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13.6.2 Rosacea

Topical agents – Rosacea

1st choiceAzelaic acid (15%) gel (Finacea®) Dose:
Apply twice daily; discontinue if no improvement after 2 months
Metronidazole 0.75% topical cream (or gel)Dose:
Apply twice daily for 3-4 months
(moderate to severe where a topical treatment is appropriate)
Ivermectin (Soolantra®) 10mg/g creamDose:
Apply daily for up to 4 months, the treatment course may be repeated; discontinue if no improvement after 3 months

Oral agents (moderate to severe papulopustular rosacea)

1st choiceLymecycline capsules 408mg

408mg daily for 2-3 months

Doxycycline 100mg capsules

100mg once daily for 3months

Prescribing Notes

  • Mild rosacea is best treated with a topical agent.
  • Topical metronidazole is usually preferred as it is well tolerated.
  • Azelaic acid may be more effective, especially in people who do not have sensitive skin. It may cause more adverse effects e.g. stinging and burning.
  • Pustular rosacea is best treated with systemic antibiotics.
  • Courses of antibiotics usually last 6-12 weeks and are repeated intermittently.
  • Brimonidine gel (Mirvaso®) can be considered for the treatment of moderate to severe persistant erythema. It may not reduce erythema in all cases and will not have any effect on papules, pustules or phymatous changes. Telangiectasia may be accentuated as general redness is reduced.
  • Doxycycline 40mg controlled release (Efracea®) can be considered if doxycycline 100mg is not tolerated.
  • Cosmetics can often cover up rosacea effectively.  Note: prescription skin camouflages are not prescribable for rosacea (see section 13.8.2).


  • Brimonidine gel (Mirvaso®): Systemic cardiovascular effects including bradycardia, hypotension and dizziness have been reported after application. It is important to avoid application to irritated or damaged skin, including after laser therapy. See Drug Safety Update June 2017.