Rosacea Treatment Options
Treatment for rosacea should follow a phenotype-based approach targeting specific symptoms with appropriate therapies, with topical ivermectin and oral doxycycline being the most effective options for moderate to severe cases. 1
Treatment Algorithm Based on Phenotype and Severity
Mild Rosacea
- First-line options:
- Topical azelaic acid
- Topical ivermectin 1% cream
- Topical metronidazole (0.75% or 1%)
- Encapsulated benzoyl peroxide 5% (E-BPO 5%) cream (newly FDA-approved with rapid onset by week 2) 1
Moderate Rosacea
- First-line options:
- Topical azelaic acid
- Topical ivermectin 1% cream
- Consider combination therapy with topical ivermectin 1% cream and oral doxycycline 40mg (modified release) for faster results 1
Severe Rosacea
- First-line options:
Treatment for Specific Rosacea Features
Persistent Erythema
- Topical brimonidine
- Intense pulsed light (IPL)
- Pulsed-dye laser (PDL)
- Oral doxycycline 2
Transient Erythema (Flushing)
Telangiectasia
- Electrodessication
- IPL
- Lasers 2
Papules/Pustules
- Clinically inflamed: Oral doxycycline
- Clinically non-inflamed: Physical modalities 2
Phymatous Changes
- Treatment depends on whether it is clinically inflamed ("active") or non-inflamed ("fibrotic") 2
Ocular Rosacea Management
- Mild symptoms: Lid hygiene and artificial tear substitutes
- Moderate to severe symptoms: Referral to an ophthalmologist
- Dermatologists should recognize blepharitis, blurred vision, foreign body sensation, interpalpebral bulbar hyperaemia, photophobia, redness, tearing and telangiectasia as ocular rosacea features 2, 1
Combination Therapy Approach
- Multiple cutaneous features can be treated with more than one agent simultaneously
- Moderate and severe presentations require combination treatments
- If first-line treatment fails, either consider an alternative first-line option or add an additional first-line agent 2
Maintenance Therapy
- Use minimum treatment to maintain control
- Treatments should be used for sufficient duration before switching
- Continuing topical treatment after successful initial therapy helps maintain remission
General Skincare Recommendations
Important Clinical Considerations
Treatment Duration
- A minimum treatment duration of 12 weeks is recommended
- Most clinical trials show continued improvement beyond 12 weeks 1
Relapse Management
- Up to two-thirds of patients will eventually relapse when therapy is discontinued
- Emphasizes need for continued topical treatment after achieving remission 1
Common Pitfalls to Avoid
Topical steroids: Not indicated in rosacea due to side effects (steroid rosacea, facial skin atrophy, rebound after cessation) 4
- Exception: Short-term use for acute forms like rosacea fulminans
Inadequate treatment duration: Switching treatments too quickly before allowing sufficient time for response
Overlooking triggers: Failing to identify and address triggers that exacerbate symptoms
Neglecting ocular involvement: Failing to recognize and appropriately manage ocular rosacea
Poor adherence due to side effects: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month 1
Monotherapy for moderate-severe disease: Using single agents when combination therapy would be more effective
Missing bacterial overgrowth: Some practitioners evaluate patients for Helicobacter pylori infection and small intestinal bacterial overgrowth as potential triggers 5
The phenotype-based approach to rosacea management allows for targeted treatment of specific symptoms, improving outcomes and patient satisfaction. Combination therapy is particularly valuable for moderate to severe cases, while maintenance therapy helps prevent relapses after successful initial treatment.