Gary W. Cole, MD, FAAD
Gary W. Cole, MD, FAAD
Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
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What is the treatment for rosacea?
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There are many treatment choices for rosacea depending on the severity and extent of symptoms. Available medical treatments include antibacterial washes, topical creams, antibiotic pills, lasers, pulsed-light therapies, photodynamic therapy, and isotretinoin.
Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition. More resistant situations may require a combination approach, using several of the treatments at the same time. A combination approach may include home care of washing with a prescription sulfa wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, intense pulsed light, or photodynamic therapies may also be used in combination with the home regimen. It is advisable to seek a physician's care for the proper evaluation and treatment of rosacea.
With the proper treatment, rosacea symptoms can be fairly well controlled. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole (Flagyl) applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid (Finacea gel 15%) is another effective treatment for patients with rosacea. Both metronidazole and azelaic acid work to control the redness and bumps in rosacea.
Some patients elect combination therapies and notice an improvement by alternating metronidazole and azelaic acid: using one in the morning and one at night. Sodium sulfacetamide (Klaron lotion) is also known to help reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin (Cleocin).
Recently a new topical prescription gel has become available designed to relieve the redness so characteristic of rosacea. Brimonidine gel (Mirvaso) applied once a day can produce a prolonged period of blanching of previously red skin in rosacea patients.
Oral antibiotics are also commonly prescribed to patients with moderate rosacea. Tetracycline (Sumycin), doxycycline (Vibramycin, Oracea, Adoxa, Atridox), minocycline (Dynacin, Minocin), and amoxicillin (Amoxil, Dispermox, Trimox) are among the many oral antibiotics commonly prescribed and they actually help reduce inflammation and pimples in rosacea. A newer low-dose doxycycline preparation called Oracea (40 mg once a day) has been used in rosacea. The dose may be initially high and then be tapered to maintenance levels. Common side effects and potential risks should be considered before taking oral antibiotics.
Short-term topical cortisone (steroid) preparations of minimal strength may in occasional cases also be used to reduce local inflammation. Some mild steroids include desonide lotion or hydrocortisone 0.5% or 1% cream applied sparingly once or twice a day just to the irritated areas. There is a risk of causing a rosacea flare by using topical steroids. Prolonged use of topical steroids on the face can also cause irritated skin around the mouth (perioral dermatitis).
Some doctors may also prescribe tretinoin (Retin-A), tazarotene (Tazorac), or adapalene (Differin), which are prescription medications also used for acne. Rarely, permethrin (Elimite) cream is prescribed for rosacea cases that are associated with skin mites. Permethrin is also used for follicular Demodex mites if warranted.
Isotretinoin is infrequently prescribed for severe and resistant rosacea. Often it is used after multiple other therapies have been tried for some time and have failed. It is used as a daily capsule for four to six months. Isotretinoin is not typically used in rosacea, and it is most commonly used in the treatment of severe, common acne called acne vulgaris. Close physician monitoring and blood testing are necessary while on isotretinoin. Generally, at least two forms of birth control are required for females using this medication, as pregnancy is absolutely contraindicated while on isotretinoin.
In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Harsh soaps and lotions should be avoided, whereas simple and pure products such as Cetaphil or Purpose gentle skin cleanser may be less irritating. Patients should avoid excessive rubbing or scrubbing the face.
Other recommended cleansers include
Laser and intense pulsed light
Many patients are now turning to laser and intense light treatments to treat the continual redness and noticeable blood vessels on the face, neck, and chest. Often considered a safe alternative, laser and intense pulse-light therapy may help to visibly improve the skin and complexion.
Laser treatment may cause some discomfort. While most patients are able to endure the procedure, ice packs and topical anesthetic cream can help alleviate the discomfort. Multiple treatments are typically necessary, and the procedure is not covered by most insurances. Treatments are recommended in three- to six-week intervals; during this time, sun avoidance is necessary. Risk, benefits, and alternatives should be reviewed with your physician prior to treatment. Laser treatments may be combined with photodynamic therapy (light-activated chemical using Levulan) for more noticeable results.
Photodynamic therapy (PDT) is one of the newly available treatments. PDT uses a topical photosensitizer liquid that is applied to the skin and a light to activate the sensitizer. Levulan (aminolevulonic acid) and blue light, commonly used to treat pre-cancers (actinic keratosis) and acne vulgaris, can also be used to treat some rosacea patients. The use of PDT in rosacea is considered off-label, since it is primarily designed for regular acne. PDT is thought to work at reducing the inflammation, PDT is performed in your physician's office. The treatment takes anywhere from one to one and a half hours to complete. Strict sun avoidance for approximately one to three days is required after the treatment. Mild discomfort during the treatment and a mild to moderate sunburn appearance after the treatment is common. Some patients have experienced remissions (disease-free periods) of several months to years from these types of treatments. Other patients may not notice significant improvement.
Glycolic-acid peels may additionally help improve and control rosacea in some people. The chemical peels can professionally be applied for approximately two to five minutes every two to four weeks. Mild stinging, itching, or burning may occur and some patients experience peeling for several days after the peel. Any peel can irritate very sensitive skin and cause flares for some people. Peels should be used with caution in rosacea as not everyone is able to tolerate these treatments.
Sun exposure is a well known flare for many rosacea sufferers. Sun protection using a wide-brimmed hat (at least 6 inches) and physical sunscreens (like zinc or titanium) are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, the use of an appropriate daily sunscreen lotion and overall sun avoidance is recommended.
Medically Reviewed by a Doctor on 6/5/2014
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