What are the treatment options for rosacea?

Treatment of Rosacea

Treat rosacea using a phenotype-based approach targeting specific clinical features rather than traditional subtypes, with topical ivermectin 1% cream as the most effective first-line agent for inflammatory papules/pustules and topical brimonidine or oxymetazoline for persistent erythema. 1, 2

Foundation: General Skincare for All Patients

Every rosacea patient requires baseline protective measures regardless of phenotype:

• Apply broad-spectrum sunscreen SPF 30+ daily 1, 3
• Use gentle, non-medicated cleansers and moisturizers to reduce transepidermal water loss 1, 3
• Identify and avoid personal triggers (spicy foods, alcohol, extreme temperatures, hot beverages) 2, 3

Treatment Algorithm by Clinical Phenotype

Inflammatory Papules and Pustules

Mild Disease:

• First-line: Topical ivermectin 1% cream once daily - superior efficacy with 84.9% achieving "clear/almost clear" versus 75.4% with metronidazole, plus longer remission periods 2
• Alternative first-line options:
  • Topical azelaic acid 15% gel/foam 1, 2
  • Topical metronidazole 0.75-1% once daily 1, 2
  • Encapsulated benzoyl peroxide 5% (E-BPO) - newest FDA-approved option showing rapid improvement by week 2 with sustained efficacy up to 52 weeks and excellent tolerability 1, 2

Moderate Disease:

• Combination therapy: Topical ivermectin 1% cream PLUS oral doxycycline 40 mg modified-release daily 1, 2
• Alternative topical options include azelaic acid or E-BPO 5% combined with oral doxycycline 1

Severe Disease:

• Topical ivermectin PLUS oral doxycycline 40 mg 1
• Consider oral isotretinoin for refractory cases (very low-dose isotretinoin shows 91% clearance in severe cases) 3

Persistent Erythema

• First-line: Topical brimonidine tartrate 0.33% gel once daily - provides rapid vasoconstriction with maximal effects 3-6 hours post-application 1, 2
• Alternative: Topical oxymetazoline HCl 1% cream once daily 1, 2
• Caveat: Brimonidine causes paradoxical erythema in 10-20% of patients - discontinue if this occurs 2

Transient Erythema/Flushing

• Topical α-adrenergics 1
• Oral beta-blockers (e.g., carvedilol) - limited evidence but consensus-supported 1, 3
• Pulsed-dye laser (PDL) for refractory cases 1

Telangiectasia

• Electrodessication 1
• Intense pulsed light (IPL) 1
• Lasers (pulsed-dye laser, potassium-titanyl-phosphate) 1

Phymatous Rosacea

Clinically Inflamed ("Active"):

• Oral doxycycline 40 mg modified-release 1, 3

Clinically Non-Inflamed ("Fibrotic/Burnt Out"):

• Physical modalities (dermatosurgical procedures, laser ablation) 1

Ocular Rosacea

Mild (burning/stinging only):

• Lid hygiene and artificial tear substitutes 1, 3

Moderate to Severe:

• Oral doxycycline 40 mg modified-release daily 1, 3
• Refer to ophthalmology for features beyond mild symptoms (blepharitis, blurred vision, foreign body sensation, photophobia) 1, 3

Critical Treatment Principles

Combination Therapy

• Multiple cutaneous features can and should be treated simultaneously with more than one agent 1, 3
• Moderate and severe presentations require combination treatments (topical plus systemic or multiple topicals) 1, 3
• If first-line treatment fails after adequate trial, either switch to alternative first-line option OR add additional first-line agent 1, 3

Treatment Duration and Response

• Allow 6-8 weeks for topical agents before declaring failure 3
• Allow 8-12 weeks for oral agents before declaring failure 3
• Most topical treatments show improvement within 3-4 weeks 2
• E-BPO 5% demonstrates efficacy as early as week 2 1, 2

Maintenance Therapy

• Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 2, 3
• Use minimum treatment necessary to maintain control 1, 3
• Long-term maintenance with topical agents is recommended to prevent relapses 2
• Ivermectin 1% cream provides more durable response with longer time until relapse compared to metronidazole 2

Common Pitfalls to Avoid

• Do not treat based on traditional subtypes - use phenotype-based approach targeting specific presenting features 3
• Do not discontinue treatment prematurely - insufficient treatment duration (less than 6-8 weeks) leads to inadequate demonstration of efficacy 3
• Do not overlook ocular manifestations - screen all patients for ocular symptoms as this leads to underdiagnosis and undertreatment 3
• Do not ignore maintenance therapy - this is the most common cause of relapse 2, 3
• Monitor for paradoxical erythema with brimonidine - occurs in 10-20% and requires discontinuation 2
• Recognize that up to 89% of patients discontinue therapy within a month if they experience treatment-related adverse effects - emphasize tolerability and set realistic expectations 2