What are the first-line treatments for a patient with rosacea and possible folliculitis, who has a history of acne and has not responded to Metrogel (metronidazole)?

Treatment Options for Rosacea with Possible Folliculitis and History of Acne

For a patient with rosacea and possible folliculitis who has not responded to metronidazole gel (Metrogel) and has a history of acne, oral doxycycline is the recommended first-line treatment, potentially combined with topical azelaic acid or ivermectin. 1, 2

First-Line Treatment Approach

Oral Therapy

• Oral doxycycline (first choice):
  • Can be used for all severities of inflammatory papules/pustules and is effective for both rosacea and folliculitis
  • Consider 40mg modified-release formulation (anti-inflammatory but not antibiotic) where available to reduce antibiotic resistance concerns
  • Standard dosing (≥50mg) if modified-release unavailable 1, 2
  • Expect improvement within 3-4 weeks, with progressive results through 12 weeks

Topical Therapy (to be used in combination with oral therapy)

• Azelaic acid 15% gel/foam (recommended to replace failed metronidazole):

  • 51-58% reduction in inflammatory lesions
  • 44-46% improvement in erythema 2
  • Apply twice daily

• Topical ivermectin 1% cream (alternative):

  • Superior efficacy compared to metronidazole (38.4-40.1% vs. 30% success rates)
  • Faster onset of action (2-3 weeks) 2
  • Particularly effective if Demodex folliculorum is suspected

For Folliculitis Component

• Benzoyl peroxide-containing products:

  • Encapsulated benzoyl peroxide 5% (E-BPO 5%) cream shows rapid onset of action by week 2 2
  • Benzoyl peroxide-erythromycin combination gel has shown efficacy in treating rosacea with follicular involvement 3
  • Particularly helpful for the folliculitis component

• Topical erythromycin (if folliculitis is predominant):

  • Apply twice daily after thoroughly washing affected areas 4
  • Avoid concomitant use with other potentially irritating topical agents

Treatment Duration and Monitoring

1. Allow sufficient time for treatment to take effect (6-12 weeks) before considering it a failure 1
2. Evaluate response at 3-4 week intervals initially 2
3. Consider adjusting treatment approach if minimal improvement after 6-8 weeks 2
4. After achieving control, implement maintenance therapy to prevent relapse 1, 2

Common Pitfalls to Avoid

• Insufficient treatment duration: Many studies showed treatment duration <8 weeks was inadequate to demonstrate efficacy 1
• Neglecting maintenance therapy: Up to two-thirds of patients relapse when therapy is discontinued 2
• Poor adherence due to irritation: Up to 89% of patients experiencing adverse effects discontinue therapy within a month 2
• Monotherapy for moderate-severe disease: Parallel combination therapy is often required for optimal management 1

Additional Considerations

• General skincare: Use gentle cleansers and moisturizers, avoid trigger factors
• Sun protection: Use SPF 30+ daily
• For persistent cases: Consider isotretinoin for severe recalcitrant cases (has shown promising results in both severe rosacea and gram-negative folliculitis) 5

If Initial Treatment Fails

If the combination of oral doxycycline with topical therapy fails after 8-12 weeks:

1. Consider referral to dermatology
2. Alternative options include:
   • Other tetracycline antibiotics
   • Isotretinoin (for severe cases)
   • Combination of benzoyl peroxide with erythromycin 3

Remember that combination therapy with oral antibiotics (at both antimicrobial and subantimicrobial doses) plus topical agents is more effective than monotherapy for treating rosacea with follicular involvement 6, 7.