What is the treatment (tx) for rosacea?

Treatment of Rosacea

Treat rosacea using a phenotype-based approach targeting specific clinical features: topical ivermectin 1% cream or azelaic acid 15% gel/foam for mild inflammatory papules/pustules, topical brimonidine or oxymetazoline for persistent erythema, and combination therapy with oral doxycycline 40 mg modified-release plus topical agents for moderate-to-severe disease. 1, 2

Phenotype-Based Treatment Algorithm

The traditional subtype classification has been replaced by targeting individual clinical features that are most bothersome to the patient. 1 This approach recognizes that patients often present with multiple overlapping features requiring simultaneous treatment. 3, 1

For Inflammatory Papules/Pustules

Mild Disease:

• First-line: Topical ivermectin 1% cream once daily demonstrates superior efficacy with 84.9% of patients achieving "clear" or "almost clear" ratings compared to 75.4% with metronidazole, plus longer remission periods. 4
• Alternative first-line: Topical azelaic acid 15% gel/foam once daily 1, 2
• Newer option: Encapsulated benzoyl peroxide 5% (E-BPO 5%) shows the most rapid onset with significant improvement by week 2 and sustained efficacy through 52 weeks. 1, 2
• Topical metronidazole 0.75-1.0% remains an option but is less effective than ivermectin. 4

Moderate-to-Severe Disease:

• Combination therapy is required: Oral doxycycline 40 mg modified-release daily PLUS topical ivermectin or azelaic acid. 1, 2
• The 40 mg modified-release formulation provides anti-inflammatory activity without antibiotic effects, reducing gastrointestinal side effects and antibiotic resistance concerns. 2
• Alternative: Topical minocycline foam 1.5% for moderate-to-severe inflammatory lesions. 1

Severe Refractory Disease:

• Oral isotretinoin for cases failing standard therapy, with very low-dose isotretinoin demonstrating 91% clearance or excellent response. 1

For Persistent Erythema

• First-line: Topical brimonidine tartrate 0.33% gel once daily provides rapid vasoconstriction with maximal effects between 3-6 hours after application. 1, 4
• Alternative: Topical oxymetazoline HCl 1% cream once daily 1, 4
• Critical caveat: Brimonidine causes paradoxical erythema in 10-20% of patients—counsel patients about this possibility before prescribing. 4
• For refractory cases: Oral beta blockers (such as carvedilol) may be considered, though evidence is limited. 1

For Transient Erythema/Flushing

• Topical α-adrenergics (brimonidine or oxymetazoline) 1
• Oral beta blockers 1
• Pulsed-dye laser or intense pulsed light for severe cases 3, 1

For Telangiectasia

• Electrodessication 3
• Intense pulsed light (IPL) 3
• Pulsed-dye laser (PDL) 3
• Physical modalities are the primary treatment; topical agents are ineffective. 3

For Phymatous Changes

Clinically Inflamed ("Active"):

• Oral doxycycline 40 mg modified-release 3, 1
• Physical modalities may be added 3

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

• Electrodessication 3
• IPL 3
• Lasers 3
• Isotretinoin for severe cases 3

Treatment Duration and Monitoring

• Allow 6-8 weeks for topical agents and 8-12 weeks for oral agents before declaring treatment failure. 1
• Improvement typically occurs within 3-4 weeks for most topical treatments. 4
• If first-line treatment fails after adequate duration, either switch to an alternative first-line topical agent or add oral doxycycline 40 mg. 1, 2

Maintenance Therapy

Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued. 1, 2, 4

• Continue the minimum treatment necessary to maintain remission. 1, 2
• Topical agents alone may suffice for maintenance after initial combination therapy. 2
• Long-term doxycycline 40 mg has demonstrated safety for extended use. 2
• Ivermectin 1% cream provides more durable response with longer time until relapse compared to metronidazole. 4

Essential Adjunctive Measures for All Patients

These general skincare measures underlie all treatment approaches and should be implemented regardless of phenotype: 1

• Sun protection with SPF 30+ daily 3, 1, 4
• Gentle, non-medicated cleansers 1, 4
• Moisturizers to support skin barrier function 1, 4
• Trigger avoidance: Identify and avoid personal triggers including spicy foods, alcohol, extreme temperatures, hot beverages, and emotional stress. 1, 4

Ocular Rosacea Management

• Mild symptoms: Lid hygiene and artificial tears 1, 4
• Moderate-to-severe symptoms: Oral doxycycline 40 mg modified-release 1, 4
• Ophthalmological referral should be considered for all but the mildest ocular features that don't bother the patient. 3, 1
• Dermatologists should recognize blepharitis, blurred vision, foreign body sensation, interpalpebral bulbar hyperemia, photophobia, redness, tearing, and telangiectasia as ocular rosacea features. 3

Critical Pitfalls to Avoid

• Do not treat based on traditional rosacea subtypes—use the phenotype-based approach targeting specific presenting features instead. 1, 2
• Do not use traditional non-encapsulated benzoyl peroxide formulations—only E-BPO 5% is FDA-approved for rosacea with reduced irritation. 2
• Do not discontinue treatment prematurely—this leads to false treatment failures and relapse. 2
• Do not extrapolate acne treatment protocols to rosacea—rosacea represents fundamentally different pathophysiology. 1
• Counsel patients about photosensitivity with doxycycline and its contraindication in pregnancy, nursing, and children under 8 years. 2
• Warn about adherence issues: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month. 4

Combination Therapy Principles

Multiple cutaneous features can and should be treated simultaneously with more than one agent. 1, 2, 4 Moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals). 1, 2 For example, a patient with moderate inflammatory papules/pustules AND persistent erythema should receive oral doxycycline 40 mg + topical ivermectin + topical brimonidine simultaneously. 1