What are the local treatment options for rosacea?

Local Treatment Options for Rosacea

The most effective topical treatment options for rosacea include azelaic acid 15% gel/foam, metronidazole 0.75% or 1% gel/cream, ivermectin 1% cream, and encapsulated benzoyl peroxide 5% cream, with azelaic acid showing superior efficacy with 51-58% reduction in inflammatory lesions and 44-46% improvement in erythema. 1

First-Line Topical Treatments

Azelaic Acid 15% Gel/Foam

• Possesses antimicrobial activity against P. acnes and S. epidermidis
• Normalizes keratinization and has anticomedonal effects
• Achieves 51-58% reduction in inflammatory lesions and 44-46% improvement in erythema 1
• Apply twice daily by gently massaging a thin film into affected areas 2
• May cause temporary skin irritation (pruritus, burning, or stinging), especially when applied to broken or inflamed skin 2

Metronidazole 0.75% or 1% Gel/Cream

• Preferred first-line treatment during pregnancy 1
• Once-daily application of 1% gel is as effective as twice-daily azelaic acid 15% gel with similar reductions in inflammatory lesion counts (77% for metronidazole vs 80% for azelaic acid) 3
• Has been used for over 30 years with demonstrated effectiveness in moderate-to-severe rosacea 4
• Available in multiple formulations (cream, gel, lotion) and strengths (0.75% and 1%) 4

Ivermectin 1% Cream

• Shows 38.4-40.1% success rates in large clinical trials 1
• Not recommended during pregnancy due to unknown risks 1

Encapsulated Benzoyl Peroxide 5% (E-BPO 5%) Cream

• Offers rapid onset of action 1
• Useful alternative for patients who don't respond to other topicals

Treatment Approach and Monitoring

Initial Treatment

1. For mild rosacea: Start with topical therapy alone

   • Metronidazole 0.75% or 1% applied once or twice daily OR
   • Azelaic acid 15% applied twice daily

2. For moderate-to-severe rosacea: Consider combination therapy

   • Oral doxycycline (preferably 40mg modified-release) plus topical azelaic acid 15% for 12 weeks 1
   • Visible improvement expected within 3-4 weeks
   • Maximum benefit typically seen by 12 weeks

Maintenance Therapy

• After achieving control, transition to azelaic acid as monotherapy
• Studies show maintenance of remission in 75% of patients over six months 1
• Continued topical treatment helps prevent relapse

Monitoring and Adjustments

• Evaluate response at 3-4 week intervals initially
• Allow 6-12 weeks before considering treatment failure
• If minimal improvement after 6-8 weeks, consider adjusting treatment approach 1
• If sensitivity or severe irritation develops, discontinue treatment and consider alternatives 2

Special Considerations

Application Techniques

• Thoroughly wash and pat skin dry before application
• Apply a thin film and gently massage into affected areas
• Wash hands after application 2
• Avoid occlusive dressings or wrappings
• Keep products away from mouth, eyes, and other mucous membranes 2

Managing Side Effects

• If irritation occurs with azelaic acid, consider reducing to once-daily application until tolerance improves 2
• For patients with darker skin tones, monitor for abnormal changes in skin color 2
• If troublesome irritation persists despite adjustments, discontinue use and consult physician 2

Ocular Rosacea

• First-line treatment includes lid hygiene (daily cleansing of eyelid margins, warm compresses, eyelid massage) 1
• Preservative-free artificial tears for mild burning/stinging 1
• Consider topical antimicrobials or oral antibiotics for more severe cases 1

Erythema and Telangiectasia

• Topical treatments have limited efficacy for persistent erythema and telangiectasia
• Pulsed-dye laser (PDL) and intense pulsed light (IPL) are effective first-line laser options
• Typically requires 3-4 treatment sessions at 3-4 week intervals 1

Treatment Efficacy Comparison

• Azelaic acid: 51-58% reduction in inflammatory lesions, 44-46% improvement in erythema 1
• Metronidazole: 77% reduction in inflammatory lesions, similar efficacy to azelaic acid in direct comparison 3
• Ivermectin 1% cream: 38.4-40.1% success rates in clinical trials 1

Common Pitfalls and Caveats

• Patient adherence is crucial—up to 89% of patients experiencing adverse effects may discontinue therapy within a month 1
• Up to two-thirds of patients relapse when therapy is discontinued without maintenance treatment 1
• Topical treatments primarily address inflammatory lesions but have limited effect on background erythema and telangiectasia
• Allow sufficient time (6-12 weeks) for full treatment response before concluding treatment failure
• Temporary skin irritation is common at initiation of therapy and often subsides with continued use 2