What is the efficacy of Metronidazole (Flagyl) 0.57% topical cream in treating Rosacea?

From the Guidelines

Metronidazole 0.57% cream is not the recommended concentration for treating rosacea, as the most effective concentrations are 0.75% and 1.0%. The standard regimen for metronidazole in treating rosacea typically involves applying a thin layer to clean, dry skin in the morning and evening for 8-12 weeks, though many patients require ongoing maintenance therapy 1. Improvement is usually seen within 3-6 weeks of consistent use. This medication works by reducing inflammation and possibly by decreasing reactive oxygen species that contribute to rosacea symptoms. It also has antimicrobial properties that may help control Demodex mites, which are implicated in some cases of rosacea.

Key Points to Consider

• Metronidazole 0.75% and 1.0% formulations have been well studied in more than 500 patients and have shown to be effective in reducing inflammatory lesions and perilesional erythema associated with rosacea 1.
• A 9-week split-face study demonstrated a 65% decrease in inflammatory lesion counts with metronidazole 0.75% compared to a 15% reduction with vehicle 1.
• The Global Rosacea Consensus (ROSco) panel recommends metronidazole as a first-line treatment for inflammatory papules/pustules, along with other options such as azelaic acid and ivermectin 1.
• Patients should avoid triggers like spicy foods, alcohol, extreme temperatures, and sun exposure, and should use gentle cleansers and broad-spectrum sunscreen daily for optimal results.
• If symptoms don't improve after 12 weeks or worsen during treatment, patients should consult their healthcare provider for alternative options.

Treatment Recommendations

• Apply metronidazole 0.75% or 1.0% cream to affected areas of the face once or twice daily.
• Use gentle cleansers and broad-spectrum sunscreen daily.
• Avoid triggers like spicy foods, alcohol, extreme temperatures, and sun exposure.
• Consider alternative options if symptoms don't improve after 12 weeks or worsen during treatment.

From the Research

Metronidazole 0.57% Cream for Rosacea

• The effectiveness of metronidazole in treating rosacea has been demonstrated in several studies 2, 3, 4, 5, 6.
• Metronidazole is thought to reduce inflammation associated with rosacea by inhibiting the production of reactive oxygen species produced by neutrophils 2.
• Topical metronidazole has been used for the treatment of rosacea for over 30 years and has been shown to be effective in preventing relapses of the disease 3.
• The goals of therapy for rosacea include reduction of papules, pustules, erythema, physical discomfort, and improvement in quality of life, which can be achieved with metronidazole treatment 4.
• Metronidazole is considered a standard topical treatment agent for rosacea, along with azelaic acid and sodium sulfacetamide-sulfur 4, 5, 6.
• A Cochrane review found that topical metronidazole, azelaic acid, and oral doxycycline (40 mg) had some evidence to support their effectiveness in moderate to severe rosacea 5, 6.
• However, it is worth noting that the majority of studies on rosacea treatments are at high or unclear risk of bias, and further well-designed, adequately-powered randomised controlled trials are required 5, 6.
• The specific concentration of 0.57% metronidazole cream is not mentioned in the provided studies, but metronidazole creams with concentrations of 0.75% and 1% have been shown to be effective in treating rosacea 2, 3.