Jordan Robertson, ND
A detailed evaluation of the most commonly prescribed topical treatments for rosacea, comparing efficacy, patient suitability, and clinical outcomes.
Rosacea significantly affects patients’ quality of life, and evidence indicates that any treatment enhances quality of life compared to pre-treatment status. However, recent research shows that treatment patterns have not aligned with evolving guidelines. This article reviews the evidence for major topical treatments, emphasizing their comparative efficacy, mechanisms of action, and practical considerations. Patients should understand the range of options available to treat their rosacea, especially since the evidence for each choice is relatively similar.
The Standard of Care Discrepancy
The guidelines for rosacea have moved away from strict classifications of rosacea to phenotypic descriptions, accounting for the fact that many patients with rosacea fall in multiple sub-categories1, and prescriptions should be chosen based on shared decision making and patient-centric goals. Current guidelines recommend three primary topical medications for rosacea: ivermectin, azelaic acid, and metronidazole.2 However, a recent survey of 6,000 US dermatologists revealed that 98% primarily prescribe metronidazole, with only 9.1% using azelaic acid and 4.1% ivermectin.3 Many practitioners, especially those in group practices, demonstrate little flexibility in treatment selection regardless of patient presentation. Despite the evidence for equivocal results, and possible subtypes of rosacea patients who benefit from one treatment over another, patients are being denied the opportunity to understand all available options before being handed a prescription.
Comparing Treatment Options for Rosacea
Ivermectin (1%)
Ivermectin therapy targets the dermatological mite, Demodex, and reduces the Demodex lesion count by directly decreasing mite density through anti-inflammatory mechanisms.4 Despite its high cost, ivermectin offers lasting improvements beyond the acute phase of treatment. It may address the root cause of rosacea in many patients, which for some may include a high density of Demodex mites.5
Pros:
- Superior mite-killing efficacy against Demodex, a key factor in rosacea pathophysiology
- Anti-inflammatory properties independent of mite reduction6
- Faster improvement (visible by week 4) than other topicals
- Low relapse rate—many patients maintain improvement for 32+ weeks after a 16-week treatment course5
- Fewer side effects than other options
- Treats both papules/pustules and shows some efficacy for erythema7
Cons:
- Cost ($150-250 for a 16-week supply)
- Prescription required
- Limited accessibility in some regions
Azelaic Acid (15-20%)
Originally formulated to treat hyperpigmentation, azelaic acid has emerged as a viable solution for rosacea, with both antimicrobial and anti-inflammatory effects.8 Available in higher concentrations as a prescription, azelaic acid has never been formally studied in a dose lower than 15%. In head-to-head trials, it outperforms metronidazole and performs equally well to ivermectin.2
Pros:
- 61-74% reduction in inflammatory lesions by 12 weeks9,10
- Fewer side effects than metronidazole11
- Some effect on erythema8
- Lower-concentration versions (10-14%) available over-the-counter**
**this has not been formally studied in clinical trials
Cons:
- Higher concentrations (15-20%) require a prescription
- Potential for skin irritation, especially at 20% concentration
- Twice-daily application required for optimal results
- No studies on concentrations below 15%, leaving uncertainty about OTC product efficacy
Metronidazole (0.75-1%)
Metronidazole is the most commonly prescribed treatment for rosacea and operates through two mechanisms of action: antimicrobial and anti-inflammatory.2 As a topical agent, it can cause fewer side effects than long-term antibiotic use for rosacea. It has remained the most affordable treatment option for patients.12 Newer research suggests that metronidazole may be the third most effective choice (following ivermectin and azelaic acid).13
Pros:
- More affordable than alternatives
- Long history of use
- Widely prescribed and available
- Anti-inflammatory properties
Cons:
- Performs equal to or worse than alternatives in head-to-head studies2,13
- Less effective at treating erythema
- Uncertain mechanism against specific rosacea pathogens
- May require longer-term use with higher relapse rates
Overall, these three treatment options provide substantial support for patients with various phenotypes of rosacea and can enhance quality of life and skin health in as little as 12 weeks. In a recent systematic review of rosacea solutions, each option discussed here emerged as viable, presenting positive and negative considerations unique to every patient. Clinicians have the opportunity to educate patients about these options and assist in selecting a solution that aligns with both the patient’s goals and their clinical picture.
Key Takeaways:
The decision to select a topical treatment should consider:
1. Primary symptoms – predominance of papules/pustules versus erythema
2. Skin type and tolerance** – consider potential for irritation
3. Cost and accessibility – including insurance coverage and prescription access
4. Patient preferences – compliance with application frequency and vehicle formulation
5. Skin of color considerations – certain treatments such as azelaic acid may affect melanocytes.
Concluding Thoughts
Evidence indicates that ivermectin may provide the highest effectiveness and lasting results, especially for patients with pronounced papulopustular components. Azelaic acid serves as a robust alternative with fewer side effects than metronidazole.
Timely, targeted treatment for rosacea is essential to prevent irreversible changes like telangiectasia. The tendency to rely on metronidazole despite evidence supporting alternatives underscores the need for practitioner flexibility in treatment selection and ongoing evaluation of treatment effectiveness. The chronicity of rosacea may lead us to deprioritize complete resolution, which can compromise patient quality of life and result in irreversible skin changes.
Dr. Jordan Robertson ND is on a mission to create a standard of care of evidence based naturopathic medicine while reducing the unpaid-research-labour of naturopathic clinicians. She is the founder of The Confident Clinician, a clinical decision making tool and database built specifically for Naturopathic Doctors. She is a graduate of CCNM (2008) and has a 15 year career teaching critical appraisal, research in integrative medicine and clinical nutrition at McMaster University Canada. Jordan can be reached at hello@theconfidentclinicianclub.com
