Fighting Antibiotic Resistance in Patients With Rosacea


A recent survey found the majority of patients with rosacea have never heard of antibiotic resistance, despite that many of the most commonly prescribed treatments for rosacea are oral or topical antibiotics.

A recent survey by the National Rosacea Society (NRS) found the majority of patients with rosacea have never heard of antibiotic resistance, despite that many of the most commonly prescribed treatments for rosacea are oral or topical antibiotics. The finding highlights the importance of proper care in the use of antibiotics by dermatologists and patients, and the need for greater awareness and education about 1 of the most serious public health challenges facing the United States.1

Rosacea is an acne-like chronic condition of the facial skin that affects 16 million Americans and is often characterized by flare-ups and remissions. According to the NRS, rosacea typically begins at any time after age 30 years as a flushing or redness on the cheeks, nose, chin or forehead that may come and go. Over time, the redness tends to become ruddier and more persistent, and small blood vessels may appear. Without treatment, bumps and pimples often develop, and in severe cases the nose may become swollen from excess tissue. In about half of patients, the eyes are also affected, feeling irritated and appearing watery or bloodshot.1

According to a recent study by the CDC, in 2015, dermatologists wrote more prescriptions for antibiotics than any other medical specialty, with individual dermatologists writing an average of 162 more prescriptions for oral antibiotics annually than primary care physicians.2 Although antibiotics are commonly used for their bacteria-killing capabilities, dermatologists also use these drugs for their anti-inflammatory properties to treat common conditions that include rosacea. The problem of antibiotic resistance can arise when high doses of antibiotics are used, as the affected bacteria may evolve an ability to withstand the drugs designed to eliminate them.1

Antibiotic-resistant strains of bacteria are commonly referred to as “superbugs.” According to the CDC, Americans contract more than an estimated 2.8 million infections caused by superbugs each year, and at least 35,000 people die as a result. The fight against antibiotic resistance is multifaceted and includes environmental strategies and health care- and community-based policy changes, as well as the research and development of new antibiotic treatments. Multiple governmental organizations, including the FDA and the CDC, as well as nongovernmental organizations are leading initiatives to protect Americans against a future without effective antibiotics.1

“Dermatologists and rosacea patients can both practice antibiotic stewardship to help protect against resistance,” said Dr. James Del Rosso, adjunct clinical professor of dermatology at Touro University College of Osteopathic Medicine, in a prepared statement. “It requires avoiding oral antibiotic dosing as much as possible and remaining aware of guideline suggestions that may be applied to patient care.”1

According to standard management options for rosacea— recently published by the NRS—oral and topical therapies are often initially prescribed in combination, followed by long-term use of a single therapy to maintain remission.3

There is strong clinical evidence supporting the use of low-dose doxycycline to treat the bumps and pimples of rosacea, including a 40 mg doxycycline modified-release capsule developed specifically for rosacea.4,5 The 40 mg dosage is sub-antimicrobial, avoiding antibiotic resistance while reducing the inflammation associated with this condition.1

In severe cases, higher doses of oral antibiotics may be prescribed. However, since higher doses may also have an antimicrobial effect, Del Rosso recommended that such treatment be carefully managed and not used for long-term maintenance.1 

“Topical formulations are advantageous for long-term therapy because they deliver effective concentrations to the skin without much risk of systemic exposure,” Del Rosso said. For long-term maintenance therapy, low-dose doxycycline or common topical treatments such as ivermectin, azelaic acid and metronidazole have been found to result in increased rates of remission.3

Patients with rosacea should ask their health care providers about an effective, nonantibiotic dose option of oral medication and a topical therapy to treat rosacea, and follow dosage and application instructions, to receive the most benefit from medical treatment and to stop the spread of antibiotic resistance. Prescribed oral therapy may mean taking the correct number of doses at the appropriate time. Patients with topical medication should follow application instructions, making sure not to forgo or reduce treatment that is meant to continue indefinitely in order to retain remission.1 

“The good news is that multiple treatment options for rosacea are now available that can be tailored for each rosacea patient while minimizing the risk of bacterial resistance,” Del Rosso said.1


  1. Rosacea sufferers and dermatologists can play important role in fighting antibiotic resistance [news release]. Barrington, IL; January 26, 2021: National Rosacea Society. Accessed February 1, 2021.
  2. Outpatient Antibiotic Prescriptions—United States, 2015. CDC. Reviewed September 12, 2017. Accessed February 1, 2021.
  3. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: the 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2020;82(6):1501–1510. doi:10.1016/j.jaad.2020.01.077
  4. Nagler AR, Del Rosso J. The use of oral antibiotics in the management of rosacea. J Drug Dermatol 2019 June;18(6) 506-513.
  5. Del Rosso J, Zeichner J. The clinical relevance of antibiotic resistance: thirteen principles that every dermatologist needs to consider when prescribing antibiotic therapy. Dermatol Clin 2016;34(2):167-173.
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