting features 1
• Inadequate trial periods: Many studies under 8 weeks are considered inadequate to demonstrate efficacy 1
• Ignoring ocular symptoms: Ocular rosacea can lead to serious complications if untreated
• Monotherapy for multiple features: Single treatments rarely address all rosacea manifestations 1

The phenotype-based approach to rosacea management represents a significant advancement over the traditional subtype-based system, allowing for more targeted and effective treatment of this chronic inflammatory condition 1, 3.