What are the treatment options for moderate to severe rosacea?

Treatment Options for Moderate to Severe Rosacea

For moderate to severe rosacea, the recommended first-line treatment is a combination of topical ivermectin 1% cream plus oral doxycycline 40 mg modified-release formulation. 1, 2

First-Line Treatment Based on Phenotype

• For moderate to severe inflammatory papules/pustules, combination therapy with topical agents plus oral doxycycline is recommended for more rapid control 1, 3
• FDA-approved 40 mg modified-release doxycycline is highly effective for treating inflammatory rosacea, with significant reduction in lesions evident within 3 weeks 2
• Topical ivermectin 1% cream is particularly effective for moderate to severe papulopustular rosacea and should be applied once daily 1, 3
• Minocycline foam 1.5% is an FDA-approved option for moderate to severe inflammatory papules/pustules 3, 1
• For persistent erythema, consider topical brimonidine or oxymetazoline 1

Oral Doxycycline for Moderate to Severe Rosacea

• The 40 mg modified-release doxycycline formulation works through anti-inflammatory mechanisms at a dose below that which typically kills bacteria 2
• This formulation is FDA-approved specifically for rosacea treatment and is non-antibiotic, avoiding concerns about antibiotic resistance 2, 4
• Doxycycline 40 mg modified-release is as effective as doxycycline 100 mg but with fewer side effects 5, 4
• Treatment should be continued for at least 8 weeks before considering it a failure 2

Combination Therapy Approach

• The Global ROSacea COnsensus (ROSCO) panel unanimously agrees that multiple cutaneous features of rosacea can be treated with more than one agent simultaneously 5, 3
• Moderate and severe presentations typically require combination treatments targeting different pathophysiological aspects of the disease 3, 5
• Topical and oral strategies used in combination provide more substantial improvements compared to monotherapy 4, 6
• When using both azelaic acid 15% gel and ivermectin 1% cream, apply one in the morning and one in the evening to minimize potential irritation 1

Alternative Systemic Options

• For patients with contraindications to doxycycline (pregnancy, children under 8 years), consider azithromycin or metronidazole as alternative systemic therapies 7
• Isotretinoin is particularly effective for forms of rosacea involving hyperplasia of sebaceous glands (phymatous changes) 7, 8
• Dapsone has been successfully used for granulomatous rosacea and rosacea fulminans 7
• Beta blockers may help reduce erythema in some patients 7

Physical Modalities for Persistent Features

• For persistent erythema and telangiectasia, consider physical modalities like intense pulsed light (IPL) or pulsed-dye laser (PDL) 1, 5
• These treatments are particularly useful for the erythemato-telangiectatic type of rosacea 8

Maintenance Therapy

• After achieving control, use the minimum treatment necessary to maintain improvement 3, 5
• Without maintenance therapy, up to two-thirds of patients may relapse when treatment is discontinued 1
• Maintenance treatment with topical agents like metronidazole decreases relapses and allows for longer intervals between flares 6

Special Considerations for Ocular Rosacea

• For mild ocular rosacea, lid hygiene is recommended as first-line treatment 3, 5
• For moderate to severe ocular rosacea, oral doxycycline is recommended 3, 7
• Consider referral to an ophthalmologist for ocular rosacea that cannot be controlled with lid hygiene 5

Common Pitfalls to Avoid

• Not allowing sufficient treatment time (at least 8 weeks) before switching therapies 2, 1
• Overlooking the need for maintenance therapy, leading to frequent relapses 1, 6
• Failing to address all phenotypic features simultaneously (e.g., treating only papules but not erythema) 5, 1
• Not counseling patients about potential photosensitivity with doxycycline 2