What is the treatment for Rosacea?

Treatment of Rosacea

Rosacea treatment should follow a phenotype-based approach targeting specific clinical features (erythema, papules/pustules, telangiectasia, phyma) rather than traditional subtypes, with topical ivermectin 1% cream or azelaic acid 15% as first-line therapy for inflammatory lesions, topical brimonidine for persistent erythema, and combination therapy for moderate-to-severe presentations. 1, 2

Foundation: General Skincare for All Patients

All rosacea patients require baseline skincare measures regardless of phenotype 1, 2:

• Sun protection with SPF 30+ daily 1, 2
• Gentle, non-medicated cleansers and moisturizers 2, 3
• Trigger avoidance (spicy foods, alcohol, extreme temperatures, though RCT evidence is limited) 2, 3

Treatment Algorithm by Clinical Phenotype

Inflammatory Papules/Pustules

Mild Disease:

• First-line: Topical ivermectin 1% cream once daily (84.9% achieve "clear/almost clear" vs 75.4% with metronidazole, with longer remission periods) 2, 3
• Alternative: Topical azelaic acid 15% gel/foam 1, 2
• Alternative: Topical metronidazole 0.75-1.0% (both strengths equally effective once daily) 1, 3
• Newest option: Encapsulated benzoyl peroxide 5% (FDA-approved, shows rapid improvement by week 2, sustained efficacy to 52 weeks) 2, 3

Moderate Disease:

• Combination therapy: Topical agent (ivermectin or azelaic acid) PLUS oral doxycycline 40 mg modified-release daily 1, 2
• Alternative: Topical minocycline foam 1.5% for moderate-to-severe inflammatory lesions 2

Severe Disease:

• Topical ivermectin PLUS oral doxycycline 2
• Oral isotretinoin for refractory cases (very low-dose shows 91% clearance/excellent response) 2

Persistent Erythema

• First-line: Topical brimonidine tartrate 0.33% gel once daily (maximal vasoconstriction 3-6 hours post-application) 1, 2, 3
• Alternative: Topical oxymetazoline HCl 1% cream once daily 2, 3
• Caveat: Brimonidine causes paradoxical erythema in 10-20% of patients 3

Transient Erythema/Flushing

• Topical α-adrenergics 1
• Oral beta blockers (e.g., carvedilol, though evidence is limited) 1, 2
• Pulsed-dye laser (PDL) 1
• Note: No high-quality evidence exists for flushing treatments; recommendations based on case reports and clinical experience 1

Telangiectasia

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

Phymatous Changes

Clinically Inflamed ("Active"):

• Oral doxycycline 40 mg modified-release 1, 2

Clinically Noninflamed ("Fibrotic" or "Burnt Out"):

• Physical modalities (laser therapy, surgical resurfacing, dermabrasion) 1

Ocular Rosacea Management

Mild Symptoms:

• Lid hygiene measures 2, 3
• Artificial tear substitutes for burning/stinging 1

Moderate-to-Severe Symptoms:

• Oral doxycycline 40 mg modified-release daily 2, 3
• Ophthalmology referral for symptoms not controlled with lid hygiene 1, 2

Treatment Duration and Failure Management

• Allow 6-8 weeks for topical agents, 8-12 weeks for oral agents before declaring treatment failure 2
• If first-line treatment fails: Switch to an alternative first-line option OR add an additional first-line agent 1, 2
• Moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals) 1, 2

Maintenance Therapy

• Use minimum treatment necessary to maintain control 1, 2
• Without maintenance, up to two-thirds of patients relapse when treatment is discontinued 2, 3
• Long-term maintenance with topical agents is essential to prevent relapses 2, 3

Special Population: Pediatric Rosacea

• Mild disease: Topical metronidazole 0.75-1.0% or azelaic acid 4
• Moderate-to-severe or ocular involvement: Topical agent PLUS oral erythromycin (tetracyclines contraindicated under age 8 due to permanent tooth staining) 4
• Critical: Ocular symptoms often precede cutaneous manifestations in children and can cause sight-threatening complications 4

Key Clinical Pitfalls to Avoid

• Insufficient treatment duration leads to premature treatment switching (many studies evaluate treatments for <8 weeks, which is inadequate) 2
• Treating based on traditional subtypes rather than phenotypes misses the full spectrum of presenting features 2
• Overlooking maintenance therapy results in high relapse rates 2, 3
• Ignoring ocular manifestations leads to underdiagnosis and potential vision loss 2, 4
• Using tetracyclines in children under 8 years causes permanent tooth staining 4
• Extrapolating acne treatment protocols to rosacea is inappropriate due to fundamentally different pathophysiology 2
• Up to 89% of patients discontinue therapy within a month due to treatment-related adverse effects, emphasizing the importance of tolerability 3