What is the recommended treatment for rosacea?

Rosacea Treatment

Treat rosacea using a phenotype-based approach that targets the specific clinical features present in each patient, rather than relying on traditional subtype classification. 1, 2

Foundation: General Skincare Measures

All patients with rosacea require baseline skincare regardless of specific features 1, 2:

• Use broad-spectrum sunscreen with SPF 30 or higher daily 1, 2
• Apply gentle cleansers and moisturizers 1, 2
• Avoid identified trigger factors (though RCT evidence for this is limited) 2

Treatment Algorithm by Clinical Feature

For Inflammatory Papules/Pustules

Mild presentations:

• First-line: Topical ivermectin 1% cream 2
• Alternative first-line: Topical azelaic acid 15% gel/foam 1, 2
• Newer option: Encapsulated benzoyl peroxide 5% (shows rapid improvement by week 2) 2

Moderate presentations:

• Topical ivermectin 1% cream OR azelaic acid 15% 1
• Consider adding topical minocycline foam 1.5% 2

Severe presentations:

• Topical ivermectin 1% cream PLUS oral doxycycline 1
• Alternative: Oral isotretinoin for severe or recalcitrant cases 1, 3

For Persistent Erythema

First-line options:

• Topical brimonidine (α-adrenergic agonist) 1, 2
• Alternative: Topical oxymetazoline 2

Additional options for moderate to severe:

• Intense pulsed light (IPL) 1
• Oral doxycycline 1

For Transient Erythema (Flushing)

Treatment options (note: limited high-quality evidence exists) 1:

• Topical α-adrenergics 1
• Oral beta blockers 1
• Pulsed-dye laser (PDL) 1

For Telangiectasia

Primary treatments:

• Electrodesiccation 1
• Intense pulsed light (IPL) 1
• Lasers 1

For Phymatous Changes

Clinically inflamed (active) phyma:

• Oral doxycycline 1

Clinically noninflamed (fibrotic/burnt out) phyma:

• Physical modalities (surgical interventions, laser therapy) 1, 3

For Ocular Rosacea

Mild symptoms:

• Lid hygiene measures 1, 2
• Artificial tears 1, 2

Moderate to severe symptoms:

• Oral doxycycline 2, 4
• Topical cyclosporine 4
• Ophthalmological referral for all but the mildest cases 1, 2

Combination Therapy Approach

Multiple cutaneous features can and should be treated simultaneously with multiple agents 1, 2:

• Moderate and severe presentations typically require combination treatments 1, 2
• If first-line treatment fails after adequate duration, either switch to an alternative first-line option OR add an additional first-line agent 1, 2

Maintenance Therapy

Use the minimum treatment necessary to maintain control 2:

• Up to two-thirds of patients relapse when treatment is discontinued 2
• Maintenance approach depends on treatment modality and patient preference 1, 2
• Continue treatments for sufficient duration before switching (duration is treatment-specific) 1

Critical Pitfalls to Avoid

Insufficient treatment duration: Many rosacea treatment studies last less than 8 weeks, which may be inadequate to demonstrate full efficacy 2. Give treatments adequate time before declaring failure.

Treating by subtype rather than phenotype: The traditional subtype approach fails to address the full spectrum of presenting features 1, 2. Always identify and treat each specific feature present.

Overlooking ocular manifestations: Ocular rosacea is frequently underdiagnosed and undertreated 2. Specifically ask about eye symptoms including burning, foreign body sensation, photophobia, tearing, and blurred vision 1.

Discontinuing maintenance therapy prematurely: Without ongoing maintenance, most patients will relapse 2. Plan for long-term management from the outset.

Applying azelaic acid to broken or inflamed skin: Due to its low pH, temporary irritation (pruritus, burning, stinging) commonly occurs when applied to broken skin 5. If severe irritation develops, reduce to once-daily application or temporarily discontinue 5.