Although 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 rosacea patients have never heard of antibiotic resistance — the development of harmful bacteria unaffected by 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 one of the most serious public health challenges facing the United States.
A recent study by the Centers for Disease Control and Prevention (CDC) found that 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. While antibiotics are commonly used for their bacteria-killing capabilities, dermatologists also use antibiotics for their anti-inflammatory properties to treat common conditions like rosacea, a chronic red-faced, acne-like disorder estimated to affect more than 16 million Americans. The problem 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.
Antibiotic-resistant strains of bacteria are commonly referred to as “superbugs.” The CDC estimates that Americans contract more than 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 healthcare- and community-based policy changes, as well as the research and development of new antibiotic treatments. Multiple governmental organizations such as the Food and Drug Administration (FDA) and the CDC, as well as non-governmental organizations like the Pew Charitable Trusts, a global research and public policy organization dedicated to serving the public, are leading initiatives to protect Americans against a future without effective antibiotics.
“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. “It requires avoiding oral antibiotic dosing as much as possible and remaining aware of guideline suggestions that may be applied to patient care.”
As noted in the NRS’s recently published standard management options for rosacea, oral and topical therapies are often initially prescribed in combination, followed by long-term use of a single therapy to maintain remission.1
There is strong clinical evidence supporting the use of low-dose doxycycline to treat the bumps and pimples (papules and pustules) of rosacea, including a 40 mg doxycycline modified-release capsule developed specifically for rosacea.2,3 The 40 mg dosage is subantimicrobial, avoiding antibiotic resistance while reducing the inflammation associated with this condition.
In severe cases, higher doses of oral antibiotics may be prescribed. However, since higher doses may also have an antimicrobial effect, Dr. Del Rosso recommended that such treatment be carefully managed and not used for long-term maintenance.
“Topical formulations are advantageous for long-term therapy because they deliver effective concentrations to the skin without much risk of systemic exposure,” Dr. Del Rosso explained. 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.1
In order to receive the most benefit from medical treatment and to stop the spread of antibiotic resistance, rosacea patients should ask their doctors about an effective, non-antibiotic dose option of oral medication as well as topical therapy to treat the bumps and pimples of rosacea, and follow dosage and application instructions. If prescribed oral therapy, that may mean taking the correct number of doses at the appropriate time. For topical medications, patients should follow application instructions, making sure not to forgo or reduce treatment that’s meant to continue indefinitely in order to retain remission.
“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,” Dr. Del Rosso said.
Rosacea sufferers can learn more about rosacea and the role antibiotics play at rosacea.org. and read more about antibiotic resistance at SaveAntibiotics.org.
Rosacea is a chronic disorder of the facial skin with various potential signs and symptoms, often characterized by flare-ups and remissions. It typically begins at any time after age 30 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 around half of patients, the eyes are also affected, feeling irritated and appearing watery or bloodshot.
Anyone who suspects they may have rosacea should see a dermatologist for diagnosis and appropriate therapy.
About the National Rosacea Society
The National Rosacea Society is the world’s largest organization dedicated to improving the lives of the estimated 16 million Americans who suffer from this widespread but poorly understood disorder. Its mission is to raise awareness of rosacea, provide public health information on the disorder and support medical research that may lead to improvements in its management, prevention and potential cure.
Comprehensive information and materials on rosacea are available on the NRS website at rosacea.org. The NRS may also be followed on Facebook, Twitter, Instagram or Pinterest for up-to-date information and tips on rosacea. Further information may be obtained by writing the National Rosacea Society, 111 Lions Dr., Suite 216, Barrington, Illinois 60010; via email at firstname.lastname@example.org; or by calling its toll-free number at 1-888-NO-BLUSH.
1. 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
2. Nagler AR, Del Rosso J. The use of oral antibiotics in the management of rosacea. J Drug Dermatol 2019 June;18(6) 506-513.
3. 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.