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
Foundation: General Skincare Measures
All patients with rosacea require baseline skincare regardless of phenotype 1, 2:
- Use broad-spectrum sunscreen with SPF 30 or higher daily 1, 2
- Apply gentle cleansers and moisturizers to avoid irritating sensitive skin 1, 2
- Avoid identified trigger factors (spicy foods, alcohol, extreme temperatures, hot beverages) though RCT evidence for this is limited 2
First-Line Treatments by Phenotype
Inflammatory Papules/Pustules
Mild presentations:
- Topical ivermectin 1% cream is the preferred first-line agent 2
- Topical azelaic acid 15% gel/foam is an effective alternative 1, 2
- Encapsulated benzoyl peroxide 5% shows rapid improvement by week 2 with sustained efficacy up to 52 weeks 2
- Topical metronidazole is another established option 1, 3
Moderate presentations:
- Combine topical agents (ivermectin or azelaic acid) with oral doxycycline 40 mg modified-release daily 1, 2
- Topical minocycline foam 1.5% can be used for moderate to severe inflammatory lesions 2
Severe presentations:
- Oral doxycycline 40 mg modified-release combined with topical ivermectin or azelaic acid 1, 2
- Oral isotretinoin for severe or recalcitrant cases 1, 4
Persistent Erythema
- Topical brimonidine (α-adrenergic agonist) is first-line for persistent centrofacial erythema 1, 2, 3
- Topical oxymetazoline is an alternative α-adrenergic option 2, 5
- Oral beta blockers (carvedilol) may be considered, though evidence is limited 2
- Intense pulsed light (IPL) or pulsed-dye laser (PDL) for refractory cases 1, 5
Transient Erythema (Flushing)
- Topical α-adrenergics (brimonidine) 1
- Oral beta blockers 1
- Pulsed-dye laser 1
- Note: Evidence for flushing treatments is based primarily on case reports and clinical experience rather than high-quality RCTs 1
Telangiectasia
Phymatous Changes
Clinically inflamed (active):
Clinically noninflamed (fibrotic/burnt out):
Ocular Rosacea
Mild symptoms:
Moderate to severe:
- Oral doxycycline 40 mg modified-release daily 2, 3
- Topical cyclosporine 3
- Ophthalmology referral for all but the mildest cases 1, 2
Treatment Duration and Response Assessment
- Allow 6-8 weeks for topical agents before declaring treatment failure 2
- Allow 8-12 weeks for oral agents before declaring treatment failure 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
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 (topical plus systemic or multiple topicals) 1, 2
- Mild presentations may be treated with monotherapy, though opinion is divided on this approach 1
Maintenance Therapy
- Use the minimum treatment necessary to maintain control 1, 2
- Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 2
- The approach depends on treatment modality and patient preference for ongoing therapy 1
Critical Pitfalls to Avoid
- Do not treat based on traditional subtypes alone—this fails to address the full spectrum of presenting features that may overlap across subtypes 1
- Do not discontinue treatment prematurely—insufficient treatment duration (less than 6-12 weeks depending on agent) leads to inadequate demonstration of efficacy 2
- Do not overlook ocular manifestations—ocular rosacea is underdiagnosed and undertreated, yet can cause significant morbidity 2
- Do not forget maintenance therapy—relapse rates are high without ongoing treatment 2
- Avoid occlusive dressings when using topical agents like azelaic acid 6
- Warn patients with dark complexions to report abnormal skin color changes when using azelaic acid 6