Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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all patients

1st line – lifestyle changes

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all patients
1st line – 

lifestyle changes

Advise patients to keep a diary recording exacerbations and anything they think may have contributed to them to help identify triggers.[16]

Common triggers include: sun/ultraviolet exposure; hot, cold, or windy weather; humidity, indoor heating, hot baths, hot beverages; heavy exercise; alcohol consumption; spicy foods; emotional stress; some skincare and toiletry products (e.g., those that contain menthol, camphor, or sodium lauryl sulfate); some medicines (e.g., amiodarone; nasal corticosteroids; and, paradoxically, topical corticosteroids); some fruits and vegetables, or certain dairy products.[14][15][16]

Lifestyle changes may help to avoid onset and exacerbation of symptoms such as flushing, facial redness, skin sensitivity, and dryness.[14][15][16]

Identify and treat potential causes of hot flushes (e.g., menopause, hyperthyroidism) to help prevent exacerbations of rosacea.

Treatment of transient erythema and flushing is limited to the above measures plus skincare and sun protection. The use of oral medicines to control flushing is off-label and there is no randomised controlled trial evidence to further guide practice.[16][44]

Plus – skincare and sun protection

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all patients
Plus – 

skincare and sun protection

Treatment recommended for ALL patients in selected patient group

Patients should wash with emollients and moisturise regularly.[14][16] Yellow- or green-tinted cosmetics may help camouflage erythema.[14][43]

Sun cream containing zinc oxide or titanium dioxide is recommended.[16] Advise patients to avoid the midday sun and to wear a wide-brimmed hat when out in the sun.

Plus – topical alpha agonist

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all patients
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with fixed centrofacial erythema
Plus – 

topical alpha agonist

Treatment recommended for ALL patients in selected patient group

The most effective topical treatments for persistent facial erythema are topical alpha agonists (e.g., brimonidine, oxymetazoline).[14][15][16][44]

People with telangiectasia should be advised that these will become more prominent with the treatment of erythema.

Primary options

brimonidine topical: (0.33%) apply to the affected area(s) once daily

OR

oxymetazoline topical: (1%) apply to the affected area(s) once daily

Consider – laser treatment

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all patients
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with fixed centrofacial erythema
Consider – 

laser treatment

Additional treatment recommended for SOME patients in selected patient group

Laser treatment may be considered if other measures do not result in a satisfactory response.

Pulsed-dye and potassium titanyl phosphate lasers are effective at reducing erythema.[15][16]

The British Association of Dermatologists recommends neodymium-doped yttrium aluminium garnet (Nd:YAG) or intense pulsed light to treat persistent facial erythema.[14] Laser therapy may be offered at any time during treatment.[50]

Consider – laser treatment

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all patients
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with telangiectases
Consider – 

laser treatment

Additional treatment recommended for SOME patients in selected patient group

Telangiectases are one of the most bothersome features for people with rosacea. Treatment of erythema makes telangiectases appear more prominent. Laser or intense pulsed light therapy may be considered if conservative measures do not result in a satisfactory response.[44]

Pulsed-dye and potassium titanyl phosphate lasers are effective in obliterating telangiectasia.[15][16] Laser therapy may be offered at any time during treatment.[50]

Plus – topical therapy

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all patients
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with papules and pustules
Plus – 

topical therapy

Treatment recommended for ALL patients in selected patient group

Combined topical and systemic therapy is often used in the initial treatment of papules and pustules, with long-term use of a single therapy to maintain remission.[16]

There is no simple treatment algorithm that is suitable for all, and these medicines are often attempted in a trial-and-error fashion until an optimal regimen is reached.

Topical azelaic acid, ivermectin, or metronidazole should be offered initially.[14][15][16][44] [ Cochrane Clinical Answers logo ]

Alternative topical treatments include sulfacetamide/sulfur, a calcineurin inhibitor (e.g., tacrolimus, pimecrolimus), a retinoid (e.g., adapalene), or permethrin.[16][48][49]

Primary options

azelaic acid topical: (15%) apply to the affected area(s) twice daily

OR

ivermectin topical: (1%) apply to the affected area(s) once daily

OR

metronidazole topical: (0.75%) apply to the affected area(s) twice daily; (1%) apply to the affected area(s) once daily

Secondary options

sulfacetamide/sulfur topical: (10/2% or 10/5%) apply to the affected area(s) once to three times daily

OR

tacrolimus topical: (0.03%, 0.1%) apply to the affected area(s) twice daily

OR

pimecrolimus topical: (1%) apply to the affected area(s) twice daily

OR

adapalene topical: (0.1%) apply to the affected area(s) once daily at night

OR

permethrin topical: (5%) consult specialist for guidance on dose

Plus – oral antibiotic or retinoid therapy

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all patients
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with papules and pustules
Plus – 

oral antibiotic or retinoid therapy

Treatment recommended for ALL patients in selected patient group

Combined topical and systemic therapy is often used in the initial treatment of papules and pustules, with long-term use of a single therapy to maintain remission.[16]

Low-dose delayed-release oral doxycycline is recommended as initial systemic therapy. It is safe for long-term use with few adverse effects, and has not been associated with the development of bacterial resistance.[14][15][16][44]

For refractory symptoms, options include an alternative oral antibiotic (e.g., tetracycline or azithromycin) or a retinoid (e.g., isotretinoin).[14][15][16]

As isotretinoin is teratogenic, all women should have a pregnancy test before starting the drug and subsequently monthly while taking it. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme. MHRA: oral retinoids - pregnancy prevention Opens in new window In the US, isotretinoin can only be prescribed through the iPledge system. iPledge system (for isotretinoin prescribing) Opens in new window These initiatives are aimed at decreasing the number of birth defects associated with this medicine.

The use of tetracycline during pregnancy may cause tooth staining in the baby.[16]

Primary options

doxycycline: 40 mg orally (delayed-release) once daily in the morning

Secondary options

tetracycline: 250-500 mg orally twice daily

OR

azithromycin: consult specialist for guidance on dose

Tertiary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

Consider – isotretinoin

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all patients
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with phymatous change
Consider – 

isotretinoin

Additional treatment recommended for SOME patients in selected patient group

Early soft changes due to sebaceous hyperplasia may improve with oral isotretinoin.[15]

As isotretinoin is teratogenic, all women should have a pregnancy test before starting the drug and subsequently monthly while taking it. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme. MHRA: oral retinoids - pregnancy prevention Opens in new window In the US, isotretinoin can only be prescribed through the iPledge system. iPledge system (for isotretinoin prescribing) Opens in new window These initiatives are aimed at decreasing the number of birth defects associated with this medicine.

Primary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

Consider – surgery/laser

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all patients
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with phymatous change
Consider – 

surgery/laser

Additional treatment recommended for SOME patients in selected patient group

Surgical options should be considered for fully developed phymatous changes. They include ablative lasers; carbon dioxide laser, erbium-doped yttrium aluminium garnet (YAG); electrosurgery; radiofrequency and surgical shaving; and dermabrasion.[15][16][45][46][47][55]

Plus – avoidance of triggers for ocular rosacea

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all patients
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with ocular manifestations
Plus – 

avoidance of triggers for ocular rosacea

Treatment recommended for ALL patients in selected patient group

Medicines (e.g., antidepressants and anxiolytics) that could trigger dry eye should be identified and changed.[14]

Patients should avoid eye make-up and environments that are smoky, have air conditioning, or have excessive central heating.[14]

Plus – eyelash hygiene

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all patients
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with ocular manifestations
Plus – 

eyelash hygiene

Treatment recommended for ALL patients in selected patient group

Warm compresses, lid hygiene wipes, and ocular lubricants or liposomal sprays can alleviate symptoms in people with ocular rosacea.[14][16]

Plus – omega 3 fatty acids

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all patients
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with ocular manifestations
Plus – 

omega 3 fatty acids

Treatment recommended for ALL patients in selected patient group

Advise patients to take omega-3 fatty acid supplements.[15][16] One randomised controlled trial found that symptoms of ocular rosacea were reduced for patients taking omega-3 fatty acids for 6 months.[44][51]

Consider – topical therapy

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all patients
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with ocular manifestations
Consider – 

topical therapy

Additional treatment recommended for SOME patients in selected patient group

A topical ophthalmic antibiotic (e.g., azithromycin), a topical calcineurin inhibitor (e.g., tacrolimus, pimecrolimus), or topical ivermectin may be used if there is blepharitis and to aid the removal of any collarettes.[15][16]

Topical azithromycin is as effective as oral doxycycline for treating ocular rosacea and has fewer adverse effects.[52][53]

Primary options

azithromycin ophthalmic: (1%) apply to the affected eye(s) twice daily for 2 days, then once daily for 5 days

OR

ivermectin topical: (1%) apply to the affected area(s) once daily

OR

tacrolimus topical: (0.03%, 0.1%) apply to the affected area(s) twice daily

OR

pimecrolimus topical: (1%) apply to the affected area(s) twice daily

Consider – topical ophthalmic ciclosporin

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all patients
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with ocular manifestations
Consider – 

topical ophthalmic ciclosporin

Additional treatment recommended for SOME patients in selected patient group

Use of topical ciclosporin drops may be effective in decreasing the topical inflammation.[16][40][44][50][54]

Primary options

ciclosporin ophthalmic: consult specialist for guidance on dose

Consider – oral antibiotic therapy

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ONGOING
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all patients
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with ocular manifestations
Consider – 

oral antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

An oral tetracycline, such as low-dose delayed-release doxycycline, may be used.[16][44] A macrolide antibiotic (e.g., azithromycin) may be considered as an alternative.[15]

Long-term use of low-dose delayed-release doxycycline may be helpful to maintain remission.[15]

Primary options

doxycycline: 40 mg orally (delayed-release) once daily in the morning

Secondary options

azithromycin: consult specialist for guidance on dose

Consider – referral to ophthalmologist

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ONGOING
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all patients
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with ocular manifestations
Consider – 

referral to ophthalmologist

Additional treatment recommended for SOME patients in selected patient group

Refer the patient to an ophthalmologist if: (1) eye discomfort and/or sticky eye discharge persist for >12 months despite ocular lubricant use >6 times/day and other adequate eyelash hygiene; or (2) 'red flag' symptoms are present (e.g., reduced vision, pain on eye movement, pain that keeps the patient awake at night).

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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