Rosacea: Drug Therapy

Therapy target

  • Complete freedom from appearance

Therapy recommendations

  • General measures: Avoidance of irritants and triggering factors.
  • Local therapy (“topical”; topical therapy).
    • Approved therapy:
    • Off-label use (use outside the indications or group of people for which the drugs are approved by drug authorities):
      • Rosacea papulopustulosa: adapalene (retinoids).
      • Rosacea-like demodicosis (excessive proliferation of hair follicle mite): permethrin (insecticide), ivermectin (antiparasitic agent), benzyl benzoate (antiscabiosum).
      • Combination of topical application of tranexamic acid (antifibrinolytic; drugs that inhibit the dissolution of fibrin and thus the development of bleeding) with microneedling followed by a moist dressing can relieve rosacea more effectively than a moist dressing alone.
  • Systemic therapy (only in severe courses of rosacea).
    • Approved therapy:
      • Rosacea papulopustulosa: doxycycline (tetracyclines), in combination with topical therapies (e.g., metronidazole or azelanic acid) if necessary.
    • Off-label use:
      • Gram-negative rosacea: isotretinoin 10-20 mg/kg bw/d orally.
      • Morbihan’s disease (chronic persistent erythema (“persistent areal skin redness) or edema (swelling) of the upper half of the face of unexplained cause): 10-20 mg isotretinoin/d for 3-6-(12-24) months (plus antihistamine if necessary); 2 mg/d ketotifen (mast cell membrane stabilizer), intralesional triancinolone instillation if necessary.
      • Rosacea granulomatosa (“characterized by the appearance of granulomas/nodular cell accumulations”): 40 mg doxycycline/d, 20-40 mg prednisolone/d for 7-14 d, 10-20 mg isotretinoin/d, dapsone if necessary.
      • Rosacea fulminans (“suddenly, rapidly and severely developed”) (pyoderma faciale): isotretinoin; 0.5-1 mg/kg bw/d prednisolone for circa 3 weeks; additionally glucocorticoids topically, dapsone if necessary.
      • Rosacea ophthalmica (ophthalmorosacea; ocular (“affecting the eyes”) rosacea): 2 x 0.05% topical ciclosporin (cyclosporin A)/d; 1.5% azithromycin for 4 weeks; tetracycline or (clarithromycin, erythromycin (macrolides)) for about 6 months in addition, use of tear substitutes (gelatinous, lipid) and eyelid margin care
      • Steroid rosacea (rosacea indicated by prolonged corticosteroid therapy): calcineurin inhibitors; isotretinoin 10-20 mg/kg bw/d orally; strict avoidance of glucocorticoids (topical and systemic).

    Further notes

    • Treatment duration: do not stop treatment until an excellent clinical outcome is achieved. Note: Patients whose treatment outcome was classified as “completely appearance free” (IGA 0) remain free of recurrence, i.e., without recurrence of symptoms, for at least 5 months longer after the end of therapy than patients who had achieved only an “almost appearance free” (IGA 1).
    • Drugs that effectively treat rosacea papulopustulosa, if applicable, improve erythema (areal skin redness) caused by inflammatory infiltrates, but not vascular (vascular-related) erythema.
    • See also under “Further therapy”.

Caveat. The U.S. Food and Drug Administration (FDA) advises caution in prescribing the antibiotic clarithromycin in patients with pre-existing cardiac conditions. Results of a 10-year follow-up after 2-week treatment with clarithromycin showed increased all-cause mortality (hazard ratio 1.10; 1.00-1.21), and the rate of cerebrovascular disease (hazard ratio 1.19; 1.02-1.38) was also increased.

Supplements (dietary supplements; vital substances)

Appropriate dietary supplements for skin, hair, and nails should contain the following vital nutrients:

Note: The listed vital substances are not a substitute for drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.