What are the treatment options for managing rosacea?

Management of Rosacea

Treatment of rosacea should be phenotype-based, targeting specific symptoms with appropriate medications and combinations based on severity, with topical therapy as the preferred initial treatment for most cases. 1

General Approach to Rosacea Management

First-Line Measures

• General skincare and trigger avoidance underlie all treatment approaches 1
  • Sun protection (SPF 30+)
  • Gentle cleansers and moisturizers
  • Avoidance of identified triggers (alcohol, spicy foods, extreme temperatures)

Treatment Based on Phenotype

Persistent Erythema

• First-line: Topical α-adrenergics 1
  • Brimonidine gel 0.33%
  • Oxymetazoline HCl cream 1%
• Second-line: Oral beta blockers (e.g., carvedilol) 1
• For telangiectasia: Laser therapy (pulsed-dye laser or intense pulsed light) 2

Inflammatory Papules/Pustules

• Mild:

  • Topical metronidazole 0.75% or 1% 1, 3
  • Topical azelaic acid 15% gel/foam 1, 3
  • Topical ivermectin 1% cream 1
  • Encapsulated benzoyl peroxide 5% (E-BPO 5%) cream 1

• Moderate to Severe:

  • Combination therapy recommended 1
  • Topical agent + oral doxycycline (40mg modified-release preferred where available) 1
  • Ivermectin 1% cream + oral doxycycline shows complementary effects 2

Phymatous Changes

• Clinically inflamed phyma: Oral doxycycline 1
• Fixed phymatous changes: Surgical intervention or laser therapy 1

Ocular Rosacea

• Mild symptoms (burning/stinging): Artificial tears (preservative-free) 2
• Beyond mild symptoms: Ophthalmological referral recommended 2
• First-line measures:
  • Lid hygiene (daily cleansing, warm compresses, eyelid massage) 2
  • Artificial tears 2
• For moderate to severe: Oral doxycycline 1, 2

Treatment Duration and Maintenance

• Allow sufficient time for treatment effect (6-12 weeks) before considering alternative options 1
• Maintenance therapy approach depends on:
  • Treatment modality
  • Patient desire for ongoing therapy 1
• Use minimum treatment necessary to maintain control 1

Combination Therapy Considerations

• Multiple cutaneous features often require combination treatment 1
• If first-line treatment fails:
  • Consider alternative first-line option, or
  • Add an additional first-line agent 1
• Moderate and severe presentations generally require combination therapy 1

Newer Treatment Options

• Encapsulated benzoyl peroxide 5% (E-BPO 5%) - FDA approved in 2022 1

  • Uses microencapsulation technology to improve efficacy and reduce irritation
  • Shows rapid onset of action (by Week 2)
  • Demonstrates sustained results for up to 52 weeks 1

• Minocycline foam 1.5% - FDA approved in 2020 1

Common Pitfalls to Avoid

• Insufficient treatment duration: Allow 6-12 weeks before switching therapies 1
• Neglecting maintenance therapy: Continuing treatment after initial success helps prevent relapse 2
• Overlooking ocular involvement: Consider ophthalmological referral for all but the mildest cases 2
• Poor adherence due to irritation: Select treatments with favorable tolerability profiles 2
• Monotherapy for severe disease: Combination therapy is typically required for moderate to severe presentations 1

Treatment Efficacy Comparison

Treatment	Efficacy
Azelaic acid	51-58% reduction in inflammatory lesions [2]
Metronidazole	65% decrease in inflammatory lesion counts [2]
Ivermectin 1% cream	38.4-40.1% IGA success rates [2]
E-BPO 5% cream	Rapid onset of action [1,2]

Rosacea is a chronic condition requiring ongoing management. The phenotype-based approach allows for targeted treatment of specific symptoms, improving outcomes and quality of life for patients.