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

Treatment Algorithm by Clinical Feature

For Inflammatory Papules/Pustules

Mild presentations:

• Topical ivermectin 1% cream or azelaic acid 15% gel/foam are first-line options 1, 2
• Topical metronidazole is an alternative first-line choice 1
• Newly FDA-approved encapsulated benzoyl peroxide 5% shows rapid improvement by week 2 with sustained efficacy up to 52 weeks 2

Moderate presentations:

• Combine topical agents (ivermectin or azelaic acid) with oral doxycycline 40 mg modified-release daily 1, 2
• Topical minocycline foam 1.5% is effective for moderate to severe inflammatory lesions 2

Severe presentations:

• Oral doxycycline 40 mg modified-release combined with topical ivermectin 1, 2
• Oral isotretinoin for refractory cases 1

For Persistent Erythema

First-line treatment:

• Topical brimonidine (α-adrenergic agonist) is the primary recommendation 1, 2
• Topical oxymetazoline is an alternative option 2

Additional options:

• Intense pulsed light (IPL) therapy 1
• Oral beta blockers (e.g., carvedilol) for refractory cases, though evidence is limited 2
• Pulsed-dye laser (PDL) 1

For Transient Erythema (Flushing)

• Topical α-adrenergics 1
• Oral beta blockers 1
• PDL therapy 1

Note: Evidence for flushing treatments is based primarily on case reports and clinical experience rather than high-quality RCTs 1

For Telangiectasia

• Electrodessication, IPL, or laser therapy are the primary treatments 1
• Physical modalities are preferred over pharmaceutical agents for this feature 1

For Phymatous Changes

Clinically inflamed (active) phyma:

• Oral doxycycline 40 mg modified-release 1, 2

Clinically noninflamed (fibrotic) phyma:

• Physical modalities including laser therapy or surgical intervention 1

For Ocular Rosacea

Mild symptoms:

• Lid hygiene and artificial tears 1, 2
• These can be managed without ophthalmology referral if symptoms are minimal and not bothersome to the patient 1

Moderate to severe symptoms:

• Oral doxycycline 40 mg modified-release daily 2
• Ophthalmology referral is recommended for all but the mildest cases 1
• Continue lid hygiene and artificial tears as adjunctive therapy 2

Combination Therapy Approach

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

• Moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals) 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

Treatment Duration and Maintenance

Initial therapy duration:

• Allow 6-12 weeks before declaring treatment failure 2
• Topical agents require 6-8 weeks for adequate assessment 2
• Oral agents require 8-12 weeks for adequate assessment 2

Maintenance therapy:

• Use the minimum treatment necessary to maintain control 2
• 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

Essential General Skincare Measures

All patients require baseline skincare regardless of specific treatments: 1, 2

• Broad-spectrum sunscreen with SPF 30 or higher 1, 2
• Gentle cleansers that do not irritate the skin 1, 2
• Moisturizers appropriate for sensitive skin 1, 2
• Trigger factor avoidance (spicy foods, alcohol, extreme temperatures, hot beverages) 2

Critical Pitfalls to Avoid

Insufficient treatment duration:

• Many clinicians switch therapies too quickly; most rosacea treatments require 6-12 weeks to demonstrate full efficacy 2

Treating by subtype rather than phenotype:

• The traditional subtype approach fails to address the full spectrum of presenting features in individual patients 1
• Target the specific features present and those most bothersome to the patient 1, 2

Neglecting maintenance therapy:

• Discontinuing treatment after initial improvement leads to relapse in up to two-thirds of patients 2

Missing ocular involvement:

• Ocular rosacea is frequently underdiagnosed and undertreated 2
• Ask specifically about eye symptoms including burning, stinging, foreign body sensation, photophobia, and blurred vision 1

Using occlusive dressings:

• Patients should avoid occlusive dressings or wrappings when using topical azelaic acid 3

Inadequate patient education:

• Patients must understand that rosacea is a chronic condition requiring long-term management, not a curable disease 2