Aaron F. Cohen, MD; Jeffrey D. Tiemstra, MD


J Am Board Fam Med. 2002;15(3) 

In This Article


The most important first step in the treatment of rosacea is the avoidance of triggers. Triggers are both exposures and situations that can cause a flare-up of the flushing and skin changes in rosacea. Principal among these is sun exposure. Rosacea patients must be advised always to apply a nonirritating facial sun block when outdoors. Stress, through autonomic activation, can also increase the flushing. Alcohol consumption, while not a cause in itself, can aggravate this condition through peripheral vasodilation. Spicy foods can also aggravate the symptoms of rosacea through autonomic stimulation. Finally, care must be taken to use only those facial cleansers, lotions, and cosmetics that are nonirritating, hypoallergenic, and noncomedogenic.

Rosacea should be treated at its earliest manifestations to mitigate progression to the stages of edema and irreversible fibrosis. Antibiotics have traditionally been considered the first line of therapy, although their success is considered to be primarily due to anti-inflammatory effects rather than antimicrobial ones.[4] Topical metronidazole, which is effective for stage I and stage II rosacea and avoids the toxicity of systemic treatment, is considered first-line therapy.[11] Metronidazole is available in a twice-daily application of 0.75% cream or gel and in a newer once-daily 1.0% formulation.[4] No significant difference in efficacy has been found between the once-daily 1.0% medicine and the twice-daily 0.75% medicine.[12] Sulfacetamide lotion can also be used in place of metronidazole. In certain patients, sulfacetamide might be less irritating than metronidazole.[4]

Rosacea responds well to oral antibiotics. Starting treatment with simultaneous oral and topical therapy reduces initial prominent symptoms, prevents relapse when oral therapy is discontinued, and maintains long-term control.[6] Oral therapy is generally continued until inflammatory lesions clear or for 12 weeks, whichever comes first.[12] Tetracycline is the primary oral antibiotic prescribed for rosacea therapy, at a dosage of 1.0 to 1.5 g/d divided into 2 to 4 daily doses. Minocycline at 100 mg two times a day is an acceptable alternative.[13] Doxycycline is another acceptable alternative, although the monohydrate formulation, in a dosage of 100 mg once daily, is more consistently effective and has fewer gastrointestinal side effects than the hyclate form.[13,14] Clarithromycin, 250 mg to 500 mg twice daily, has been found to be as effective as doxycycline but with a more benign side effect profile.[15]


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