What are the topical treatments for mild rosacea?

From the Guidelines

For mild rosacea, topical metronidazole (0.75% or 1% gel or cream) applied once or twice daily is the first-line treatment, as it has been shown to be effective in reducing inflammatory lesions and perilesional erythema associated with rosacea 1.

Treatment Options

• Azelaic acid (15-20% gel or cream) applied twice daily is another effective option, which can be used alone or in combination with metronidazole for enhanced results.
• Ivermectin 1% cream applied once daily is also effective, particularly for inflammatory lesions, as it has been shown to reduce demodex mite density and improve cutaneous inflammatory markers 1.
• Sodium sulfacetamide 10% with sulfur 5% can be used as an alternative, especially for patients with combination rosacea and seborrheic dermatitis.

Key Considerations

• Treatment should be continued for at least 8-12 weeks to see optimal results, and long-term maintenance therapy is often necessary to prevent flares.
• In addition to medication, patients should use gentle, fragrance-free cleansers, apply daily broad-spectrum sunscreen, avoid known triggers (such as spicy foods, alcohol, extreme temperatures), and consider using green-tinted moisturizers to neutralize redness.
• If no improvement occurs after 12 weeks, or if symptoms worsen, patients should consult their healthcare provider for possible adjustment to their treatment plan or consideration of oral medications.

Recent Developments

• Microencapsulated benzoyl peroxide 5% (E-BPO 5%) is a newly FDA-approved topical treatment for rosacea that shows promise in enhancing therapeutic response and minimizing skin irritation 1.
• However, more research is needed to determine the exact role of E-BPO 5% in the therapeutic landscape for rosacea.

From the Research

Topical Treatment Options for Mild Rosacea

• Metronidazole 1% gel: once-daily application has been shown to be effective in reducing inflammatory lesion counts and erythema 2, 3
• Azelaic acid 15% gel: twice-daily application has been shown to be effective in reducing inflammatory lesion counts and erythema 2, 3
• Metronidazole 0.75% lotion: can be used in combination with oral antibiotics for increased efficacy 3
• Sodium sulfacetamide-sulfur: a validated topical therapy for rosacea 4
• Other topical therapies: such as calcineurin inhibitors, benzoyl peroxide, clindamycin, retinoids, and permethrin have demonstrated varying degrees of success 4

Efficacy of Topical Metronidazole

• Topical metronidazole 1% cream is approved by the US FDA for the treatment of inflammatory lesions and erythema associated with rosacea 5
• Metronidazole has been shown to be effective in reducing inflammatory lesion counts and erythema in patients with moderate rosacea 2, 3
• Maintenance treatment with topical metronidazole can decrease relapses and allow for longer intervals between flares 3

Comparison of Topical Treatments

• Metronidazole 1% gel and azelaic acid 15% gel have been shown to have similar efficacy in reducing inflammatory lesion counts and erythema 2
• Metronidazole 1.0% cream is as effective as 250 mg tetracycline twice daily 3
• Metronidazole 1.0% gel used once daily is as effective as azelaic acid 15% gel dosed twice daily 3