What is the recommended treatment for rosacea?

Recommended Treatment for Rosacea

Treatment for rosacea should be phenotype-led, with specific therapies targeted to the patient's predominant features (erythema, papules/pustules, phymatous changes, or ocular manifestations). 1

General Approach

• General skincare forms the foundation of rosacea management, including sun protection (SPF 30+), gentle cleansers, moisturizers, and trigger avoidance 1, 2
• Treatment should be allowed sufficient time (6-12 weeks) before considering it a failure 1
• Combination therapy is often necessary for moderate to severe presentations 1
• Maintenance therapy should use the minimum treatment necessary to maintain control 1

Treatment by Phenotype

Transient Erythema (Flushing)

• Topical α-adrenergics (brimonidine) 1
• Oral beta blockers 1, 3
• Pulsed-dye laser (PDL) 1, 3
• Oral doxycycline 1

Persistent Erythema

• Topical brimonidine 1, 4
• Intense pulsed light (IPL) 1, 3
• Topical metronidazole 1, 3
• Oral doxycycline 1

Inflammatory Papules/Pustules

• Mild: Topical azelaic acid 15%, ivermectin 1%, or metronidazole 0.75% 1, 2, 5
• Moderate: Same topicals as for mild, plus oral doxycycline 1, 4
• Severe: Topical ivermectin, oral doxycycline, or oral isotretinoin 1, 6

Telangiectasia

• Electrodessication 1
• Intense pulsed light (IPL) 1, 3
• Lasers (pulsed-dye laser) 1, 4

Phymatous Changes

• Clinically inflamed: Oral doxycycline 1
• Clinically noninflamed: Physical modalities (laser therapy, surgical correction) 1, 3

Ocular Rosacea

• Lid hygiene for mild cases 2, 4
• Artificial tear substitutes for mild ocular burning/stinging 1
• Oral doxycycline for moderate to severe cases 2, 4
• Referral to ophthalmologist for cases that cannot be controlled with lid hygiene 1

Medication Details

Topical Treatments

• Azelaic acid 15%: Effective for mild inflammatory papules/pustules and reduces erythema 7, 5
  • Caution: May cause temporary skin irritation, especially on broken skin 7
• Metronidazole 0.75-1%: Effective for mild to moderate papulopustular rosacea 5, 4
• Ivermectin 1%: Effective for inflammatory lesions 2, 6
• Brimonidine tartrate 0.5%: Specifically reduces persistent facial erythema 3, 4

Oral Treatments

• Doxycycline: Effective for moderate to severe inflammatory lesions, ocular rosacea, and clinically inflamed phyma 1
  • Available as standard doses (≥50mg) with antibiotic activity or as 40mg modified-release with anti-inflammatory but not antibiotic activity 1
• Isotretinoin: Reserved for severe papulopustular rosacea 1, 6

Common Pitfalls and Caveats

• Insufficient treatment duration is a common mistake; studies shorter than 8 weeks may inadequately demonstrate efficacy 1
• Ocular rosacea is often overlooked but requires specific management 1, 4
• Topical corticosteroids should be avoided as they can worsen rosacea or cause steroid rosacea 8
• Without maintenance therapy, up to two-thirds of patients may relapse 2
• Patients with dark complexions should report abnormal changes in skin color when using azelaic acid 7

Special Considerations

• Moderate and severe presentations typically require combination therapy rather than monotherapy 1
• If first-line treatment fails, consider an alternative first-line option or add another first-line agent 1
• Referral to specialists is necessary for severe or recalcitrant rosacea, phymatous changes, or ocular rosacea with ophthalmic complications 5