What are the treatment options for rosacea?

From the Guidelines

Rosacea treatment should involve a combination of lifestyle changes and medications tailored to the specific subtype and severity, with first-line treatments including metronidazole 0.75% or 1% gel/cream applied twice daily, azelaic acid 15-20% applied twice daily, or ivermectin 1% cream applied once daily, as supported by recent studies 1, 2, 3. For mild to moderate rosacea, these topical treatments are typically first-line, while for more severe or inflammatory rosacea, oral antibiotics such as doxycycline (40mg daily for anti-inflammatory effects) for 8-12 weeks can be effective 3. Some key points to consider in treatment include:

• Persistent facial redness may respond to brimonidine 0.33% gel or oxymetazoline 1% cream applied once daily
• For ocular rosacea, artificial tears and eyelid hygiene are recommended, along with oral doxycycline if severe
• Lifestyle modifications are crucial and include avoiding triggers like spicy foods, alcohol, extreme temperatures, and sun exposure; using gentle, fragrance-free cleansers; applying broad-spectrum sunscreen daily; and using moisturizers to repair skin barrier function
• Laser or intense pulsed light therapy may help with persistent redness and visible blood vessels, as suggested by the global rosacea consensus panel 4 These treatments work by reducing inflammation, controlling skin microbes like Demodex mites, constricting blood vessels, or improving skin barrier function, addressing the multifactorial nature of rosacea. The most recent and highest quality studies support the use of these treatments, with metronidazole and azelaic acid being well-studied and effective options for reducing inflammatory lesions and perilesional erythema associated with rosacea 1, 2. Additionally, doxycycline has been shown to be effective in reducing inflammatory lesions and preventing relapse in rosacea patients 3. Overall, a comprehensive treatment approach that incorporates lifestyle modifications, topical treatments, and oral antibiotics as needed can help to improve symptoms and quality of life for patients with rosacea.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION After the skin is thoroughly washed and patted dry, a thin film of AZELEX® Cream should be gently but thoroughly massaged into the affected areas twice daily, in the morning and evening. The treatment for rosacea involves applying a thin film of azelaic acid cream to the affected areas twice daily, in the morning and evening 5.

• The hands should be washed following application.
• The duration of use of AZELEX Cream can vary from person to person and depends on the severity of the condition. However, the provided information does not explicitly state that the treatment is for rosacea, it mentions acne. Since rosacea is not explicitly mentioned in the provided drug labels, no conclusion can be drawn about the treatment of rosacea with azelaic acid cream.

From the Research

Treatment Options for Rosacea

• Topical medications such as azelaic acid, metronidazole, and sulfacetamide/sulfur are commonly used to treat rosacea 6, 7, 8, 9, 10
• Oral antibiotics such as tetracyclines, metronidazole, and macrolides can also be effective in treating rosacea 6, 9, 10
• Light-based therapies like intense pulsed light and pulsed dye laser can be used to treat erythemato-telangiectatic type of rosacea 6, 8
• Newer treatment options include topical brimonidine, oxymetazoline, ivermectin, tacrolimus, pimecrolimus, and botulinum toxin 8

Management of Different Subtypes of Rosacea

• Erythematotelangiectatic rosacea can be treated with topical α-adrenergic receptor agonist brimonidine tartrate 0.5% and intradermal botulinum toxin injection 6
• Papulopustular rosacea can be treated with systemic and topical remedies, including metronidazole, doxycycline, minocycline, clarithromycin, and isotretinoin 6, 10
• Ocular involvement can be treated with oral or topical antibacterial agents 6, 9
• Rhinophyma can be corrected by dermatosurgical procedures, decortication, and various types of lasers 6

Comparison of Treatment Options

• A study comparing once-daily metronidazole 1% gel with twice-daily azelaic acid 15% gel found similar reductions in inflammatory lesion counts and high success rates in both global severity and erythema 7
• A Cochrane review found some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40mg) in the treatment of moderate to severe rosacea 9