Which topical products are most effective for treating moderate to severe rosacea?

The comparative efficacy and tolerability of topical therapies for rosacea are not fully understood, particularly for new agents such as encapsulated benzoyl peroxide. To further examine this issue, researchers in Boston, MA compared the efficacy and tolerability of topical treatments for moderate to severe rosacea by performing a systematic review and network meta-analysis of randomized clinical trials (RCTs).The analysis included RCTs that assessed topical therapies for rosacea in adults with moderate to severe rosacea. Only those agents approved by the US Food and Drug Administration (FDA) were included (i.e., metronidazole, ivermectin, azelaic acid, minocycline, encapsulated benzoyl peroxide, brimonidine, oxymetazoline, sulfacetamide). Treatment rankings were estimated using SUCRA (surface under the cumulative ranking) values. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.The prespecified primary outcomes were mean change in absolute lesion count, Investigator Global Assessment (IGA) success, and discontinuation due to adverse events. Secondary outcomes included patient-reported measures and clinician-assessed erythema.Key results:32 RCTs met the inclusion criteria; a total of 11,399 adults were treated with 10 topical interventions. Most studies had an eight- to 16-week follow-up period.Compared with metronidazole (the current standard first-line topical therapy), ivermectin and encapsulated benzoyl peroxide demonstrated greater reductions in lesion count (mean difference [MD], 4.17; 95% confidence interval [CI], 1.85–6.48 for ivermectin; and MD, 4.14; 95%CI, 0.62–7.66 for encapsulated benzoyl peroxide).Compared with metronidazole, ivermectin and encapsulated benzoyl peroxide had a higher likelihood of IGA success (MD, 10.31; 95%CI, 2.85–17.77 for ivermectin; and MD, 15.51; 95%CI, 2.35–28.68 for encapsulated benzoyl peroxide).Frequency of discontinuation due to adverse events was similar among treatments, although discontinuation was more frequent with encapsulated benzoyl peroxide than metronidazole (MD, 8.33; 95%CI, 0.45–16.22). Limited data prevented quantitative analysis of patient-reported outcomes and erythema outcomes.The authors conclude that in this systematic review and network meta-analysis, topicalivermectin and encapsulated benzoyl peroxide were more effective than metronidazole for moderate to severe rosacea; however, encapsulated benzoyl peroxide was associated with higher discontinuation due to adverse events. The authors believe their findings provide comparative evidence to inform initial topical treatment selection for moderate to severe rosacea, but they caution that their analysis was limited to short-term outcomes. They recommend future trials to evaluate long-term efficacy, tolerability and standardized patient-reported outcomes.ReferenceAmstutz AV, Sánchez-Feliciano A, Dewey E, et al. Topical preparations for moderate to severe rosacea treatment. A systematic review and network meta-analysis. JAMA Dermatol 2026; Published online July 1, 2026. (accessed July 9, 2026).

Which topical products are most effective for treating moderate to severe rosacea?

Register for free access or login.

Related Topics