Jessica Wu, MD (drjessicawu.com) For my patients with mild or early rosacea, I discuss lifestyle changes, with an emphasis on avoiding factors that trigger their symptoms. Many of my patients prefer to avoid antibiotics, and I’ve been impressed with how well some of them can control their symptoms by being strict and diligent with their food, skincare, and lifestyle choices. For those who need additional help, I may prescribe metronidazole gel (Metrogel) or azelaic acid gel (Finacea). If the flare-up if stubborn or sudden, I might recommend oral antibiotics including doxycycline or minocycline. I typically start with a low dose to take advantage of the anti-inflammatory effects of the antibiotic while minimizing the risk of side effects. I see patients in the office every three to four weeks to monitor their progress, and keep them at the minimum dose needed to control their symptoms. Once the symptoms subside, usually in a month or so, I taper them off the antibiotics. I explain to patients that the goal is to manage their flare-ups, not to stay on the antibiotics forever, since it’s not a real cure. Nicholas Perricone, MD (perriconemd.com) Systemic antibiotics would be low on my list of treatments for all of the obvious reasons. Elizabeth Tanzi, MD (skinlaser.com) I like to minimize my oral antibiotic use only for rosacea flare-ups — when there is an explosive breakout and inflammation. Otherwise, I like the combination of topical products and laser treatments. Howard Murad, MD (murad.com) The signs and symptoms of rosacea vary substantially from one patient to another, and treatment must be tailored for each individual case. For patients with redness and pimples, doctors often prescribe oral antibiotics such as tetracycline and topical therapy to bring the condition under immediate control, followed by long-term use of the topical therapy alone to maintain remission. When appropriate, laser treatment or other surgical procedures may be used to remove visible blood vessels, reduce extensive redness or correct disfigurement of the nose. Eye symptoms are commonly treated with oral antibiotics and ophthalmic therapy, but if left untreated, can lead to blindness. Rosacea patients are advised to identify and avoid lifestyle and environmental factors that may aggravate their individual conditions. Patients may also benefit from gentle and appropriate skin care, and cosmetics may be used to reduce the effect of rosacea on appearance. It is unknown exactly why antibiotics work against rosacea, but it is widely believed that it is due to their anti-inflammatory properties, rather than their bacteria-fighting capabilities. Treating your topical skincare needs, following a proper diet and identifying stress triggers that lead to flare ups, a three-pronged approach that I call “inclusive health," will all help lessen the effects of rosacea. Macrene Alexiades-Armenakas, MD (drmacrene.com) Yes, in patients whose rosacea does not clear on topical treatment and lasers, antibiotics may be necessary for some time. Once clear, I wean patients off of antibiotics. Dennis Gross, MD (dennisgrossmd.com) Sometimes lifestyle changes and over-the-counter remedies are enough to keep rosacea at bay, so I would recommend that to a patient before antibiotics. However, if a patient has been adhering to a regimen for at least a month and has not seen visible results then I do recommend a prescription topical, oral antibiotics or light acid peels. Oral medications such as tetracycline, doxycycline, and minocycline, all have been proven to keep rosacea’s bacterial component under control and also seem to have an anti-inflammatory benefit. Topical products such as metronidazole and clindamycin work in much the same way. Light peels help to keep the skin antiseptic and combat bacteria. Jeannette Graf, MD (askdrgraf.com) I am always concerned about overusing antibiotics and antibiotic resistance; however, when indicated in rosacea they can be extremely helpful when topical treatment alone is ineffective. Situations where I recommend antibiotics include an acute flare-up of perioral dermatitis, a flare-up of inflammatory papules and pustules in spite of topical treatment, and ocular rosacea with blepharitis. Neil Sadick, MD (sadickdermatology.com) Typically, I would only recommend antibiotics in cases where a patient has inflammatory pustule lesions and significant redness. There is always a concern regarding overuse of antibiotics and resistance. Marta Rendon, MD (drrendon.com) Yes, in certain circumstances oral antibiotics are indicated to treat rosacea. Antibiotics are used in moderate to severe pustular rosacea. Often the dose of the antibiotics is a very low dose that is not effective as an antibiotic but is effective as an anti-inflammatory. Antibiotics are discontinued as soon as possible in order to limit any possible antibiotic resistance. The oral antibiotics are used along with topical medications in order to facilitate this. H.L. Greenberg, MD (lasvegasdermatology.com) Yes, if there is severe inflammation, I would recommend an antibiotic, be it a topical or pill form. Resistance is always an issue with antibiotic therapy; however, I would not let that issue dictate my therapy for an individual patient. Sarah Swanson (sarahswansonskincare.com) The initial management of rosacea should be topical: mild cleansers, avoidance of irritants, and topical antibiotics or benzoyl peroxide. We recommend topical metronidazole, usually our first-line agent, with or without benzoyl peroxide. This avoids the overuse of oral antibiotics and resistance. When patients fail initial therapy, topical retinoids and oral antibiotics are necessary. Tetracycline is the most common antibiotic used and when possible should be tapered after initial therapy and/or replaced by topical metronidazole to minimize the risks of antibiotic overuse. Eric Schweiger, MD (nyccosmeticdermatology.com) Antibiotic use can be very helpful for inflammatory and papular (bumpy) rosacea. I use them frequently for patients with deep red cheeks and acne-like lesions with success, as long as we limit the course of antibiotics in patients with rosacea to three months or under, or as long as we think it is safe and effective. Nelson Lee Novick, MD (youngerlookingwithoutsurgery.com) Yes, I am concerned about the overuse of antibiotics and the potential for bacterial resistance to antibiotics that may result from this. As a rule, I try to avoid oral antibiotics for most mild to moderately severe cases of rosacea. Topical therapies that include metronidazole cream or gel, azelaic acid cream or gel, and niacinamide can be quite effective in these instances. For more difficult cases, I usually do add an oral antibiotic. My favorite is Oracea, which is a tetracycline-derivative antibiotic that is given in sub-antibiotic doses. Given in this fashion, the medication works as an anti-inflammatory agent, that is, to suppress the inflammation and redness of rosacea acne, without leading to the problems or concerns engendered by the use of conventional antibiotics. Darrell W. Gonzales, MD (coastaldermonline.com) There are both topical and oral treatment options to help control and halt the process of rosacea, but there is some very reasonable concern that the overuse of these medications may lead to bacterial resistance. Ideally, it is best to treat rosacea with topical agents such as metronidazole and sodium sulfacetamide. These products work for many rosacea patients without the risk of developing antibiotic resistance. For patients with more persistent, pustular, or inflammatory rosacea, oral antibiotics are sometimes necessary and effective. One of the most common forms of oral antibiotics for the treatment of rosacea is doxycycline. Fortunately, there are newer formulations of doxycycline with concentrations that can treat rosacea without running the risk of antibacterial resistance. Persons with rosacea not responding to topical agents should ask their dermatologist about this special formulation of doxycycline. Jeffrey Ellis, MD and Amy Slear, MD (belaray.com) Many medications are available, and the key in treating the condition is to find a dermatologist who will be able to identify the best options for your individual situation. Options may include topical creams, oral antibiotics, or low dose Accutane. Each option has its own pros and cons that need to be carefully considered on an individual basis. William Ting, MD (drwilliamting.com) Oral antibiotics may be indicated for inflammatory acne rosacea, particularly with formation of puss bumps. Recent introduction of submicrobial doxycycline minimizes risks of antibiotic resistance. Dina Strachan, MD (dinastrachanmd.com) Yes, I do recommed use of antibiotics for some patients and yes, I am concerned about antibiotic resistance. The good news is that rosacea is not caused by bacteria, so you don’t need a truly “antibiotic” dose of a drug such as doxycycline, to treat rosacea — a lower, antiinflammatory dose will do. This is called a subantimicrobial dose. Brad Abrams, DO (abramsderm.com) Antibiotics are commonly recommended for the treatment of rosacea. However, once facial veins have appeared on the surface of the skin more efficient treatment are available. Because antibiotic resistance is a concern, I always suggest a laser treatment alleviate the use of drug. Patients have seen amazing results with the laser treatment for rosacea. Eric Huang, MD (plasticsandderm.com) Moderate to severe rosacea patients may have papules, pustules, and phymatous changes, all of which can have a significant impact on patients’ lives. Some patients will limit social and professional activities due to embarrassment and low self-esteem concerning their appearance, thus the emotional and psychological impact of rosacea is important to acknowledge. Further, ocular involvement may occur in up to 50 percent of patients and may lead to iritis, corneal neovascularization, and scarring. Thus, despite the rightful concern over antibiotic overuse and resistance, I believe oral antibiotics play an important role in the treatment of rosacea patients.
