Systemic Therapy for Rosacea

H. E. Baldwin, MD


Skin Therapy Letter. 2007;12(2) 

In This Article

Therapy Based on Rosacea Subtype

The erythematotelangiectatic subtype of rosacea is the most difficult to treat. There is little evidence that topical or oral antibiotics have any role in the treatment of erythema, telangiectasias and flushing-blushing reactions. Isotretinoin may improve erythema resulting from inflammation, but this effect may be transient. Drugs that antagonize flushing may be helpful in some patients. Vascular laser and light therapy is the most effective modality in this subtype.

The papulopustular type of rosacea is the easiest subtype to treat. Most of these patients respond readily to topical medications such as metronidazole, benzoyl peroxide, clindamycin, erythromycin, and azelaic acid. In several studies, topical medications were shown to be equally effective to oral medications although therapy may take longer to be effective.

Since 2006 there has been a paradigm shift in the therapeutic decision-making process for treating rosacea. In the past, topical agents were considered as first-line therapy, and oral agents were introduced only when topical medications were ineffective, or were used in patients for whom immediate response was paramount. With the advent of once-daily, non-antibiotic dosing of doxycycline, oral therapy has become more commonly prescribed as first-line treatment. Often oral and topical antibiotics are used in combination; the resulting effect may be synergistic. Ultimately the patient may be converted to topical therapy alone for maintenance purposes. However long-term, anti-inflammatory dose doxycycline offers a viable alternative.

Isotretinoin is highly effective in this type of rosacea, especially given that low-dose, long-term therapy is an option particularly in men and women of nonchildbearing potential.

Dapsone may be necessary in refractory rosacea or in a patient for whom isotretinoin is contraindicated.

Surgical or laser ablation is often necessary to eradicate existing lesions of significant size. Isotretinoin has been reported to halt the progression of rhinophymata and to shrink overall volume of phymata by reducing the size of the sebaceous glands, but it does not appear to be curative.[37,39,40,47,48,49,50]

Mild, chronic ocular rosacea responds well to topical agents and eyelid hygiene. More significant disease responds promptly and substantially to virtually any oral antibiotic. Tetracyclines, because of their safety profile, are most often used.[51,52] Isotretinoin use may improve the more severe presentations of ocular rosacea, including coloboma formation and corneal erosions. Potential side-effects for this type of rosacea include dry eyes and gritty irritation during therapy.

The granulomatous variant of rosacea is treated in the same manner as papulopustular rosacea reviewed above. Severe disease also responds to the use of oral and intralesional corticosteroids.


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