From the Guidelines
Topical treatments for facial erythema in rosacea include brimonidine gel 0.33% (Mirvaso) and oxymetazoline hydrochloride cream 1% (Rhofade), which are FDA-approved specifically for this purpose, as well as metronidazole, azelaic acid, and ivermectin, which address both inflammation and some degree of redness. These medications work as alpha-adrenergic receptor agonists that constrict dilated blood vessels in the face, providing temporary reduction in redness for up to 12 hours 1. Apply a pea-sized amount once daily to the entire face, avoiding the eyes and lips. Side effects may include worsening erythema upon discontinuation, skin irritation, or rebound redness.
Treatment Options
- Brimonidine gel 0.33% (Mirvaso)
- Oxymetazoline hydrochloride cream 1% (Rhofade)
- Metronidazole (0.75% or 1% cream, applied twice daily)
- Azelaic acid (15-20% cream or gel, applied twice daily)
- Ivermectin 1% cream (applied once daily)
Additional Considerations
For patients with inflammatory papules and pustules alongside erythema, these treatments may be beneficial as they address both inflammation and some degree of redness. Topical calcineurin inhibitors like tacrolimus or pimecrolimus may help in some cases, though they're used off-label. These treatments work best when combined with trigger avoidance (spicy foods, alcohol, extreme temperatures, sun exposure) and gentle skincare routines using fragrance-free, non-irritating products and daily broad-spectrum sunscreen 1.
Evidence-Based Recommendations
The most recent and highest quality study, published in 2024, supports the use of azelaic acid, metronidazole, and ivermectin for the treatment of rosacea-induced facial erythema 1. The global rosacea consensus (ROSco) panel also recommends a phenotype-led treatment approach, considering each feature and its severity individually 1.
From the Research
Topical Treatment Options for Rosacea-Induced Facial Erythema
The following topical treatment options are available for rosacea-induced facial erythema:
- Metronidazole: effective for patients with mild rosacea 2, 3, 4, 5
- Azelaic acid: effective for patients with mild rosacea 2, 6, 3, 4, 5
- Sulfacetamide/sulfur: effective for patients with mild rosacea 2, 6, 3
- Brimonidine: a new addition to the therapeutic armamentarium for rosacea 6
- Oxymetazoline: a new addition to the therapeutic armamentarium for rosacea 6
- Ivermectin: a new addition to the therapeutic armamentarium for rosacea 6
- Tacrolimus: a new addition to the therapeutic armamentarium for rosacea 6
- Pimecrolimus: a new addition to the therapeutic armamentarium for rosacea 6
- Low-dose modified-release tetracyclines: a new addition to the therapeutic armamentarium for rosacea 6
- Botulinum toxin: a new addition to the therapeutic armamentarium for rosacea 6
Additional Topical Therapies
Additional topical therapies that may be used to treat rosacea include:
- Benzoyl peroxide: not approved for the treatment of rosacea, but may play a variable role in management 3
- Clindamycin: not approved for the treatment of rosacea, but may play a variable role in management 3
- Retinoids: not approved for the treatment of rosacea, but may play a variable role in management 3, 4, 5
- Topical steroids: not approved for the treatment of rosacea, but may play a variable role in management 3
- Calcineurin inhibitors: not approved for the treatment of rosacea, but may play a variable role in management 3
- Permethrin: not approved for the treatment of rosacea, but may play a variable role in management 3
- Crotamiton 10%: may be used to treat Demodex folliculorum infestation 4, 5