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Gold Standard for Rosacea Treatment

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The gold standard for rosacea treatment is Oracea and Soolantra, both Rx(s) from Galderma (yes, Galderma has sponsored three RRDi education grants).  

A recent report states, "First randomized clinical trial comparing the efficacy and safety of combined doxycycline 40 mg modified release (DMR) and ivermectin 1% cream (IVM), versus ivermectin 1% cream plus placebo in adults with severe papulopustular rosacea, reveals more than double the number of patients reach 'clear' (100% lesion clearance) at 12 weeks." Galderma: New Data Reveals Benefits of Combining Oral and Topical Treatment in Patients With Severe Papulopustular Rosacea, Press Release, P&T Community

"Combining IVM and DMR can produce faster responses, improve response rates, and increase patient satisfaction in severe rosacea." 
A randomized phase 3b/4 study to evaluate concomitant use of topical ivermectin 1% cream and doxycycline 40 mg modified-release capsules versus topical ivermectin 1% cream and placebo in the treatment of severe rosacea.

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Soolantra
"In comparing topical ivermectin and metronidazole, ivermectin was more effective; this treatment modality boasted more improved quality of life, reduced lesion counts, and more favorable participant and physician assessment of disease severity. Patients who received ivermectin 1% cream had an acceptable safety profile. Ivermectin is efficacious in decreasing inflammatory lesion counts and erythema." Ivermectin More Effective Than Metronidazole

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Oracea
Oracea is 40 mg (10 mg is timed released doxycycline while the other 30 mg is immediate release) taken orally and Soolantra contains 1% Ivermectin applied topically. Some physicians also recommend using the Soolantra at night and then washing it off and applying metronidazole topical in the am. 

"In addition, there were significant differences in the distribution of baseline and week 12 IGA scores in the PP group (P = .0012). At week 12, most participants (63.6%) had mild CEA scores; the distribution was significantly different from baseline (P = .0407). Only 7% of participants had treatment-related adverse events (AEs), mostly mild or moderate in severity. Thus the 40-mg formulation of doxycycline proved to be effective and well-tolerated in a real-world setting in participants with rosacea who were receiving topical therapy but still experiencing symptoms." Effectiveness and safety of doxycycline 40 mg (30-mg immediate-release and 10-mg delayed-release beads) once daily as add-on therapy to existing topical regimens for the treatment of papulopustular rosacea: results from a community-based trial.

The Treatment
If your physician (hopefully a dermatologist) hasn't treated you with the gold standard, then, your physician simply isn't keeping up with the latest information on rosacea treatment. So if you received a prescription for doxycycline and metronidazole, your physician simply isn't keep up with the latest state of art medical treatment for rosacea, the 'gold standard'. However, if your physician has prescribed the gold standard treatment, some may also give you a topical to use during the day (use the Soolantra at night) like metronidazole or azelic acid or recommend a moisturizer for the day, especially if you have dry skin. There are reports that some physicians are also giving metronidazole cream or gel for their patients to use during the day after applying the Soolantra at night, washing off the Soolantra in the AM and applying metronidazole during the day, repeating this regimen each night, along with taking Oracea orally each day. 

If Oracea and Soolantra does not improve your rosacea within a month, then you obviously have some other rosacea variant, rosacea mimic, or some other possible co-existing condition or another skin condition. Usually it takes 12 weeks for clearance, then after that a reduced maintenance treatment may be required, since the demodex mites do come back. 

Also, if your physician diagnoses you with a subtype of rosacea, your physician hasn't been keeping up with the new phenotype classification of rosacea, so you may want to find one who is keeping up with the latest information on rosacea.

Once you are on the gold standard of treatment for rosacea you should improve within thirty days. Some may take longer, say sixty to ninety days, but usually you will know whether this treatment improves your rosacea within this time period. If not, you simply go back to your physician (hopefully a dermatologist) who will prescribe a different treatment if you don't respond to the gold standard. Not everyone will respond well to the gold standard, but it is worth trying since many do improve their rosacea with this treatment. If you are suffering from demodectic rosacea the gold standard will either improve your rosacea or rule out demodectic rosacea

Because the gold standard is so expensive (hence the gold designation), in many social media groups, i.e., Facebook, Twitter, Reddit, there are reports that many have been trying an inexpensive horse paste and rave about the success. 50 mg generic doxycycline is also available which is not as expensive (or 20 mg generic doxycycline twice a day). There are other options or alternatives  also reported using oral ivermectin and metronidazole, benzyl benzoate and crotamiton, other demodectic treatmentsother prescriptionssecondary therapy, the ZZ Creamdemodex treatments,  probiotics (probiotic therapy), or when rosacea doesn't respond to standard therapies

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