What are the treatments for popular rosacea (acne rosacea)?

From the Guidelines

Rosacea treatment should prioritize topical metronidazole (0.75% or 1% gel or cream) applied once or twice daily, as it is effective in reducing inflammation and redness, with a 65% decrease in inflammatory lesion counts compared to a 15% reduction with vehicle, as shown in a 9-week split-face study 1.

Treatment Options

• Topical metronidazole (0.75% or 1% gel or cream) applied once or twice daily is effective for reducing inflammation and redness, with a 65% decrease in inflammatory lesion counts compared to a 15% reduction with vehicle, as shown in a 9-week split-face study 1.
• Azelaic acid (15-20% gel or cream) applied twice daily is another excellent option that targets both inflammation and acne-like bumps, with a 51% rate of marked improvement or complete remission in a 12-week double-blind, randomized, parallel-group, vehicle-controlled study 1.
• For more severe cases, oral antibiotics like doxycycline (40-100mg daily for 8-12 weeks) can be prescribed, with the lower dose (40mg) being anti-inflammatory without antibiotic effects, and showing a mean inflammatory lesion reduction of 11.8 in a 16-week study 1.

Lifestyle Modifications

• Avoiding triggers like spicy foods, alcohol, extreme temperatures, and sun exposure is crucial for management.
• Using gentle, fragrance-free cleansers, applying broad-spectrum sunscreen daily, and avoiding harsh skincare products can prevent flare-ups.

Additional Treatment Options

• Brimonidine gel (0.33%) can temporarily reduce redness for special occasions when applied 30 minutes before.
• Other treatment options, such as ivermectin (topical), isotretinoin (oral), and physical modalities like electrodessication, IPL, and lasers, may be considered for specific cases, as outlined in the phenotype-led treatment algorithm by the ROSCO panel 1.

From the Research

Overview of Rosacea

• Rosacea is a chronic cutaneous disorder affecting primarily the face, characterized by erythema, transient or persistent, telangiectasia, and inflammatory lesions including papulo-pustules and swelling 2
• The essential component of the disease is the persistent erythema of facial skin, with episodes of flushing and swelling of the nose along with dilatation of the pilosebaceous poral orifices, known as rhinophyma, in chronic cases 2

Treatment Options for Rosacea

• Topical medications such as azelaic acid, metronidazole, and sulfacetamide/sulfur are commonly used to treat rosacea, with azelaic acid and metronidazole showing high to moderate quality evidence of effectiveness in reducing symptoms 3
• Oral antibiotics such as tetracyclines and doxycycline are also used to treat rosacea, with doxycycline showing high quality evidence of effectiveness in reducing symptoms 3
• Laser and light-based therapies, such as intense pulsed light and pulsed dye laser, are used to treat the erythemato-telangiectatic type of rosacea, with low to moderate quality evidence of effectiveness 3
• Other treatment options include skin care and cosmetic treatments, injection therapies, and combination therapies, with the goal of tailoring treatment to the individual patient's symptoms and needs 4

Specific Treatments for Rosacea

• Topical ivermectin has been shown to be effective in reducing symptoms of papulopustular rosacea, with high quality evidence of effectiveness 3
• Topical brimonidine has been shown to be effective in reducing erythema in rosacea, with high quality evidence of effectiveness 3
• Oral isotretinoin has been shown to be effective in reducing symptoms of rosacea, with high quality evidence of effectiveness, but is typically reserved for severe cases due to potential side effects 3

Challenges in Treating Rosacea

• The majority of studies on rosacea treatments are at high or unclear risk of bias, highlighting the need for further well-designed and adequately-powered randomized controlled trials to determine the effectiveness of different treatments 5, 3
• The quality of the body of evidence for many treatments is rated as low to moderate, highlighting the need for further research to determine the most effective treatments for rosacea 3