Brimonidine

Brimonidine (trade name: Mirvaso) makes the blood vessels narrower, reducing the blood flow to the face and decreasing the redness. But it is not effective in reducing other symptoms of rosacea, such as bumps or pustules.

Brimonidine gel is applied to the skin of the face once a day (for instance, in the morning). It should not be applied to the eyes, lips, mouth or nostrils. Up to 1 gram of the gel should be enough each time you use it. This is about five pea-sized amounts: one for the forehead, one for the chin, one for the nose and one for each cheek. In the first week of treatment, people are advised to use smaller amounts at first and then gradually use more (up to 1 gram) as needed. Once the gel has been absorbed and the skin is dry again, you can use other creams and cosmetics too.

Studies have shown that brimonidine can reduce facial redness: This symptom improved in

• 50 out of 100 people who did not use brimonidine, and
• 76 out of 100 people who used brimonidine.

It usually starts working within one hour, and the effect lasts up to twelve hours.

Possible side effects include skin irritation and allergic reactions in the skin that may make the skin redness even worse. It is important not to get any of the gel in your eyes.

Laser treatment and intense pulsed light therapy

Laser treatment or intense pulsed light therapy are particularly suitable for rosacea with bothersome red blood vessels. Both treatments involve damaging the small blood vessels using heat (also known as cauterizing). But there is hardly any research on these treatment approaches. In Germany, the costs of these treatments aren't covered by statutory health insurers.

Mild pain may occur during and after laser treatment. Cooling the skin can help to reduce the pain. It might also cause superficial skin burns. In addition to pain, this may cause temporary redness, blisters, scabs and swelling. Bleeding at small points on the skin may also occur. But the skin usually heals within a few days. In very rare cases, small scars may remain.

Beta blockers

Facial redness is sometimes treated with beta blockers. This medication causes the blood vessels to become narrower, which lets less blood flow through the skin on the face.

Beta blockers are generally used to treat high blood pressure and other kinds of cardiovascular disease. In Germany, beta blockers are currently not approved for the treatment of rosacea, so they can only be prescribed “off-label”.

Because beta blockers are taken in tablet form, and travel around the body in the bloodstream, they can cause more side effects than creams or gels, which are applied directly to the skin. These side effects include tiredness, dizziness and lightheadedness.

Beta blockers are considered for the treatment of rosacea if the symptoms are severe and no other treatments have helped. But there isn't much research on how effective they are in the treatment of skin redness caused by rosacea. And not everyone is able to take beta blockers. They aren't suitable for people who have asthma, for example, because they could narrow the bronchi in the lungs.

Azelaic acid

Azelaic acid (trade names: Skinoren, Finacea) reduces inflammation and helps prevent pores from becoming blocked. The gel is carefully applied to the affected areas of skin in the morning and in the evening. Half a gram is used per application. That’s about the amount that is squeezed out of a tube along the last section of an adult’s finger (about 2.5 cm long – see illustration).

1 fingertip unit (1 FTU)

Studies have shown that azelaic acid can noticeably reduce rosacea symptoms: The symptoms improved or disappeared in

• 44 out of 100 people who didn't use azelaic acid, compared to
• 62 out of 100 people who did use it.

Ivermectin

Ivermectin (trade name: Soolantra) reduces inflammation and also fights certain mites that increase the risk of rosacea (Demodex mites). It is applied to the facial skin once a day. A pea-sized amount of the cream is used on each of five areas: the forehead, chin, nose and each of the cheeks. Contact with the eyes, lips and mucous membranes should be avoided. Once the cream has been absorbed by the skin, you can use other creams and cosmetics too.

Ivermectin is used for up to four months. The treatment can be repeated if necessary.

Research has shown that ivermectin can relieve the symptoms of rosacea in many people. They improved considerably in

• 37 out of 100 people who did not use ivermectin, and
• 68 out of 100 people who used ivermectin.

Metronidazole

Metronidazole is an antibiotic drug that reduces inflammation. It is very commonly used in the treatment of rosacea. Metronidazole products are applied to the affected areas of skin once or twice a day in the form of a cream, lotion or gel. It is important to make sure that these medications don't come into contact with your eyes or any mucous membranes. Good sunblock is needed if you go outside because they make the skin more sensitive to sunlight. Tanning beds should be avoided.

A few studies have compared azelaic acid with metronidazole, but they led to contradictory results. So it still isn’t clear whether one is more effective than the other.

Doxycycline

If topical treatments don’t help enough or if the rosacea symptoms are severe, oral medication (to be swallowed) may be considered. The antibiotic drug doxycycline is then typically used.

Doxycycline fights bacteria and also reduces inflammation. When used to treat rosacea, it is often taken at lower doses than when used to treat bacterial infections alone.

Because oral doxycycline enters the bloodstream and travels around the whole body, it causes more side effects than topical treatments do: About 10 out of 100 people have side effects due to doxycycline. The possible side effects include diarrhea, nausea and sensitivity to light.