How is papulopustular rosacea treated?

Unlike other forms, papulo-pustular rosacea is characterised by the presence of pustules and papules on the skin's surface. While there are various therapeutic options, the treatments suggested by the dermatologist depend on the severity of the rosacea.

When the symptoms of rosacea are relatively mild and the number of papules and pustules is less than 10, this is a fairly benign form of rosacea. In this case, the doctor will generally prescribe a single type of treatment from among the topical treatments or oral treatments.

On the other hand, when the symptoms of rosacea are relatively strong and the number of papules and pustules is more than 10 or even 20, this is a form of rosacea referred to as moderate to severe. In this case, the doctor will prescribe a combination of a topical treatment and an oral treatment.

For the various prescriptions made, the treatment is often prescribed for a duration of 6 to 8 weeks. At the end of this period, the progression of symptoms is observed. If the treatment is effective, it is maintained for a duration of 6 to 9 months. However, in the event that the treatment proves ineffective, the management is reconsidered. The doctor can then change the topical treatment used or move to higher doses.

Metronidazole.

The metronidazole is an antibiotic from the imidazole family available in the form of cream, gel or even emulsion. It is known in pharmacies under the name of Rozacreme, Rozagel and Rozex. This medication leads to a significant improvement in the number of pustules, papules and partially erythema, thanks to its anti-inflammatory, anti-parasitic and anti-bacterial activities.

Typically formulated at 0.75% or 1%, metronidazole is most commonly prescribed in twice-daily applications over several weeks depending on the severity and duration of rosacea. Subsequently, it is used as a maintenance treatment to prevent relapses. It is contraindicated in cases of history of allergy to metronidazole or any of the components of the formulation. Finally, it is necessary during a metronidazole treatment to take precautions regarding exposure to the sun and ultraviolet radiation. This should be avoided for the treated area.

Azelaic Acid.

Theazelaic acid is an antibiotic found in the form of a cream called Finacea. It is typically formulated at 15%. This medication has anti-microbial, anti-bacterial, and anti-inflammatory activity. It can also influence follicular hyperkeratosis by inhibiting the proliferation of keratinocytes through the inhibition of DNA synthesis.

It is often prescribed for twice-daily use, in the morning and evening. It is also necessary to avoid sun exposure as a precaution when undergoing the treatment. Azelaic acid is often prescribed as a second-line treatment, as it is less potent than metronidazole. However, it is better tolerated in patients who experience fewer side effects.

Ivermectin.

Theivermectin is an anti-helminthic and anti-parasitic that has recently been used as a new treatment for inflammatory lesions of papulopustular rosacea in adults. Indeed, it exhibits an anti-inflammatory activity. Thus, it limits the symptoms of skin inflammation. Ivermectin also acts on the parasite Demodex, a pro-inflammatory agent in rosacea. It can be found in pharmacies under the name of Soolantra, a cream formulated with 10 mg of ivermectin. Generally, it is prescribed for application once a day, preferably in the evening, avoiding sensitive areas. It can also be combined with other topical treatments. However, treatment with ivermectin is not reimbursed by health insurance and is more expensive than other existing treatments.

Adapalene.

Theadapalene is a retinoid family antibiotic medication with anti-inflammatory activity. It is found in the form of a gel or cream of the same name, formulated at 0.1%, and is prescribed for daily application, preferably in the evening. Adapalene was originally used as an anti-acne treatment, but it also has interesting properties in the case of papulopustular rosacea. However, its prescription is still limited for this condition due to side effects. These can manifest as skin dryness and irritation, burning sensations, or even skin erythema.

Clindamycin Phosphate.

Clindamycin is a antibiotic belonging to the lincosamide class. It possesses anti-bacterial activity that allows it to inhibit the growth of bacteria responsible for the development of inflammation in the case of rosacea acne. Clindamycin phosphate also has anti-inflammatory properties, helping to reduce various symptoms of skin inflammation. It is relatively well tolerated in sensitive skin. This antibiotic can notably be used in combination with other treatments for an optimal effect. Thus, the management can be best adapted according to the intensity of each patient's rosacea acne.

Benzoyl Peroxide.

Benzoyl peroxide is a antioxidant agent. It also acts on hyperkeratinisation and seborrhoeic hypersecretion due to its keratolytic and sebostatic activity. Benzoyl peroxide is often prescribed in combination with another antibiotic, often clindamycin. This combination helps to reduce the number of inflammatory lesions. It also allows a reduction in the risks of bacterial resistance. The combination of benzoyl peroxide and clindamycin is formulated in the form of a 1 to 5% gel found under the name of ClindoxylGel in pharmacies. This gel is effective in reducing the number of papules and pustules associated with rosacea acne.

Tretinoin.

Tretinoin, like adapalene, belongs to the retinoid family. It regulates the growth and maturation of skin cells. Tretinoin acts on the inflammatory phase, leading to a reduction in major symptoms of inflammation such as redness and dilation of blood vessels. It promotes cell regeneration and improves skin texture. Like adapalene, tretinoin is a topical retinoid. It is particularly found in the form of a cream, formulated at a concentration of 0.05% known as Retacnyl.

Doxycycline.

This is a cycline family antibiotic that is administered orally in the form of a tablet or capsule, typically dosed at 50 mg or 100 mg, known as Tolexine. Doxycycline has significant anti-inflammatory properties, helping to reduce papules and pustules. It is a standard treatment that can be prescribed in conjunction with topical metronidazole.

Its prescription is typically daily and it is preferably taken in the evening. Doxycycline is contraindicated in combination with medications from the retinoid family. It should not be used in cases of known allergy to the tetracycline class of antibiotics. Furthermore, as with metronidazole, the intake of doxycycline has a photosensitising effect. Therefore, it is necessary to avoid sun exposure during its use.

Low-dose Isotretinoin.

Isotretinoin is a medication belonging to the retinoid family. It is the stereo-isomer of tretinoin. It comes in the form of a capsule containing 10 mg of isotretinoin, found in pharmacies under the name Curacne or Roaccutane depending on the dosage. It is indicated when the patient develops a resistance to first-line treatments. This medication is prescribed at dosages of 0.5 mg/kg to 1 mg/kg depending on the severity of rosacea. Isotretinoin is relatively effective in treating various forms of papulopustular rosacea. It is contraindicated for pregnant or breastfeeding women, as its intake poses a risk to the foetus. When prescribed, it requires strict dermatological monitoring and regular check-ups.

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• VAN DJIK M. & al. Topical ivermectin in the treatment of papulopustular rosacea: A systematic review of evidence and clinical guideline recommendations. Dermatology and Therapy (2018).