What is the treatment algorithm for rosacea?

From the Guidelines

The treatment of rosacea should follow a stepwise approach based on subtype and severity, starting with topical agents like metronidazole 0.75-1% gel/cream, azelaic acid 15-20%, or ivermectin 1% cream applied once or twice daily, as recommended by the global rosacea consensus panel 1.

Treatment Algorithm

The treatment algorithm for rosacea is based on the phenotype-led approach, which considers the major cutaneous features of the disease, including transient erythema, persistent erythema, inflammatory papules/pustules, telangiectasia, and phyma.

• For mild to moderate erythematotelangiectatic rosacea, topical agents like metronidazole 0.75-1% gel/cream, azelaic acid 15-20%, or ivermectin 1% cream are first-line treatments, with ivermectin showing superior efficacy for papulopustular rosacea 1.
• If topicals provide insufficient response after 8-12 weeks, oral antibiotics such as doxycycline (40mg modified-release or 50-100mg daily) can be added for 8-12 weeks, as they have been shown to be effective in reducing inflammatory lesions and improving symptoms 1.
• For severe or refractory cases, consider isotretinoin (0.25-0.5mg/kg/day for 12-16 weeks), which has been shown to be effective in reducing symptoms and improving quality of life 1.

Additional Considerations

• Ocular rosacea typically requires lid hygiene, artificial tears, and topical antibiotics, with oral doxycycline for moderate to severe cases 1.
• Phymatous rosacea may need surgical intervention, including laser therapy, dermabrasion, or electrosurgery 1.
• Throughout treatment, patients should practice gentle skincare, use daily broad-spectrum sunscreen, identify and avoid personal triggers (like spicy foods, alcohol, extreme temperatures), and consider brimonidine 0.33% gel or oxymetazoline 1% cream for temporary erythema relief 1.

Evidence-Based Recommendations

The recommendations are based on the latest evidence from high-quality studies, including the global rosacea consensus panel 1 and recent reviews of the current treatment landscape 1.

• The use of metronidazole 0.75% and 1.0% formulations has been well studied, and they have been shown to be effective in reducing inflammatory lesions and improving symptoms 1.
• Ivermectin 1% cream has been shown to be effective in reducing inflammatory lesions and improving symptoms, with a significant reduction in demodex mite density and inflammatory markers 1.

From the Research

Rosacea Treatment Algorithm

The treatment of rosacea involves a range of options, including topical and oral medications, as well as lifestyle changes. The following are some of the key considerations in developing a treatment algorithm for rosacea:

• Topical treatments: Topical metronidazole, azelaic acid, and ivermectin have been shown to be effective in reducing inflammatory lesion counts and improving symptoms of rosacea 2, 3, 4, 5.
• Oral treatments: Oral antibiotics, such as doxycycline and tetracycline, have been used to treat moderate to severe rosacea, particularly in cases where topical treatments are not effective or are contraindicated 2, 6, 4, 5.
• Laser and light-based treatments: Laser and intense pulsed light therapy have been shown to be effective in reducing erythema and telangiectasia in rosacea patients 4, 5.
• Ocular rosacea: Topical ciclosporin ophthalmic emulsion and oral omega-3 fatty acids have been shown to be effective in treating ocular rosacea 4, 5.

Treatment Options by Rosacea Subtype

The treatment of rosacea can be tailored to the specific subtype of the disease:

• Papulopustular rosacea: Topical metronidazole, azelaic acid, and ivermectin, as well as oral doxycycline and tetracycline, have been shown to be effective in reducing inflammatory lesion counts and improving symptoms 2, 6, 3, 4, 5.
• Erythematotelangiectatic rosacea: Topical brimonidine and laser and intense pulsed light therapy have been shown to be effective in reducing erythema and telangiectasia 4, 5.
• Ocular rosacea: Topical ciclosporin ophthalmic emulsion and oral omega-3 fatty acids have been shown to be effective in treating ocular rosacea 4, 5.

Considerations for Treatment

When developing a treatment algorithm for rosacea, the following considerations should be taken into account:

• Patient factors: The patient's medical history, skin type, and lifestyle should be taken into account when selecting a treatment option 2, 6.
• Treatment efficacy: The efficacy of different treatment options should be considered, as well as the potential for adverse effects 2, 6, 3, 4, 5.
• Treatment duration: The duration of treatment should be considered, as well as the potential for relapse after treatment is discontinued 2, 6, 3, 4, 5.