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Papulopustular Rosacea

Papulopustular Rosacea resembles acne but has a completely different mechanism. It also requires a different treatment approach.

Papulopustular Rosacea

Papulopustular Rosacea

Topical treatments

  • Ivermectin

  • Metronidazole

  • Azelaic acid

  • Sodium sulfacetamide/sulfur

Topical ivermectin

Ivermectin 10 mg/g cream (Soolantra)

Mechanism of action

It has anti-parasitic activity against Demodex folliculorum.

Anti-inflammatory action: up-regulates the anti-inflammatory cytokine IL-10, inhibits pro-inflammatory cytokines such as IL-1b and TNF- alpha, and decreases neutrophilic phagocytosis and chemotaxis.


Well tolerated

More effective than topical metronidazole.

Effects last longer but takes longer to have an effect.

No concerns with antibiotic resistance.

Stings on application.

It may worsen rosacea initially.


Once daily

Apply a pea-sized amount of ivermectin cream to each of the 5 areas of the face: forehead, chin, nose, and each cheek.

The cream should be spread as a thin layer across the entire face, avoiding the eyes, lips and mucosa.


Apply once daily for up to 4 months.

If there is no improvement after 3 months, the treatment should be discontinued.

The treatment course may be repeated.


Severe hepatic impairment



Drug interactions as systemic absorption can follow topical application.

Adverse effects

Skin reactions

Topical Metronidazole (Metrogel 0.75%)

Topical metronidazole 0.75% (cream or gel).

No effect on flushing


Antimicrobial, anti-inflammatory, or antioxidant properties.

The anti- inflammatory effect of topical metronidazole in rosacea is mediated through reduced release of ROS from neutrophils.


Apply a thin layer twice daily

Limit use to 6-9 weeks.


Avoid exposure to strong sunlight or ultraviolet light with topical use.

Avoid contact with the eyes, mouth, and mucous membranes.

Adverse effects

Mild skin reaction

Severe bullous skin reactions:

Stevens-Johnson syndrome (SJS)

Toxic epidermal necrolysis (TEN)

Acute generalised exanthematous pustulosis (AGEP)

Topical azelaic acid

Azelaic acid 15% gel or 16% foam (Finacea)

Mechanism of action

A naturally occurring dicarboxylic acid with anti-inflammatory and anti-oxidative properties.

Inhibits NADPH oxidase activity on the neutrophilic cell membrane - decreases the reactive oxygen species (ROS) activity.


Avoid if sensitive skin (causes dryness, burning, and stinging)

Apply once to twice daily.

Once daily is equally effective.


Avoid contact with the eyes, mouth, and mucous membranes.

Adverse effects

Skin reactions (uncommon).

Exacerbation of asthma (rare).

Cheilitis (rare).

Topical Sodium sulfacetamide/sulfur

Sodium sulfacetamide 10%/sulfur 5% cleanser, alone or in combination with topical metronidazole 0.75%, appears to be effective in patients with moderate rosacea.

Oral antibiotics

a) Tetracyclines

b) Metronidazole

c) Trimethoprim

The optimal duration of antibiotic therapy is not known.

A lack of response after 2–3 months of antibiotic therapy is usually regarded as treatment failure.

No effect on flushing.

Reserve for papules and pustules.

6-12 weeks

Switching to an alternative oral antibiotic is unlikely to be of benefit.

Discontinue if no improvement is seen after 6 weeks.

On label:

Oxytetracycline 500mg bd

Tetracycline 500 mg bd

Doxycycline modified release 40 mg od (Efracea).

Off label

Doxycycline 100 mg od – take with food (not just water) as sticky.

Lymecycline 408 mg od

Trimethoprim 200mg bd (good second line)

Erythromycin 500mg bd

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