What are the treatment options for rosacea?

Treatment Options for Rosacea

Encapsulated benzoyl peroxide 5% (E-BPO 5%) is the newest FDA-approved topical treatment for rosacea, showing rapid efficacy by week 2 and excellent tolerability for up to 52 weeks of treatment. 1

First-Line Topical Treatments Based on Phenotype

• For mild to moderate inflammatory lesions:

  • Topical azelaic acid 15% gel/foam (applied twice daily) 2, 3
  • Topical ivermectin 1% cream (applied once daily) 2
  • Topical metronidazole 0.75% or 1% formulations (applied once or twice daily) 1, 2

• For persistent facial erythema:

  • Topical brimonidine gel 0.33% 2
  • Topical oxymetazoline HCl cream 1% 2

• For moderate to severe inflammatory lesions:

  • Combination therapy with oral doxycycline (anti-inflammatory dose of 40mg daily) plus topical agent 2

Efficacy of Established Treatments

• Metronidazole (0.75% and 1.0%):

  • Reduces inflammatory lesions by up to 65% 1
  • Once-daily application of 1% gel is as effective as twice-daily azelaic acid 15% gel 4
  • Maintenance treatment decreases relapses and extends intervals between flares 5

• Azelaic acid (15% gel and foam):

  • Produces significant reduction in inflammatory lesion counts 2
  • Treatment success rates of 46-51% after 12 weeks 1
  • Apply thin film twice daily to affected areas after washing and drying skin 3

• Ivermectin (1% cream):

  • Superior efficacy to metronidazole 0.75% cream (84.9% vs 75.4% achieving "clear" or "almost clear" ratings) 2
  • 38.4-40.1% treatment success rate at 12 weeks 2
  • Works by reducing Demodex folliculorum density and downregulating inflammatory markers 2

Newer Treatment Options

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

  • FDA-approved in 2022 1
  • Uses microencapsulation technology to extend drug delivery time 1
  • Provides rapid onset of action with efficacy evident by week 2 1, 2
  • Demonstrates excellent tolerability with sustained results for up to 52 weeks 1, 2

• Minocycline foam 1.5%:

  • FDA-approved in 2020 1, 2
  • Effective for inflammatory lesions 2

Combination Therapy Approaches

• For moderate rosacea:

  • Topical agent plus oral doxycycline for more rapid control 2
  • Metronidazole 0.75% lotion is more effective when combined with doxycycline 20mg twice daily 5

• For severe inflammatory lesions:

  • Topical ivermectin plus oral doxycycline 2

Important Clinical Considerations

• Treatment adherence:

  • Poor adherence due to skin irritation can result in up to 89% of patients discontinuing therapy within a month 2
  • If irritation occurs with azelaic acid, reduce application to once daily or discontinue until irritation subsides 3

• Maintenance therapy:

  • Up to two-thirds of patients relapse when therapy is discontinued 2
  • Topical metronidazole is effective for maintenance therapy 5

• Physical modalities:

  • Consider intense pulsed light (IPL) or pulsed dye laser (PDL) for persistent erythema 2

• General measures:

  • Long-term avoidance of triggers, gentle skin care, and sun protection (SPF 30+) are essential adjuncts to pharmacological treatment 2

Special Populations

• Pregnant patients:

  • Azelaic acid is pregnancy category B, but should be used only if clearly needed 3

• Nursing mothers:

  • Less than 4% of topically applied azelaic acid is systemically absorbed, but caution is advised 3

• Pediatric patients:

  • Safety and effectiveness of azelaic acid in patients under 12 years have not been established 3

• Patients with ocular involvement:

  • May benefit from long-term oral antibiotics and metronidazole gel 6
  • Referral to ophthalmology is necessary for ocular rosacea with complications 6