What are the treatment options for rosacea?

Treatment Options for Rosacea

The most effective treatment approach for rosacea involves topical agents as first-line therapy (metronidazole or azelaic acid), with oral doxycycline added for moderate to severe papulopustular cases, and laser/light therapies for persistent erythema and telangiectasia. 1

First-Line Topical Treatments

• Topical metronidazole (0.75% or 1%): First-line treatment with 65% reduction in inflammatory lesions and 62.5% improvement rates in clinical trials 1
• Azelaic acid (15% gel/foam): Alternative first-line option with 51-58% reduction in inflammatory lesions and 44-46% improvement in erythema 1
• Ivermectin 1% cream: Effective with 38.4-40.1% success rates in clinical trials (not recommended during pregnancy) 1
• Encapsulated benzoyl peroxide 5% cream: Provides rapid onset of action 1

Treatment Algorithm Based on Severity and Type

Mild Rosacea

1. Start with topical metronidazole 0.75% or 1% once daily 1
2. If inadequate response after 3-4 weeks, increase to twice daily application 1
3. Consider adding azelaic acid for inadequate response 1

Moderate to Severe Papulopustular Rosacea

1. Combination therapy: oral doxycycline plus topical azelaic acid 15% gel/foam 1
   • Significant reduction in inflammatory lesions by 3 weeks
   • Continued improvement through 12-16 weeks
2. Allow 6-12 weeks before considering treatment failure 1
3. Adjust treatment if minimal improvement after 6-8 weeks 1

Erythematotelangiectatic Rosacea

1. Laser or light-based therapies are most effective 1, 2
   • Pulsed-dye laser (PDL) or intense pulsed light (IPL)
   • Typically requires 3-4 treatment sessions at 3-4 week intervals 1

Ocular Rosacea

1. First-line: Lid hygiene (daily cleansing of eyelid margins, warm compresses, eyelid massage) 1
2. Preservative-free artificial tears for mild burning/stinging 1
3. For moderate to severe cases: topical antimicrobials, oral antibiotics, cyclosporine ophthalmic emulsion 1
4. Systemic ivermectin for cases with significant Demodex folliculorum 1

Phymatous Rosacea

1. Primary treatment: laser or light-based therapies 3
2. Surgical intervention may be necessary for advanced cases 4

Special Populations

Pediatric Rosacea

• Mild cases: gentle skincare, sun protection (SPF 30+), topical metronidazole 0.75% or 1% once daily 1
• Moderate cases: topical metronidazole twice daily, consider adding azelaic acid 1
• For children ≥8 years with inadequate response: consider oral antibiotics 1

Pregnant Patients

• Topical metronidazole 0.75% or 1% is preferred first-line treatment 1
• Azelaic acid has better safety profile during pregnancy compared to ivermectin 1
• Avoid ivermectin due to unknown risks 1

Common Pitfalls and Caveats

1. Inadequate treatment duration: Allow sufficient time (6-12 weeks) before considering treatment failure 1
2. Poor adherence: Up to 89% of patients experiencing adverse effects discontinue therapy within a month 1
3. Overlooking triggers: Identify and avoid triggers (sun exposure, spicy foods, alcohol, extreme temperatures) 2, 5
4. Neglecting skin care: Use gentle cleansing agents and moisturizing regimens 3
5. Insufficient photoprotection: Recommend wide-brimmed hats and broad-spectrum sunscreens (minimum SPF 30) 3
6. Missing ocular involvement: Always assess for and treat ocular manifestations, which may require referral to an ophthalmologist for severe cases 6

Monitoring and Follow-up

• Evaluate response at 3-4 week intervals initially 1
• Reassess treatment approach if minimal improvement after 6-8 weeks 1
• Recognize that rosacea is a chronic condition requiring ongoing management to prevent relapse 1