Beyond Metrocream and Doxycycline: Up your Game in Rosacea Treatment

Linda Stein Gold, MD reframed rosacea management using the ROSCO 2019 feature-based treatment algorithm, which moves away from traditional subtyping and instead targets individual clinical features. Persistent facial erythema is best addressed with optimized skincare, α-adrenergic agents, or devices, while inflammatory papules and pustules are treated with targeted topical therapies such as ivermectin, azelaic acid, or metronidazole, and systemic agents including doxycycline or isotretinoin. Telangiectasias typically require procedural intervention, and phymatous changes may respond to isotretinoin when inflamed or surgical management when fibrotic.

Advances in erythema control were highlighted with α-adrenergic agonists brimonidine and oxymetazoline, both shown to significantly reduce background redness, with practical tips to minimize irritation through conservative dosing. For papulopustular rosacea, Dr Stein Gold emphasized that tetracyclines act through anti-inflammatory rather than antimicrobial effects, paving the way for non-antibiotic formulations. Promising therapies included low-dose extended-release minocycline (DFD-29), which demonstrated early efficacy without disrupting the microbiome, and microencapsulated benzoyl peroxide, designed to reduce irritation while maintaining efficacy. Topical ivermectin was highlighted for its dual anti-inflammatory and anti-parasitic activity and superior performance compared with metronidazole.

The session underscored the importance of aiming for complete clearance (IGA 0), as patients who achieve “clear” disease experience longer remission than those who are only “almost clear.” Dr Stein Gold also flagged emerging safety considerations, noting reports of rosacea fulminans and acneiform eruptions following initiation of TYK2 inhibitors in patients with underlying rosacea. Overall, the presentation reinforced that precision, patience, and feature-driven therapy are key to achieving durable rosacea control.