Dermatologist Debriefs

Beyond the Basics: Understanding the Top 3 Prescription Creams for Rosacea

• Stefanie Williams

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Struggling to make sense of your rosacea prescription? In this essential episode of Dermatologist Debriefs, no-nonsense dermatologist Dr. Stefanie Williams cuts through the confusion, giving you a professional breakdown of the three most-prescribed creams for rosacea.

Discover the real reason these treatments work – it might not be what you think! Dr. Williams explains the science behind Metronidazole, Azelaic Acid, and Ivermectin, revealing how they target inflammation. You'll learn which cream is best for sensitive skin, why the formulation you choose matters (including a crucial "life hack" from Dr. Williams), and the vital first step you must take before even considering laser treatment for redness.

Stop the guesswork and start understanding your skin. This is the expert, factual guide to topical rosacea treatments you've been searching for. Tune in to empower yourself with the knowledge to manage your skin effectively.

Speaker 1:

Dermatologist debriefs. Join no-nonsense dermatologist Dr Stephanie Williams as she debunks myths and shares her professional insights, separating facts from fiction, in just a few minutes speak about the three most commonly used prescription creams for rosacea.

Speaker 2:

And before we get into that, just a very quick recap. Rosacea is, of course, a chronic inflammatory skin condition, which is important to know for what we speak about in a little bit. In a little bit, rosacea is characterized by facial redness, including flushing or teliangiectasias, plus inflammatory lesions. So these can be little red bumps or pustules in medical language, and the cause for rosacea is multifactorial. It involves things like immune dysregulation, abnormal vascular responses and also an increased density of demodex mites. And then there are certain environmental triggers like UV exposure, heat or simply using the wrong skin care that can make rosacea skin worse. So if a patient comes to see me in clinic with rosacea and skin care changes alone did not manage to clear the skin, which are the three main topical treatments at our disposal as dermatologists and of course there are also oral treatments we might use. But for today I'm speaking about topical treatment, as that would be a first sensible step for mild to moderate rosacea. And, to clarify, we're talking about treatment of these inflammatory rosacea lesions, so the papules and pustules, those little red bumps or pustules, because those have to be cleared first before we can then go on to treat vascular changes like broken vessels and redness with lasers or IPL. So this always has to be a two-step process. So the first and probably most commonly prescribed cream for rosacea is something called Rosex cream, and this is a brand name. There are other brands with the same ingredient, but this is probably the most well-known one. It contains an active ingredient called metronidazole at a concentration of 0.75%. So in the past there were also creams with 1% available, but because we saw not much of a difference between the response of an 0.75% and a 1% metronidazole cream, we tend to just use 0.75% now. We tend to just use 0.75% now. Now, the precise mechanism by which metronidazole improves rosacea is not entirely understood, but primarily it acts as an anti-inflammatory. So metronidazole inhibits the release of reactive oxygen species from neutrophils. This is a part, one type of our white blood cells and this reduces oxidative tissue damage and inflammation in the skin. Via that reduction of reactive oxygen species, metronidazole also decreases production of a variety of pro-inflammatory cytokines, including TNF-alpha or IL-6, interleukin-6, and in addition it also has a known antimicrobial action, because systemically it's actually used as an antibiotic, but when topically used for rosacea, that is not why we use it, so it's not the primary mechanism of action of metronidazole used topically in rosacea. What we're using it for is really its anti-inflammatory benefit. And the other good thing about metronidazole is that it's generally really well tolerated and doesn't irritate the skin, unlike, for example, ingredients like azelaic acid or retinoids. So for that reason it can generally be used once or twice per day without a need of slowly and gradually having to taper it in. And what metronidazole cream does best is it works against those tiny little red bumps. So the inflammatory rosacea lesions. And here's a life hack from a dermatologist Don't use the gel but the cream formulation. So this ingredient, in the UK anyway, comes as both a gel and a cream. And in my experience as a dermatologist who's treated rosacea for more than 20 years now, I can definitely say that the cream is much more suitable for rosacea skin because the gel can be a little bit irritating for patients, whereas the cream doesn't have that issue at all.

Speaker 2:

Next one up. So the second most commonly used topical treatment for rosacea is finacea gel, which contains azelaic acid at a concentration of 15%. So in the UK this is prescription only at this concentration, but you can get lower concentrations of azelaic acid over the counter. Azelaic acid acts through multiple mechanisms. So on the one hand it is antibacterial, but its primary mechanism of action in rosacea is its anti-inflammatory effect. So it's an anti-inflammatory and an antioxidant as well, and plus it modulates abnormal keratinization. So it has quite a few different mechanisms of action, but the anti-inflammatory effect is the main one we're after when we are treating rosacea skin, and the way it does that is somewhat similar to metronidazole. So it also reduces the release of reactive oxygen species from those neutrophils but and it also reduces the expression of pro-inflammatory cytokines. But it also does this thing that's different from metronidazole it inhibits the Toll-like receptor 2, which is a molecule that has been found to be up regulated in rosacea and is something that drives inflammation. Interesting, the azelaic acid is naturally produced by the yeast Malassezia and can actually improve microbial diversity on the skin too. So this is something that may potentially help restoring a healthier skin microbiome, which we know can be an issue in rosacea sufferers, can be an issue in rosacea sufferers. And last but not least, we also know that azelaic acid can be very helpful to even out irregular pigmentation. So this is a really interesting active ingredient.

Speaker 2:

However, unlike metronidazole cream, azelaic acid gel can be a little bit irritating to the skin. So this should really be tapered in very gradually and used as tolerated and here everybody's different. Most patients over time manage to use it once per day, but even that's too much for you and you can just use it maybe two or three times per week. That's still a good addition. Another potential issue with azelaic acid is that it is notoriously difficult to dissolve in standard base formulation of topicals, so it's poorly soluble in water and cosmetic oils and it requires quite high concentrations of sometimes 20 or even 50 or 60 percent of in my opinion, quite nasty solvents. So something like propylene glycol, which in low concentrations might be all right. But if we are going into really double digits of, you know, up to 50% or so propylene glycol, I would personally not want to use this regularly on my skin. But that's just my personal opinion and that's why some of the topicals containing azelaic acid can be potentially problematic to foracea skin, purely because of these help ingredients needed to formulate that product. But if you get a good formulation of azelaic acid, then this is a really helpful ingredient for rosacea skin.

Speaker 2:

Which brings us to the third most commonly prescribed active ingredient for rosacea, which is a cream called cilantro cream. This contains an active ingredient, ivermectin, at a concentration of one percent. This ingredient name actually may ring a bell because it was relatively widely used as an off-label treatment for early COVID. This then fueled a whole global debate about its effectiveness, but that is a story for a different day. But it is a very well-known ingredient and it has been for a long time, and in fact, two scientists received the Nobel Prize in Physiology and Medicine in 2015, so 20 years ago for developing ivermectin or, to be more specific, the compound that ivermectin was then developed from. And ivermectin has since been an extremely significant anti-parasitic drug worldwide as a systemic medication because it's renowned for dramatically reducing the incident of river blindness dramatically reducing the incident of river blindness, which is a debilitating roundworm infection in parts of Africa and South America.

Speaker 2:

But the use of topical ivermectin for rosacea is a little bit more recent and the main mechanism of action for rosacea is again not the anti-parasitic effect but actually its anti-inflammatory benefit. Ivermectin down regulates multiple key inflammatory mediators, helping to calm the immune response in the skin and, with that, clear inflammatory rosacea lesions. In addition to that and this is quite a unique action compared to the other rosacea creams is that ivermectin also reduces the LL37 peptide, which is known to be overexpressed on rosacea and is an amplifier of inflammation. In addition to that, the antiparasitic effects of ivermectin do have some benefit, actually for rosacea too, because it targets the demodex mites on the skin which have been found in higher densities in rosacea affected skin, and they act as a potential trigger for inflammation. So ivermectin reduces or normalizes the concentration of demodex on the skin. In contrast to azelaic acid, ivermectin is not irritating at all for the skin, so it's very useful in particular for either very sensitive rosacea skin or in cases where there is a more pronounced overgrowth of demodexamides present. So there you have it.

Speaker 2:

These are the three most commonly prescribed creams that we use as dermatologists. Retinoids are sometimes used too, but we have to be a little bit more careful in rosacea skin with retinoids, so vitamin a derivatives, and have to taper them in very gradually and use them as tolerated, because rosacea skin is very sensitive and not everybody who suffers with rosacea can tolerate retinoids, especially not the quite potent prescription strength ones like tretinoin, for example. And in my experience of treating rosacea for more than 20 years now, I found that combining two of these three commonly used ingredients plus lifestyle modifications, generally get the best result rather than just a monotherapy with one of them, because then we are addressing the disease from different angles. And don't forget treat the inflammatory lesions first before proceeding to treatment of vascular rosacea symptoms, which are broken vessels and redness, with laser or IPL. I hope this makes sense and I will speak to you soon. Thank you.