What is the recommended treatment for rosacea?

Recommended Treatment for Rosacea

For inflammatory papules and pustules, start with topical ivermectin 1% cream once daily as first-line therapy, which demonstrates superior efficacy (84.9% achieving "clear" or "almost clear" ratings) and longer remission periods compared to other topical agents. 1

Treatment Algorithm by Phenotype

Inflammatory Papules/Pustules

Mild Disease:

• Topical ivermectin 1% cream once daily is the most effective first-line option 1, 2
• Alternative first-line agents include topical azelaic acid 15% gel/foam twice daily 1, 3 or topical metronidazole 0.75-1.0% once daily 1, 2
• Encapsulated benzoyl peroxide 5% (E-BPO 5%) is the newest FDA-approved option showing rapid improvement by week 2 and sustained efficacy up to 52 weeks with excellent tolerability 4, 1

Moderate to Severe Disease:

• Combination therapy is required: topical ivermectin 1% cream plus oral doxycycline 40 mg modified-release daily 1, 2
• Topical minocycline foam 1.5% is FDA-approved for moderate to severe inflammatory lesions 1
• Improvement typically occurs within 3-4 weeks for most topical treatments, but allow 6-8 weeks for topical agents and 8-12 weeks for oral agents before declaring treatment failure 1

Persistent Erythema

First-Line Options:

• Topical brimonidine tartrate 0.33% gel once daily provides rapid vasoconstriction with maximal effects between 3-6 hours after application 1, 2
• Topical oxymetazoline HCl 1% cream once daily is an alternative α1-receptor agonist 1
• Critical caveat: Brimonidine may cause paradoxical erythema in 10-20% of patients 2

Ocular Rosacea

Mild Cases:

• Lid hygiene and artificial tears 1

Moderate to Severe Cases:

• Oral doxycycline 40 mg modified-release daily combined with lid hygiene 1
• Ophthalmological referral should be considered for all but the mildest ocular features 1

Combination Therapy Approach

Multiple cutaneous features can and should be treated simultaneously with more than one agent, as moderate and severe presentations typically require combination treatments (topical plus systemic or multiple topicals). 1

For example, a patient with both inflammatory lesions and persistent erythema would receive topical ivermectin 1% cream for papules/pustules plus topical brimonidine for erythema 1

Maintenance Therapy

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

• Use the minimum treatment necessary to maintain control 1
• Long-term maintenance with topical agents is essential to prevent relapses 2
• Ivermectin 1% cream provides more durable response with longer time until relapse compared to metronidazole 2

Essential Adjunctive Measures

All patients require:

• Sun protection with SPF 30+ daily 1
• Gentle cleansers and moisturizers 1
• Identification and avoidance of personal triggers (spicy foods, alcohol, extreme temperatures) 1, 2

Special Populations

Pediatric Rosacea (Under 8 Years)

Never use tetracyclines in children under 8 years due to permanent tooth staining. 5

• Mild disease: Topical metronidazole 0.75-1.0% once daily 5
• Moderate to severe disease or ocular involvement: Combination of topical agent (ivermectin, metronidazole, or azelaic acid) plus oral erythromycin 5
• Ocular symptoms often precede cutaneous manifestations in children and can lead to sight-threatening complications including corneal melting/perforation 5

Common Pitfalls to Avoid

• Insufficient treatment duration: Many clinicians declare treatment failure too early; allow adequate time (6-12 weeks) before switching therapies 1
• Treating based on traditional subtypes rather than phenotypes: This leads to inadequate management of the full spectrum of presenting features 1
• Overlooking maintenance therapy: This results in high relapse rates 1
• Ignoring ocular manifestations: Ocular rosacea is commonly underdiagnosed and undertreated 1
• Poor adherence due to adverse effects: Up to 89% of patients who experience treatment-related adverse effects discontinue therapy within a month 2
• Using topical corticosteroids on the face: This can cause steroid rosacea 6