Rosacea treatment

Medical information

Written and reviewed by a team of doctors. Dr Fox is regulated by the CQC & GPhC.

What is rosacea?

Rosacea is a condition causing reddening and sensitivity of skin, with increased flushing and sometimes visible thread-like blood vessels in the areas of the cheeks, forehead, nose, and chin. There can also be red pimples/papules which can become inflamed and infected in more severe cases. Rosacea is more common in fair-skinned people. Rosacea often recurs so repeated courses of treatment and varying the treatment used may be necessary.

Rosacea is different from acne, and treatment is different. They can look similar, but in rosacea redness tends to come and go depending on factors like stress and heat, and stimulants such as spicy food and alcohol. In rosacea there are no blackheads and whiteheads, or the infected nodules found in severe acne. Rosacea is sometimes called acne rosacea, but this is a misleading name. Rosacea is not a type of acne.

The exact cause of rosacea is not known. Various genetic, immune system, and environmental causes, possibly including demodex mites (microscopic skin mites), are all thought to play a part. Disturbances of blood flow to the skin and chronic inflammation may be factors. Exposure to ultraviolet radiation (sun or sunbeds) can sometimes aggravate rosacea.

See a doctor before treatment

People with troublesome facial redness should see a doctor before treatment. Not all facial redness is caused by rosacea - some is due to acne - and there are some other less common and potentially serious conditions, including infection, which need to be considered.

Further information

• NHS - Rosacea
• NHS 111 Wales - Rosacea
• British Association of Dermatologists - Rosacea
• Dermnet NZ - Rosacea

Rosacea treatments

There are several treatments to choose from depending on which features are causing the most problem and how severe the rosacea is.

It is best to use one type of treatment for at least two months before switching to another treatment or adding in a new one.

Dr Fox supplies the following rosacea treatments:

• Mirvaso gel
• Soolantra cream
• Rozex (gel or cream)
• Efracea capsules

These are generally the most effective treatments, but dermatologists may sometimes use other treatments including different antibiotics.

How to choose which treatment is best for you

• If redness and flushing are the main problem, Mirvaso gel is a good first choice. Mirvaso can also be used with any of the other treatments. Mirvaso (brimonidine) applied once daily lasts 12 hours.
• If the main problem is mild inflammation, soreness and infected spots, choose either Soolantra cream or Rozex gel/cream. If skin is not improving after a couple of months, swap to the other one, or include another additional treatment. They work in slightly different ways, but they should not be used together. Some people find Soolantra cream slightly more effective. Soolantra (ivermectin) applied once daily, or Rozex (metronidazole antibiotic gel or cream) applied twice daily.
• If the inflammation is more severe with more infected spots, or a two month trial of other treatment has not settled the condition, try adding in Efracea (doxycycline 40mg capsules) daily for 8-16 weeks. Efracea can be added to any of the other treatments.
• General measures for all rosacea: avoid factors which can cause facial flushing, such as spicy food, sun and sunbed exposure, hot showers, overheated rooms, and in some cases alcohol. Don't use oily skin preparations - choose water based makeup and sunscreens, and particularly do not use topical steroids as they worsen things in the long term. Some people find that they can reduce facial redness for short periods by holding an ice block in their mouth, between the gum and cheek.
• If symptoms are not improving, are worsening, or are causing severe psychological distress then consult a GP or dermatologist face-to-face.

Combining rosacea treatments

Combining rosacea treatments

Product	Frequency	Use with Mirvaso	Use with Soolantra	Use with Rozex	Use with Efracea
Mirvaso gel	Once daily	n/a	Yes	Yes	Yes
Soolantra cream	Once daily	Yes	n/a	No	Yes
Rozex gel/cream	Twice daily	Yes	No	n/a	Yes
Efracea capsules	Once daily	Yes	Yes	Yes	n/a

• Mirvaso can be used together with Soolantra or Rozex. Apply the Mirvaso first and allow it to dry, before applying Soolantra or Rozex.
• Efracea can be taken at the same time as using Rozex or Soolantra, and Mirvaso.
• It may be useful to take a photograph before and after using the treatments to gauge effectiveness.

If there is no improvement with the above treatments, a skin specialist/dermatologist may be consulted and they may recommend more specialist treatments such as oral isotretinoin, and pulsed light or laser therapy for persistent localised areas of redness (telangiectasia). Surgery may sometimes be advised for rhinophyma - a lumpy misshapen nose which can rarely occur in severe cases of rosacea in men.

Treatment plans

Mostly redness, flushing, and thread veins (erythematotelangiectatic rosacea)

1. Initially try Mirvaso gel once daily in the mornings. This will reduce flushing and redness for up to 12 hours.
2. If no help or worsening from Mirvaso - stop the treatment and take Efracea capsules once daily for up to 16 weeks.
3. If no improvement after 6 weeks, stop Efracea capsules and consult a GP or dermatologist. If there is no improvement in redness and flushing then stop Mirvaso as well.

Mild to moderate spots and pimples (papulopustular rosacea)

1. Initially try Soolantra cream once daily.
2. If also redness and flushing add Mirvaso gel once daily in the mornings as necessary.
3. If no improvement after 2 months swap, from Soolantra cream to Rozex gel twice daily.
4. If still not resolved after 2 months, add Efracea capsules once daily for up to 4 months.
5. If no improvement after 6 weeks, stop Efracea capsules and consult a GP or dermatologist.

Moderate to severe spots and pimples with inflammation and redness

1. Start with Efracea capsules once daily for up to 4 months.
2. If also redness and flushing, add Mirvaso gel once daily in the mornings as necessary.
3. If no improvement after 6 weeks, stop Efracea capsules and consult a GP or dermatologist.

More severe rosacea

Severe rosacea includes thickening and swelling of the nose (rhinophyma), symptoms affecting the eyes (ocular), and associated psychological effects such as severe distress and social phobia. Consult a GP or dermatologist with these conditions and do not self treat.

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Mirvaso gel

Mirvaso gel reduces the redness and facial flushing of rosacea by shrinking the blood vessels in the skin. Mirvaso gel contains the active ingredient brimonidine. It is applied thinly to the face once daily, preferably in the morning, and lessens the redness of rosacea quickly, usually within 30 minutes. It works for up to 12 hours. It should not be used more than once in a 24 hour period.

In studies 7 out of 10 people with rosacea had reduced redness 3 hours after applying Mirvaso. The improvement with Mirvaso lasts up to 12 hours (see detailed study data).

Mirvaso can actually worsen symptoms in 1 in 6 people and care must be taken when starting treatment - see details below. Worsening of redness can occur soon after Mirvaso is applied or later when the effects are wearing off (after 8-12 hours). In trials, the worsening redness settled for most people when they stopped using Mirvaso. Do not use Mirvaso again if it worsened the symptoms. Consult a GP/dermatologist if the worsening redness does not settle within a few days of stopping.

Side effects of Mirvaso gel (brimonidine)

The most common side effects, occurring in up to 16% of users, are flushing, reddening of the skin, a burning sensation and skin irritation. Other possible side effects include dry mouth, headache, low heart rate, low blood pressure and dizziness, and skin reactions, including worsening of rosacea. Mirvaso should not be applied to broken skin, particularly following laser therapy, as this is more likely to lead to severe side effects.

See manufacturer's Mirvaso patient information leaflet for full details.

How to start and use Mirvaso gel

Start treatment with a very small amount of gel (less than the maximum dose) for at least 1 week and increase the dose gradually to the full dose, based on tolerability and response to treatment.

Apply thinly and evenly once daily only over the affected areas of the face, avoiding the lips and eyes. The full dose is a pea-sized amount of gel for each of the reddened areas of the cheeks, forehead, nose, and chin. Gel should not be applied to open sores. Wash hands thoroughly after use.

It is important not to exceed the maximum daily dose (which is 1gm of gel in total weight, approximately 5 pea-sized amounts). One tube should last a month.

Makeup can be applied once the gel has dried.

Consult a doctor face-to-face if symptoms are getting worse.

Who should NOT use Mirvaso gel

Checks are carried out during the Dr Fox online consultation to ensure Mirvaso gel is suitable.

Mirvaso gel is only for use by adults over 18, including over 65s, and NOT children.

Most people can use Mirvaso gel without significant side effects. Only a small amount of the active ingredient, brimonidine, is absorbed through the skin. Not suitable for people prone to low blood pressure or people with serious heart conditions. Some prescribed medicines can interact with Mirvaso gel, most notably medicines which lower blood pressure, and some types of antidepressants.

Although there is no evidence of harm, Mirvaso gel should be avoided in pregnant and breastfeeding women.

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Soolantra cream

Soolantra cream (ivermectin) is used for mild/moderate inflammatory papules and pustules of rosacea. Use once daily, initially for 3-4 months. If there is no improvement after 2-3 months, stop using Soolantra. The course can be repeated if symptoms reoccur on stopping. A break of 1 month is recommended after using for 12 months and to assess if further treatment is needed. It is only to be used by adults.

How to apply Soolantra cream

Only use on the face.

Use a pea-sized amount of the cream once daily only on each part of the face: forehead, chin, nose, and both cheeks. Spread thinly over the whole face, making sure to avoid eyes, lips, and mouth.

Wash hands after applying. Once dried, make up can be applied.

If using with Mirvaso gel: apply the Mirvaso gel first and allow that to dry, before applying Soolantra cream. Alternatively, use Mirvaso gel in the morning and Soolantra cream in the evening.

Side effects of Soolantra cream

Rarely there is a slight worsening of rosacea on starting treatment but this usually settles within a week. If it continues, stop using Soolantra cream.

Up to 1 in 10 people feel some initial burning on application. This usually settles as your skin gets used to the treatment.

For a full list of less common side effects see manufacturer's Soolantra patient information leaflet.

Can anyone use Soolantra cream?

Do not use if you:

• Are pregnant or breastfeeding.
• have severe liver problems.
• Are under 18.

Do not use Soolantra cream if taking these medications:

• Warfarin or other coumarin type blood thinning tablets (anticoagulants where you need regular blood tests).
• Levamisole (rarely used to treat roundworm infection).

Further detail available from the manufacturer's website: How to Use SOOLANTRA Cream (US audience).

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Rozex gel and cream

Rozex (metronidazole) is used for mild to moderate inflammatory pimples, papules, redness, and pustules (spots) of rosacea. Use twice daily, morning and evening. An average course of treatment is 3-4 months. If there is no improvement after 2-3 months, stop and try a different treatment. Always use the least amount and for the shortest time required. Courses can be repeated or continued.

How to apply Rozex

• Wash the face with a mild cleanser before applying the Rozex gel or cream.
• Smooth a thin layer onto the affected skin only.
• Keep Rozex out of eyes (rinse well with large amounts of water if it gets in the eyes).
• Wash hands after use.

If using with Mirvaso gel: apply the Mirvaso gel first and once dried apply Rozex.

Side effects of Rozex

All medicines can cause side effects but not everyone gets them.

Very small amounts of Rozex will be absorbed into the body, so the most common side effects will be skin related.

Up to 1 in 10 people may develop dry skin, redness, itching, burning or stinging feelings, or worsening of rosacea. If the skin is irritated, it should settle by using Rozex less frequently (such as once a day or on alternate days), or stopping it for a while.

More information on side effects can be found in the manufacturer's Rozex patient information leaflet.

Sun and sunbeds

Keep skin out of strong sunlight and avoid exposure to ultraviolet light (sun & sunbeds) as this can make Rozex less effective.

Rozex gel and alcohol

Metronidazole, the active ingredient in Rozex, taken by mouth can react with alcohol, causing an unpleasant Antabuse type reaction (nausea, vomiting, flushing, dizziness, throbbing headache, chest and abdominal discomfort). This is unlikely with Rozex because it is only applied to the skin. However, it is still advised not to drink alcohol whilst using Rozex.

When not to use Rozex

Do not use Rozex if:

• Pregnant or breastfeeding.
• Under 18.
• You suffer from any type of blood disorder.
• Taking warfarin or other coumarin type blood thinning tablets (anticoagulants where you need regular blood tests).

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Efracea capsules

Efracea capsules are an effective treatment for moderate to severe papules and pustules (spots) of rosacea, improving appearances in over 8 out of 10 patients.

Efracea capsules should only be used after first trying a topical treatment (skin application) such as Soolantra cream or Rozex gel/cream for at least 3 months.

Efracea capsules contain a low dose (40mg) of doxycycline, and work through the anti-inflammatory (not antibiotic) effects of doxycycline.

The course is 8-16 weeks but if there is no improvement by 6 weeks stop taking the capsules.

After finishing the course, some symptoms may gradually recur. Wait at least 1 month, before repeating the course.

How to take Efracea capsules

Take one capsule a day in the morning.

Take it on an empty stomach with a full glass of water, either one hour before or two hours after food.

Can anyone take Efracea capsules?

Do not take Efracea if you are/have:

• Pregnant, breastfeeding, or under 12 years old.
• Taking certain other medications - checks made in the online consultation.
• Exposed to strong sunlight/sunbeds.
• Reduced stomach acidity, or pre-existing gullet irritation/ulceration.
• Liver disease, colitis, myasthenia gravis, ocular rosacea.

Side effects of Efracea

All medications can cause side effects. Possible side effects listed by the manufacturer for Efracea are those found at any dose of doxycycline. As Efracea contains a low dose of doxycycline, side effects are generally not common. They can include stomach problems such as heartburn, nausea, vomiting & diarrhoea, and light sensitive skin reactions and rashes.

More information on side effects can be found in the manufacturer's Efracea patient information leaflet.

Buy treatment

Dr Fox supplies rosacea medication on prescription - you are required to answer a short medical questionnaire before your order can be completed.

1. Medical questions
2. Choose treatment
3. Complete order

Answer medical questions to order(rosacea)

Honest & accurate responses are necessary for safe medical assessment