What is the recommended treatment for rosacea?

Rosacea Treatment: A Phenotype-Based Approach

The recommended treatment for rosacea should follow a phenotype-based approach targeting specific features rather than subtypes, often requiring combination therapy to address multiple symptoms simultaneously. 1

Treatment Algorithm Based on Clinical Features

First-Line Topical Treatments

• For inflammatory lesions (papules/pustules):

  • Ivermectin 1% cream 1
  • Metronidazole 0.75-1% 1
  • Azelaic acid 15-20% 1

• For persistent erythema:

  • Brimonidine tartrate 0.5% (α-adrenergic agonist) 1
  • Oxymetazoline 2

First-Line Procedural Options

• For erythema and telangiectasia:
  • Intense pulsed light (IPL) 1
  • Pulsed-dye laser (PDL) 1

Systemic Treatment Options

• For moderate to severe papulopustular rosacea:
  • Doxycycline (preferably 40mg modified-release formulation) 1, 2
  • Low-dose isotretinoin (alternative) 2

Treatment by Disease Severity

Mild Rosacea

• Topical azelaic acid, ivermectin, or metronidazole 1
• For erythema: brimonidine or oxymetazoline 1, 2

Moderate Rosacea

• Topical azelaic acid or ivermectin 1
• Consider adding oral doxycycline 40mg (modified-release) 1, 2

Severe Rosacea

• Oral doxycycline 1
• Topical ivermectin 1
• Consider oral isotretinoin for resistant cases 2

Ocular Rosacea Management

• Mild symptoms:

  • Lid hygiene and artificial tears 1, 3

• Moderate to severe symptoms:

  • Ophthalmological referral is essential 1
  • Oral doxycycline 1, 3
  • Topical options (under ophthalmologist direction):
    • Topical antimicrobials 3
    • Cyclosporine ophthalmic emulsion 3, 2

Important Clinical Considerations

Treatment Duration

• Allow 6-12 weeks before determining treatment failure 1
• Inadequate trial periods (less than 8 weeks) may not demonstrate true efficacy 1

Combination Therapy

• Multiple features often coexist and require simultaneous treatment with multiple agents 1
• Monotherapy rarely addresses all rosacea manifestations 1
• Consider combining oral and topical treatments for better outcomes 4

Adverse Effects and Precautions

• With azelaic acid, temporary skin irritation (pruritus, burning, stinging) may occur, especially on broken skin 5
• If irritation persists with azelaic acid, reduce application frequency or discontinue 5
• The 40mg modified-release doxycycline formulation is preferred to reduce antibiotic resistance concerns 1

Long-term Management

• Use the minimum treatment necessary to maintain control 1
• Consider maintenance therapy after achieving control of symptoms 6
• Patient education about trigger avoidance is essential 7

Treatment Efficacy

• Topical antimicrobials and oral antibiotics achieve complete or partial response in approximately 90% of ocular rosacea cases 3
• Intense pulsed light shows 89% partial response rate for ocular symptoms 3
• Combination treatments achieve a complete or partial response in 90% of cases 3

The phenotype-based approach to rosacea management represents a significant advancement over the traditional subtype-based treatment, allowing for more personalized and effective therapy targeting the specific manifestations that are most bothersome to the patient 6, 1.