Is paroxetine (Paxil) used to treat rosacea?

Paroxetine for Rosacea Treatment

Paroxetine 25 mg daily is an effective treatment option specifically for moderate-to-severe refractory erythema and flushing in rosacea patients who have failed standard therapies, but it is not included in first-line treatment guidelines. 1

Evidence for Paroxetine Use

The strongest evidence comes from a 2023 multicenter, randomized, double-blind, placebo-controlled trial that specifically evaluated paroxetine for refractory rosacea erythema. 1 This study demonstrated:

• 42.9% of patients achieved Clinical Erythema Assessment success (defined as score of 0,1, or ≥2-grade improvement) compared to 20.8% with placebo (P = 0.02) 1
• 44.9% achieved flushing success (≥2 point reduction) versus 25.0% with placebo (P = 0.04) 1
• Significant improvement in burning sensation (46.9% vs 18.8%, P = 0.003) 1
• Additional benefit of improving depression symptoms (P = 0.041) 1

Position in Treatment Algorithm

Paroxetine is not mentioned in current international treatment guidelines as a first-line or even alternative therapy. 2, 3 The British Journal of Dermatology consensus guidelines recommend the following for erythema instead:

• First-line for persistent erythema: topical α-adrenergics (brimonidine) or oral beta blockers (carvedilol) 2
• Topical oxymetazoline as an alternative 3

When to Consider Paroxetine

Paroxetine should be reserved for patients with:

• Moderate-to-severe erythema and flushing that has failed standard topical therapies (brimonidine, oxymetazoline) 1
• Refractory cases not responding to oral beta blockers 1
• Concurrent depression or anxiety, where dual benefit may be achieved 1

Dosing and Duration

• Dose: 25 mg daily 1
• Duration evaluated: 12 weeks 1
• Efficacy becomes apparent within this timeframe 1

Safety Profile

Common adverse events include:

• Dizziness 1
• Lethargy 1
• Nausea 1
• Dyspepsia 1
• Muscle tremors 1

The medication was generally well-tolerated in the trial population. 1

Clinical Caveats

• Paroxetine is not a guideline-recommended therapy and represents off-label use 2, 3
• Only a single dosage regimen (25 mg) has been studied in a controlled trial 1
• The evidence base consists of one high-quality RCT, which is limited compared to established therapies 1
• Standard first-line therapies should be exhausted before considering paroxetine 2, 3
• Consider psychiatric consultation if using primarily for rosacea rather than comorbid mood disorder, given the medication class 1