What are the treatment options for managing rosacea?

Management of Rosacea

Rosacea management should follow a phenotype-based approach, with topical ivermectin 1% cream as the preferred first-line treatment for inflammatory papules/pustules, topical brimonidine for persistent erythema, and combination therapy reserved for moderate-to-severe presentations. 1, 2

Treatment Algorithm by Clinical Phenotype

Inflammatory Papules/Pustules

Mild Disease:

• Topical ivermectin 1% cream once daily is the most effective first-line option, demonstrating 84.9% of patients achieving "clear" or "almost clear" ratings compared to 75.4% with metronidazole, with superior remission periods 1, 2
• Alternative first-line agents include topical azelaic acid 15% gel/foam twice daily 1, 3 or topical metronidazole 0.75-1% 2
• Encapsulated benzoyl peroxide 5% (E-BPO 5%) offers rapid improvement by week 2 with sustained efficacy up to 52 weeks and excellent tolerability 4, 1, 2

Moderate-to-Severe Disease:

• Combine topical ivermectin 1% cream with oral doxycycline 40 mg modified-release daily for faster control 2
• Topical minocycline foam 1.5% is FDA-approved for moderate-to-severe inflammatory lesions 1, 2
• Oral doxycycline can be used across all severities; the 40 mg modified-release formulation has anti-inflammatory (not antibiotic) activity with reduced gastrointestinal side effects 4

Persistent Erythema

• Topical brimonidine tartrate 0.33% gel once daily is first-line, providing rapid vasoconstriction with maximal effects between 3-6 hours post-application 1, 2
• Topical oxymetazoline HCl 1% cream once daily is an alternative α1-receptor agonist 1, 2
• Caution: Brimonidine causes paradoxical erythema in 10-20% of patients 2
• Oral beta blockers (specifically carvedilol) may be considered based on clinical experience, though evidence is limited 4

Telangiectasia

• Laser and light-based therapies are primary treatment: pulsed-dye laser, intense pulsed light, or potassium-titanyl-phosphate laser 5, 6
• Opinion remains divided on whether monotherapy or combination therapy is optimal at any severity level 4

Phymatous Changes

• Clinically inflamed ("active") phyma: Oral doxycycline can be considered 4
• Clinically noninflamed ("fibrotic" or "burnt out") phyma: Laser therapy, electrosurgery, dermabrasion, or surgical resurfacing 7, 8

Ocular Rosacea

• Mild symptoms: Lid hygiene and artificial tears 1, 2
• Moderate-to-severe symptoms: Oral doxycycline 1, 2
• Ophthalmological referral should be considered for all but the mildest features 4, 1

Combination Therapy Principles

• Multiple cutaneous features can and should be treated simultaneously with more than one agent 4, 1, 2
• Moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals) 4, 1, 2
• If first-line treatment fails, either switch to an alternative first-line option or add an additional first-line agent 4, 1

Treatment Duration and Maintenance

• Allow 6-12 weeks for initial therapy before declaring failure: topical agents require shorter duration (6-8 weeks), oral agents longer (8-12 weeks) 4
• Improvement typically occurs within 3-4 weeks for most topical treatments 2
• Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 1, 2
• Use the minimum treatment necessary to maintain control long-term 4, 1

Essential Adjunctive Measures

• General skincare underlies all treatment approaches: gentle cleansers, moisturizers, and sun protection (SPF 30+) 4, 1, 2
• Trigger factor avoidance (spicy foods, alcohol, extreme temperatures) is essential, though RCT evidence is limited 4, 1, 2
• Patient education regarding chronic nature and need for long-term management 4

Critical Pitfalls to Avoid

• Insufficient treatment duration: Many studies evaluate treatments for less than 8 weeks, which is inadequate to demonstrate efficacy 4, 1
• Treating based on traditional subtypes rather than phenotypes leads to inadequate management of the full spectrum of presenting features 1
• Overlooking maintenance therapy: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month 2
• Ignoring ocular manifestations leads to underdiagnosis and undertreatment 1
• Applying azelaic acid to broken or inflamed skin: Temporary irritation (pruritus, burning, stinging) may occur due to low pH; if this persists, apply once daily or discontinue until subsided 3