What are the treatment options for rosacea?

Treatment Options for Rosacea

The most effective treatment for rosacea is a phenotype-based approach using topical ivermectin 1% cream, azelaic acid 15% gel/foam, or the newly FDA-approved encapsulated benzoyl peroxide 5% (E-BPO 5%) as first-line therapies for inflammatory lesions, with brimonidine or oxymetazoline for persistent erythema. 1

First-Line Treatment Based on Phenotype

For Inflammatory Papules/Pustules:

• Topical ivermectin 1% cream is recommended as first-line therapy for mild inflammatory papules/pustules 1
• Topical azelaic acid 15% gel/foam is an effective alternative first-line option 2, 1
• Encapsulated benzoyl peroxide 5% (E-BPO 5%) shows rapid improvement by week 2 and sustained efficacy for up to 52 weeks 3, 4
• Topical metronidazole (0.75% and 1.0% formulations) produces up to 65% decrease in inflammatory lesion counts 4
• Topical minocycline foam 1.5% is recommended for moderate to severe inflammatory lesions 2, 1

For Persistent Erythema:

• Topical α-adrenergics, specifically brimonidine, are first-line therapy 3, 1
• Topical oxymetazoline is an effective alternative option 4, 1
• Physical modalities like IPL or PDL can be considered for persistent erythema 4

Combination Therapy Approach

• For moderate inflammatory papules/pustules, combine topical therapy with oral doxycycline for faster control 3, 2
• For severe inflammatory lesions, topical ivermectin plus oral doxycycline is recommended 4
• Multiple cutaneous features of rosacea can be treated with more than one agent simultaneously 2, 4
• Moderate and severe presentations typically require combination treatments 1

Oral Therapies

• Oral doxycycline is effective for all severities of inflammatory papules/pustules, clinically inflamed phyma, and ocular features 3
• Anti-inflammatory dose doxycycline (40-mg modified-release) has reduced gastrointestinal side effects and no antibiotic activity, making it preferable when available 3
• Other tetracycline antibiotics may be considered when doxycycline is unsuitable or unavailable 3

Maintenance Therapy

• The minimum treatment necessary to maintain control should be used 2, 1
• Without maintenance therapy, up to two-thirds of patients may relapse when treatment is discontinued 4, 1
• Approach to maintenance depends on treatment modality and patient desire for ongoing therapy 1

General Skincare Measures

• Sun protection (SPF 30+) is essential 4, 1
• Use gentle cleansers and moisturizers 4, 1
• Avoid trigger factors, though limited RCT evidence exists for this approach 1

Special Considerations for Ocular Rosacea

• Lid hygiene and artificial tears are recommended for mild ocular symptoms 1
• Oral doxycycline is recommended for moderate to severe cases of ocular rosacea 3, 1
• Ophthalmological referral should be considered for all but the mildest ocular features 1

Common Pitfalls and Caveats

• Insufficient treatment duration can lead to inadequate demonstration of efficacy; treatments should be given 6-12 weeks before considering them failures 3, 1
• Treating based on traditional subtypes rather than phenotypes may lead to inadequate management 1
• Poor adherence due to skin irritation can result in up to 89% of patients discontinuing therapy within a month 4
• Overlooking maintenance therapy can lead to relapse 4, 1
• Ignoring ocular manifestations can lead to underdiagnosis and undertreatment of ocular rosacea 1