Treatment of inflammatory papules and pustules in rosacea
Advise patients presenting with inflammatory papules and pustules (papulopustular rosacea) on general measures to minimise irritation of rosacea. Consider whether the patient presents with other clinical features and subtypes of rosacea, and treat accordingly; see Presentation and approach to management of rosacea.
Patients with mild erythema and minimal lesions often do not need treatment. If desired for cosmetic reasons or because the skin is sensitive, use1:
1ivermectin 1% cream topically, once dailyDel Rosso, 2019Siddiqui, 2016Taieb, 2016van Zuuren, 2015van Zuuren, 2019 ivermectin ivermectin ivermectin
OR
2metronidazole 0.75% gel or cream topically, once or twice daily metronidazole metronidazole metronidazole
OR
3azelaic acid 15% gel topically, once or twice daily azelaic acid azelaic acid azelaic acid
OR
3azelaic acid 20% lotion topically, once or twice daily. azelaic acid azelaic acid azelaic acid
Topical azelaic acid or topical metronidazole are preferred in patients who are pregnant or breastfeeding.
Apply topical therapy for 6 to 12 weeks for maximal response; however, response to therapy is variable.
Recurrent intermittent topical therapy is often required because rosacea is a chronic relapsing disease. Some patients may use topical therapy long term; however, most patients only use treatment for 2 to 3 months at a time.
If topical therapy is unsuccessful, consider adding oral antibiotic therapy.
In patients with more severe inflammation and lesions at presentation, consider using oral antibiotic therapy (for their anti-inflammatory effect) instead of topical therapy.
If using oral antibiotic therapy for rosacea, use:
1doxycycline 50 to 100 mg orally, once daily until a response is seen (usually 3 to 4 weeks, but can be up to 8 weeks) doxycycline doxycycline doxycycline
OR
2erythromycin 250 to 500 mg orally, twice daily until a response is seen (usually 3 to 4 weeks, but can be up to 8 weeks) erythromycin erythromycin erythromycin
OR
2erythromycin (ethyl succinate formulation) 400 to 800 mg orally, twice daily until a response is seen (usually 3 to 4 weeks, but can be up to 8 weeks). erythromycin (ethyl succinate formulation) erythromycin erythromycin
If the oral antibiotic is not tolerated or the response after 4 weeks is inadequate, change the oral antibiotic to:
minocycline 50 to 100 mg orally, once daily until a response is seen (can be up to 8 weeks). minocycline minocycline minocycline
Once rosacea is controlled, stop oral treatment (and topical treatment if this is being used as well). If rosacea recurs, repeat treatment.
If rosacea recurs within a month, consider using a lower dose of doxycycline or minocycline for a longer duration (up to a maximum of 12 months). Use:
1doxycycline 50 mg orally, once daily or every second day for 6 to 12 months doxycycline doxycycline doxycycline
OR
1minocycline 50 mg orally, once daily or every second day for 6 to 12 months. minocycline minocycline minocycline
If treatment is not effective, refer for dermatologist advice—the patient may respond to a low dose of oral isotretinoin.