What are the treatment options for rosacea?

Rosacea Treatment

Treat rosacea using a phenotype-based approach that targets specific presenting features rather than traditional subtypes, with first-line topical agents for mild disease and combination therapy for moderate-to-severe presentations. 1

Treatment Algorithm by Phenotype

Inflammatory Papules/Pustules

Mild Disease:

• Start with topical ivermectin 1% cream as the preferred first-line agent 2, 3
• Alternative first-line options include azelaic acid 15% gel/foam or the newly FDA-approved encapsulated benzoyl peroxide 5% (E-BPO 5%), which shows rapid improvement by week 2 2, 3
• Topical metronidazole is also effective but demonstrates inferior efficacy compared to ivermectin (73.7% vs 83% lesion reduction at 16 weeks) 3

Moderate-to-Severe Disease:

• Use combination therapy with oral doxycycline 40 mg modified-release daily PLUS a topical agent (ivermectin or azelaic acid) 2, 3
• The 40 mg modified-release formulation provides anti-inflammatory activity without antibiotic effects, reducing gastrointestinal side effects and antibiotic resistance concerns 2, 3
• For severe refractory disease, consider oral isotretinoin, which demonstrates 91% clearance or excellent response even at very low doses 2

Persistent Erythema

• First-line treatment is topical brimonidine (α-adrenergic agonist) 2
• Alternative option is topical oxymetazoline 2
• Oral beta blockers such as carvedilol may be considered, though evidence is limited 2

Transient Erythema/Flushing

• Topical α-adrenergics are first-line 2
• Oral beta blockers or pulsed-dye laser are alternative options 2

Telangiectasia

• Laser or light-based therapies (intense pulsed light, pulsed dye laser) are the primary treatment modalities 4, 5

Phymatous Changes

• Laser or light-based therapies are the primary treatment 5
• Oral isotretinoin may be considered for severe cases 2

Essential Adjunctive Measures (All Patients)

• Sun protection: Daily broad-spectrum SPF 30+ sunscreen 2, 3
• Gentle skincare: Use mild, non-medicated cleansers and moisturizers to support skin barrier function 2, 3
• Trigger avoidance: Identify and avoid individual triggers including spicy foods, alcohol, extreme temperatures, though RCT evidence for this approach is limited 2, 3

Treatment Duration and Response Assessment

• Allow 6-8 weeks for topical agents before declaring treatment failure 2
• Allow 8-12 weeks for oral agents before declaring treatment failure 2
• If first-line treatment fails after adequate duration, either switch to an alternative first-line agent OR add an additional first-line agent 1, 3

Combination Therapy Approach

Multiple cutaneous features should be treated simultaneously with multiple agents, as moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals). 2, 3

Maintenance Therapy

• Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 2, 3
• Continue the minimum treatment necessary to maintain remission 2, 3
• Topical agents alone may suffice for maintenance after initial combination therapy 3
• Long-term doxycycline 40 mg has demonstrated safety for extended use 3

Ocular Rosacea Management

• Mild symptoms: Lid hygiene and artificial tears 1, 2
• Moderate-to-severe symptoms: Oral doxycycline 40 mg modified-release 2
• Ophthalmological referral should be considered for all but the mildest ocular features 1, 2

Critical Pitfalls to Avoid

• Do not treat based on traditional rosacea subtypes—this approach fails to address the full spectrum of presenting features and may lead to inadequate management 1, 3
• Do not use traditional non-encapsulated benzoyl peroxide formulations—only E-BPO 5% is FDA-approved for rosacea with reduced irritation 3
• Do not extrapolate acne treatment protocols to rosacea—rosacea represents fundamentally different pathophysiology 2
• Do not discontinue treatment prematurely—insufficient treatment duration leads to false treatment failures 2
• Counsel patients about photosensitivity with doxycycline and its contraindication in pregnancy, nursing, and children under 8 years 3
• Do not overlook ocular manifestations—ocular rosacea is frequently underdiagnosed and undertreated 2