What are the current treatment options for rosacea?

Current Treatment Options for Rosacea

Encapsulated benzoyl peroxide 5% (E-BPO 5%) cream is the latest FDA-approved therapy for rosacea (2022) and should be considered a first-line treatment option due to its rapid onset of action, excellent tolerability, and progressive clinical improvement for up to 52 weeks. 1, 2

First-Line Treatment Options

For Inflammatory Lesions (Papulopustular Rosacea)

• Topical options:

  • E-BPO 5% cream (once daily): Newest FDA-approved treatment showing:

    • Rapid onset (improvement by week 2)
    • 44-50% of patients achieve clear/almost clear skin by week 12
    • No therapeutic plateau at 12 weeks
    • Excellent tolerability profile 1

  • Ivermectin 1% cream (once daily):

    • Superior efficacy compared to metronidazole (83% vs 73.7% reduction in inflammatory lesions)
    • Longer remission period (115 days vs 85 days for metronidazole)
    • Dual mechanism: anti-parasitic and anti-inflammatory 2

  • Alternative topicals:

    • Azelaic acid 15% gel (twice daily)
    • Metronidazole 0.75% or 1% (once or twice daily)
    • Minocycline 1.5% foam (FDA-approved in 2020) 1, 2

For Persistent Facial Erythema

• Topical α-adrenergic agonists (FDA-approved vasoconstrictors):
  • Reduce persistent redness not responsive to anti-inflammatory treatments
  • Show 25% median reduction in redness at 3 hours post-application
  • Maintain efficacy and safety for up to 52 weeks without tachyphylaxis 1

Treatment Algorithm Based on Severity

Mild to Moderate Rosacea

1. Start with a topical agent:

   • E-BPO 5% cream once daily OR
   • Ivermectin 1% cream once daily

2. If inadequate response after 4-6 weeks:

   • Consider switching to alternative topical agent OR
   • Add oral therapy (see combination therapy)

Moderate to Severe Rosacea

1. Consider combination therapy:

   • Topical ivermectin 1% cream once daily PLUS
   • Oral doxycycline 40 mg (modified release) once daily
   • Alternative: E-BPO 5% cream with oral doxycycline 2

2. For resistant cases:

   • Consider oral isotretinoin 3

Maintenance Therapy

• Continue topical treatment after achieving remission:

  • Ivermectin preferred due to longer remission periods
  • Metronidazole decreases relapses and extends intervals between flares 2, 4

• Important consideration: When therapy is discontinued, up to two-thirds of patients will eventually relapse 1

Special Populations: Pediatric Rosacea

• First-line: Topical metronidazole (0.75% or 1%) once daily
• For children <8 years: Oral erythromycin if needed (avoid tetracyclines)
• For children ≥8 years: Consider doxycycline (subantimicrobial dose when possible) if topicals fail 2

Treatment Pitfalls and Considerations

1. Treatment adherence challenges:

   • Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month 1
   • E-BPO 5% and ivermectin show better tolerability profiles

2. Treatment duration:

   • Most clinical trials show continued improvement beyond 12 weeks
   • No abrupt treatment-effect plateau observed with newer agents
   • Minimum treatment duration of 12 weeks recommended 1, 2

3. Addressing triggers:

   • Sun exposure, hot beverages, temperature extremes
   • Consider testing for Helicobacter pylori and small intestinal bacterial overgrowth in resistant cases 3
   • Demodex folliculorum infestation may require specific treatment when concentration >5/cm² 3

4. Combination therapy considerations:

   • Evidence suggests synergistic effects when combining oral and topical treatments
   • Oral doxycycline 40 mg with topical metronidazole shows enhanced efficacy 5

The treatment landscape for rosacea has evolved significantly with newer agents showing improved efficacy and tolerability profiles. E-BPO 5% cream represents the latest advancement, offering rapid onset and sustained improvement with excellent tolerability.