What are the treatment options for acne rosacea?

Treatment Options for Acne Rosacea

The treatment of acne rosacea should be phenotype-based, tailoring therapy to the specific signs and symptoms observed by the clinician and reported as most troubling by the patient. 1

First-Line Treatment Based on Phenotype

For Inflammatory Papules/Pustules:

• Mild:

  • Topical azelaic acid 15% gel/foam 1, 2, 3
  • Topical ivermectin 1% cream 1, 2
  • Topical metronidazole 0.75% or 1% 1, 2, 4
  • Encapsulated benzoyl peroxide 5% (E-BPO 5%) - newest FDA-approved option (2022) 1

• Moderate:

  • Topical azelaic acid 15% 1, 2
  • Topical ivermectin 1% 1, 2
  • Consider combination with oral doxycycline for faster control 1, 2
  • Minocycline foam 1.5% (FDA-approved in 2020) 1, 2

• Severe:

  • Topical ivermectin 1% plus oral doxycycline 1, 2
  • Oral isotretinoin 1

For Persistent Erythema:

• Topical brimonidine 0.33% gel 1, 2
• Topical oxymetazoline HCl 1% cream 2
• Intense pulsed light (IPL) therapy 1
• Pulsed-dye laser (PDL) 1

For Transient Erythema (Flushing):

• Topical α-adrenergics 1
• Oral beta blockers (e.g., carvedilol) 1
• Pulsed-dye laser 1

For Telangiectasia:

• Electrodessication 1
• IPL therapy 1
• Laser treatments 1

For Phymatous Changes:

• Clinically inflamed: Oral doxycycline 1
• Clinically noninflamed: Physical modalities (surgical intervention) 1

Newer Treatment Options

• Encapsulated benzoyl peroxide 5% (E-BPO 5%):

  • Uses novel microencapsulation technology to improve therapeutic effects while reducing irritation 1
  • Shows rapid improvement by week 2 of treatment 1, 2
  • Demonstrates sustained efficacy for up to 52 weeks 1, 2

• Minocycline foam 1.5%:

  • FDA-approved in 2020 specifically for rosacea 1, 2

Combination Therapy Approach

• Multiple cutaneous features of rosacea can be treated with more than one agent simultaneously 1
• Moderate and severe presentations typically require combination treatments 1, 2
• If first-line treatment fails, either consider an alternative first-line option or add an additional agent 1
• For severely affected patients, initial combination of topical therapy plus a systemic agent is recommended for more rapid control 1

Maintenance Therapy

• The minimum treatment necessary to maintain control should be used 1
• Treatment approach depends on the specific modality and patient preference for ongoing therapy 1
• Treatments should be given sufficient time (typically 6-12 weeks) before switching to alternatives 1
• Without maintenance therapy, up to two-thirds of patients may relapse when treatment is discontinued 2

General Skincare Measures

• Sun protection (SPF 30+) 1, 2
• Gentle cleansers 1
• Moisturizers 1
• Trigger avoidance (individualized) 1

Common Pitfalls to Avoid

• Insufficient treatment duration: Allow 6-12 weeks before considering a treatment failure 1, 2
• Ignoring skin irritation: Up to 89% of patients may discontinue therapy within a month due to irritation 2
• Not addressing all phenotypic features: Multiple features may require simultaneous treatment with different agents 1, 2
• Overlooking maintenance therapy: Discontinuation often leads to relapse 2
• Using standard-dose doxycycline when unnecessary: Consider 40mg modified-release doxycycline (anti-inflammatory but not antibiotic dose) to reduce antibiotic resistance concerns when appropriate 1

Special Considerations for Ocular Rosacea

• Lid hygiene for mild cases 1
• Artificial tear substitutes for mild ocular burning/stinging 1
• Oral doxycycline for moderate to severe cases 1
• Referral to ophthalmologist for cases that cannot be controlled with lid hygiene or for more severe presentations 1