What are the treatment options for rosacea?

Treatment Options for Rosacea

Treat rosacea with a phenotype-directed approach using topical ivermectin 1% cream as first-line therapy for inflammatory papules/pustules, topical brimonidine or oxymetazoline for persistent erythema, and add oral doxycycline 40mg modified-release for moderate-to-severe disease. 1

Foundation: General Skincare for All Patients

Every rosacea patient requires baseline protective measures regardless of phenotype:

• Use broad-spectrum sunscreen SPF 30+ daily 2
• Apply gentle cleansers and moisturizers to reduce transepidermal water loss 2
• Identify and avoid personal triggers including spicy foods, alcohol, and extreme temperatures 1

These measures are not optional—they form the foundation upon which all pharmacologic therapy is built 2.

Treatment Algorithm by Phenotype

Inflammatory Papules/Pustules

Mild Disease:

• Start with topical ivermectin 1% cream once daily as the most effective first-line option, achieving 84.9% "clear" or "almost clear" ratings versus 75.4% with metronidazole 1
• Alternative first-line agents include topical azelaic acid 15% gel/foam 1 or topical metronidazole 0.75-1.0% once daily 1
• Encapsulated benzoyl peroxide 5% (E-BPO) is the newest FDA-approved option showing rapid improvement by week 2 with sustained efficacy up to 52 weeks and excellent tolerability 2, 1

Moderate-to-Severe Disease:

• Combine topical ivermectin 1% cream with oral doxycycline 40mg modified-release daily for faster disease control 1
• The 40mg modified-release formulation provides anti-inflammatory (not antibiotic) activity, reducing concerns about antibiotic resistance 2
• Minocycline foam 1.5% is FDA-approved for moderate-to-severe inflammatory lesions 1

Critical timing consideration: Expect improvement within 3-4 weeks for most topical treatments 1. Allow sufficient treatment duration (6-12 weeks depending on agent) before declaring failure 2.

Persistent Facial Erythema

• Topical brimonidine tartrate 0.33% gel once daily provides rapid vasoconstriction with maximal effects between 3-6 hours post-application 1
• Topical oxymetazoline HCl 1% cream once daily serves as an alternative α1-receptor agonist 1
• Oral doxycycline can be considered for persistent erythema across all severities 2

Important caveat: Brimonidine causes paradoxical erythema in 10-20% of patients—warn patients about this possibility 1.

Telangiectasia

• Electrodessication, intense pulsed light (IPL), or lasers are the primary treatment modalities 2
• Physical modalities are preferred over pharmacologic options for this phenotype 2

Phymatous Changes

Clinically Inflamed (Active):

• Oral doxycycline as first-line therapy 2

Clinically Non-inflamed (Fibrotic/Burnt Out):

• Physical modalities including laser therapy, dermabrasion, or surgical resurfacing 2

Ocular Rosacea

• Lid hygiene for very mild cases that don't bother the patient 2
• Artificial tear substitutes for mild burning/stinging 2
• Refer to ophthalmology for severity beyond lid hygiene control 2
• Oral doxycycline for moderate-to-severe ocular involvement 2

Combination Therapy Strategy

Multiple cutaneous features can and should be treated simultaneously 2. The ROSCO panel reached unanimous consensus (15 of 15) on this approach 2.

• Moderate and severe presentations require combination treatments including general skincare, physical modalities, and pharmaceutical agents 2
• If first-line treatment fails, either switch to an alternative first-line option or add an additional first-line agent 2

The exception is telangiectasia, where expert opinion remains divided on monotherapy versus combination therapy 2.

Maintenance Therapy: The Critical Component

Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 1. This is perhaps the most important counseling point for patients.

• Use the minimum treatment necessary to maintain control 2, 1
• Long-term maintenance with topical agents is recommended to prevent relapses 1
• Ivermectin 1% cream provides more durable response with longer time until relapse compared to metronidazole 1
• E-BPO 5% maintained similar safety profile for up to 52 weeks, making it suitable for long-term use 1

Common Pitfalls to Avoid

Adherence failure: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within one month 1. Set realistic expectations about tolerability and have backup options ready.

Premature treatment switching: Allow 6-12 weeks before declaring treatment failure, depending on whether the agent is topical (shorter) or oral (longer duration) 2.

Ignoring the phenotype: Treatment must be tailored to the specific signs and symptoms the patient presents with and finds most troubling 2. A one-size-fits-all approach fails in rosacea management.

Stopping treatment too soon: The chronic relapsing nature of rosacea demands long-term maintenance strategies 2, 1.