What are the first-line and other treatments for rosacea?

First-Line Treatment for Rosacea and Other Treatment Options

Topical ivermectin 1% cream is the most effective first-line treatment for inflammatory lesions of rosacea, demonstrating superior efficacy compared to other topical treatments with a reduction of inflammatory lesions by 83% versus 73.7% with metronidazole. 1

First-Line Treatment Options

Topical Treatments

• Ivermectin 1% cream:

  • Apply once daily to affected areas
  • Works through dual mechanisms: anti-parasitic effect against Demodex mites and anti-inflammatory properties
  • Provides higher treatment success rates (38.4-40.1%) compared to vehicle (11.6-18.8%)
  • Offers longer remission period (115 days) compared to metronidazole (85 days) 1

• Alternative first-line options:

  • Metronidazole (0.75% or 1%) - applied once or twice daily
  • Azelaic acid 15% gel - applied twice daily (alternative for patients intolerant to other treatments) 1
  • Encapsulated benzoyl peroxide 5% (E-BPO 5%) - newest FDA-approved topical agent (2022) using microencapsulation technology to improve efficacy and reduce irritation 2

Treatment for Moderate to Severe Rosacea

Combination Therapy

• For moderate to severe cases, the American Academy of Dermatology recommends:

  • Topical ivermectin 1% cream once daily PLUS
  • Oral doxycycline 40 mg (modified release) once daily 1

• This combination provides:

  • Anti-inflammatory effects from both medications
  • Faster control of symptoms
  • Subantimicrobial dosing of doxycycline to minimize antibiotic resistance 1

Special Populations

Pediatric Rosacea Treatment

• First-line: Topical metronidazole (0.75% or 1%)
• For children under 8 years with moderate-severe disease: oral erythromycin (weight-based dosing)
• For children 8+ years: doxycycline (subantimicrobial dose when possible) or minocycline (with caution) 1

Maintenance Therapy

• Continuing topical treatment after successful initial therapy helps maintain remission
• Topical metronidazole decreases relapses and extends intervals between flares 3, 4
• In one study, only 23% of patients using metronidazole gel experienced relapse compared to 42% using vehicle 4

Treatment Algorithm

1. Mild rosacea:

   • Start with topical ivermectin 1% cream once daily
   • Alternative: metronidazole 0.75% or 1%, or azelaic acid 15% gel
   • Newer option: E-BPO 5% cream

2. Moderate to severe rosacea:

   • Combination therapy: topical ivermectin 1% cream + oral doxycycline 40 mg
   • Treatment duration: minimum 12 weeks

3. Maintenance phase:

   • Continue topical therapy to prevent relapse
   • Ivermectin preferred due to longer remission periods

Common Pitfalls and Caveats

• Treatment duration: Insufficient treatment duration is common - continue for at least 12 weeks before evaluating efficacy
• Trigger avoidance: Treatment should be accompanied by avoidance of triggers (sun exposure, hot beverages, temperature extremes)
• Gentle skincare: Use gentle, non-irritating cleansers and moisturizers
• Ocular involvement: Often overlooked - may require specific management including lid hygiene, artificial tears, and ophthalmology referral for moderate to severe symptoms 1
• Treatment resistance: Consider testing for Helicobacter pylori infection or Demodex folliculorum infestation in resistant cases 5

Emerging Treatments

• Minocycline foam 1.5%: FDA-approved in 2020 for rosacea 2
• E-BPO 5% cream: Shows rapid onset of action (by Week 2) and sustained results for up to 52 weeks 2