Rosacea and Its Topical Management

M. Gooderham, MSc, MD, FRCPC


Skin Therapy Letter. 2009;14(2) 

In This Article


Metronidazole has been the mainstay of topical rosacea treatment. It is a nitroimidazole antibiotic whose mechanism of action in rosacea is not well established, but appears to work through an anti-inflammatory mechanism.[12,13] It is the most widely used topical agent for rosacea and is available in a 0.75% gel, lotion, and cream format for twice daily use, and a 1% cream or gel for once daily use. Jorizzo et al.[14] found that once daily dosing of 1% metronidazole cream was as effective as twice daily dosing. It is generally well tolerated and has a low incidence of adverse effects.[12,13] A recent review by the Cochrane Collaboration[15] and a condensed version of this work by van Zuuren et al.,[5] summarizes 9 "high and intermediate quality" trials, which show clear evidence that topical metronidazole is significantly more effective than vehicle alone. Most of these studies used 0.75% metronidazole and ranged from 8–9 weeks in duration, with 1 trial lasting 6 months. A reduction in inflammatory lesions and erythema scores were noted, as was an improvement in physician's global evaluation, and patient-assessed measures when these were available.[5,15] No benefits were noted for the telangiectasia in these studies, however, a study by Tan et al. showed improvement in telangiectasiae scores, as well as erythema and inflammatory lesion counts, using a 1% metronidazole cream with SPF 15.[16]

Although data are limited, 2 studies have shown that topical metronidazole may be as effective as oral tetracycline in reducing the inflammatory component of rosacea.[17,18] Efficacy of metronidazole is constant regardless of the formulation, strength, and frequency of application.[12] This drug also plays a role in maintenance therapy, either with or without prior concomitant systemic antibiotic therapy.[12] Given its high efficacy and tolerability, it will continue to play an important role in the management of rosacea.


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