What are the treatment options for rosacea?

Rosacea Treatment

Treat rosacea using a phenotype-based approach targeting individual clinical features rather than traditional subtypes, with topical ivermectin 1% or azelaic acid 15% as first-line for inflammatory lesions, topical brimonidine or oxymetazoline for persistent erythema, and combination therapy for moderate-to-severe presentations. 1

Treatment Algorithm by Clinical Feature

Inflammatory Papules and Pustules

Mild Disease:

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

Moderate Disease:

• Topical azelaic acid 15% 1
• Topical ivermectin 1% 1
• Oral doxycycline 40 mg modified-release daily (anti-inflammatory dose with reduced GI side effects) 1, 2
• Topical minocycline foam 1.5% for moderate-to-severe inflammatory lesions 2

Severe Disease:

• Topical ivermectin 1% 1
• Oral doxycycline 40 mg modified-release 1, 2
• Oral isotretinoin (for refractory cases) 1, 2

Persistent Erythema

• Topical brimonidine (α-adrenergic, first-line) 1, 2
• Topical oxymetazoline (alternative) 2
• Intense pulsed light (IPL) 1
• Oral beta blockers such as carvedilol (limited evidence) 2

Transient Erythema/Flushing

• Topical α-adrenergics 1
• Oral beta blockers 1, 2
• Pulsed-dye laser (PDL) 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 Non-inflamed ("Fibrotic" or "Burnt Out"):

• Physical modalities (surgical intervention) 1

Ocular Rosacea

Mild Symptoms:

• Lid hygiene 1, 2
• Artificial tears 1, 2
• No ophthalmology referral needed for very mild cases that don't bother the patient 1

Moderate to Severe:

• Oral doxycycline 40 mg modified-release 2
• Ophthalmological referral for all but the mildest features 1, 2
• Dermatologists should recognize blepharitis, blurred vision, foreign body sensation, interpalpebral bulbar hyperemia, photophobia, redness, tearing, and telangiectasia as ocular features requiring referral 1

Combination Therapy Approach

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

Treatment Duration and Maintenance

Initial Treatment Duration:

• Allow 6-8 weeks for topical agents before declaring failure 2
• Allow 8-12 weeks for oral agents before declaring failure 2
• Treatments should be used for sufficient duration specific to each modality before switching 1

Maintenance Therapy:

• Use the minimum treatment necessary to maintain control 1, 2
• Up to two-thirds of patients relapse when treatment is discontinued 2
• Maintenance approach depends on treatment modality and patient desire for ongoing therapy 1, 2

Essential General Skincare Measures

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

• Sun protection with SPF 30+ daily 1, 2
• Gentle, non-medicated cleansers 1, 2
• Moisturizers 1, 2
• Trigger factor avoidance (spicy foods, alcohol, extreme temperatures) 2

Critical Pitfalls to Avoid

Insufficient Treatment Duration:

• Many clinicians switch therapies too early; topical agents need 6-8 weeks and oral agents need 8-12 weeks to demonstrate full efficacy 2

Subtype-Based Rather Than Phenotype-Based Treatment:

• The traditional subtype approach fails to address the full spectrum of presenting features in individual patients 1, 2
• Treating specific phenotypic features (erythema, papules/pustules, telangiectasia) yields better outcomes 1

Neglecting Maintenance Therapy:

• Without ongoing maintenance, up to two-thirds of patients relapse 2
• The chronic nature of rosacea requires long-term management strategies 2

Overlooking Ocular Manifestations:

• Ocular rosacea is commonly underdiagnosed and undertreated 2
• Systematically assess for ocular symptoms in all rosacea patients 1

Extrapolating Acne Treatment Protocols:

• Rosacea represents fundamentally different pathophysiology from acne 2
• Topical retinoids are notably absent from the Global Rosacea Consensus treatment algorithm 2