What is the recommended treatment for rosacea?

Phenotype-Based Treatment Approach for Rosacea

The recommended treatment for rosacea should follow a phenotype-based approach that addresses individual features rather than subtypes, with first-line treatments selected according to the specific manifestations present in each patient. 1, 2

General Measures for All Rosacea Patients

• Implement general skincare measures including sun protection (SPF 30+), gentle cleansers, moisturizers, and trigger factor avoidance as the foundation of treatment 1, 2
• Allow sufficient time for treatments to take effect before considering alternatives (typically 6-12 weeks depending on whether treatment is topical or oral) 1
• Use the minimum treatment necessary to maintain control during maintenance therapy 1, 2

First-Line Treatments by Phenotype

For Inflammatory Papules/Pustules

• Mild: Topical azelaic acid, ivermectin, or metronidazole 1, 2
• Moderate: Topical azelaic acid or ivermectin; consider adding oral doxycycline for faster control 1, 2
• Severe: Topical ivermectin plus oral doxycycline or oral isotretinoin 1, 2

For Persistent Erythema

• Topical brimonidine, intense pulsed light (IPL), pulsed-dye laser (PDL), or oral doxycycline 1, 2

For Transient Erythema/Flushing

• Topical α-adrenergics (brimonidine), oral beta blockers (carvedilol), or PDL 1, 2

For Telangiectasia

• Electrodessication, IPL, or lasers 1, 2

For Phymatous Changes

• Clinically inflamed: Oral doxycycline 1
• Clinically non-inflamed: Physical modalities 1

For Ocular Rosacea

• Mild cases: Lid hygiene and artificial tears 1, 2
• Moderate to severe cases: Ophthalmological referral and oral doxycycline 1, 2

Combination Therapy Approach

• Multiple cutaneous features can and should be treated simultaneously with multiple agents 1, 2
• If first-line treatment fails after an adequate trial period, either:
  • Consider an alternative first-line option, or
  • Add an additional first-line agent 1
• Moderate and severe presentations typically require combination treatments 1, 2

Special Considerations

• Doxycycline is available in standard formulations (≥50 mg with antibiotic activity) and as a 40-mg modified-release dose with anti-inflammatory but not antibiotic activity 1
• The 40-mg modified-release doxycycline formulation may help reduce concerns about antibiotic resistance 1
• Without maintenance therapy, up to two-thirds of patients may relapse when treatment is discontinued 2
• Newer treatment options like encapsulated benzoyl peroxide 5% show rapid improvement and sustained efficacy 2

Treatment Algorithm Pitfalls to Avoid

• Avoid treating rosacea according to subtypes rather than phenotypes, as this may not address the full spectrum of presenting features 1
• Don't expect a single treatment to address all features of rosacea 1
• Avoid inadequate treatment duration before switching therapies 1
• Don't overlook ocular involvement, which requires specific management approaches 1, 2
• Remember that maintenance therapy is often necessary to prevent relapse 1, 2