What are the treatment options for rosacea?

Treatment Options for Rosacea

First-line treatment for rosacea should be tailored to the specific phenotype, with topical azelaic acid, ivermectin, or metronidazole recommended for mild to moderate inflammatory lesions, while more severe cases require combination therapy with oral medications. 1

Phenotype-Based Treatment Algorithm

• For mild to moderate inflammatory lesions (papulopustular rosacea):

  • First-line: Topical azelaic acid, ivermectin, or metronidazole 1
  • Metronidazole (0.75% and 1.0% formulations) can produce up to 65% decrease in inflammatory lesion counts 2, 1
  • Azelaic acid (15% gel and foam) effectively treats inflammatory lesions and perilesional erythema 1

• For moderate rosacea requiring more rapid control:

  • Consider combination therapy with topical agent plus oral doxycycline 1
  • Oral doxycycline at subantimicrobial doses (40 mg modified release) is effective for inflammatory lesions 2

• For severe inflammatory lesions:

  • Topical ivermectin plus oral doxycycline is recommended 1
  • Ivermectin 1% cream shows superior efficacy for moderate to severe papulopustular rosacea 2, 1

• For persistent erythema:

  • Topical brimonidine or oxymetazoline 1
  • Consider physical modalities like intense pulsed light (IPL) or pulsed dye laser (PDL) for persistent cases 1

Newer FDA-Approved Treatment Options

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

  • FDA-approved in 2022 2
  • Uses microencapsulation technology to extend drug delivery time 2
  • Shows rapid improvement by week 2 with progressive clinical improvement for up to 52 weeks 1
  • Reduces risk of skin irritation through silica microcapsule delivery system 2

• Minocycline foam 1.5%:

  • FDA-approved in 2020 for rosacea 2
  • Provides another topical therapeutic option for inflammatory lesions 2, 1

Maintenance Therapy Considerations

• Long-term maintenance therapy is crucial as up to two-thirds of patients relapse when therapy is discontinued 1
• Topical metronidazole is effective for maintenance therapy and helps prevent relapses 3
• Combination treatment with oral antibiotics at both antimicrobial and subantimicrobial doses is efficacious for treating rosacea 3

General Management Strategies

• Avoid common triggers and use gentle skincare products 2, 1
• Sun protection (SPF 30+), gentle cleansers, and moisturizers are essential adjuncts to pharmacological treatment 1
• Treatment should address the specific signs and symptoms that the patient finds most troubling 2, 1

Common Pitfalls to Avoid

• Poor adherence due to skin irritation can result in up to 89% of patients discontinuing therapy within a month 1
• Overlooking combination therapy for moderate and severe presentations 1
• Not addressing all phenotypic features of rosacea, as multiple cutaneous features may require simultaneous treatment with different agents 1
• Ignoring maintenance therapy, which is essential for preventing relapses 1, 3

Special Considerations

• For ocular rosacea, long-term oral antibiotics and metronidazole gel may be beneficial 4
• Referral to specialists is necessary for patients with ocular complications, severe/recalcitrant rosacea, or phymatous changes 4
• Rhinophyma (swelling and erythema of the nose with dilated pilosebaceous poral orifices) may develop in chronic cases 5