American Acne and Rosacea Society Updates Rosacea Management Guideline

papulopustular rosacea, close-up of the patient’s cheek
The guideline update on the management of rosacea is based on systematic literature and evidence-based reviews of available therapeutic agents and physical modalities.

The American Acne and Rosacea Society (AARS) has published a guideline update on the management of rosacea, with new recommendations focused on emerging rosacea therapeutic agents and formulations. The update was published in a recent edition of the Journal of Clinical and Aesthetic Dermatology.

Summary of Rosacea Guidance: Updates on New Agents

According to the AARS, published guidelines for rosacea typically recommend proper skin care, photoprotection, and avoidance of triggers as the cornerstones of prevention. But new evidence supporting novel therapeutic agents has emerged since previous guidance statements. Below is a summary of the new AARS recommendations regarding new and established agents based on rosacea presentation.

Persistent Central Facial Erythema Without Papulopustular Lesions

Patients with rosacea presenting with persistent central facial erythema without papulopustular lesions may do well with a topical alpha-agonist therapy, such as brimonidine or oxymetazoline, according to the AARS.

Studies cited in the guideline suggest topical brimonidine and oxymetazoline improve diffuse facial erythema and produce a better facial appearance compared with devices alone. Despite the data from these studies, the AARS recommends intense pulsed light (IPL), potassium titanyl phosphate (KTP) crystal laser, or pulsed dye laser as adjunct or alternative therapies for persistent central facial erythema without papulopustular lesions. Comments made by the guideline committee indicate the need for more data on the optimal use of device therapies in combination with alpha-agonist therapies in these patients.

Diffuse Central Facial Erythema With Papulopustular Lesions

For cases of diffuse central facial erythema with papulopustular lesions, the AARS recommends several topical and oral therapies, including:

  • topical metronidazole
  • topical azelaic acid
  • topical ivermectin
  • oral tetracyclines
  • topical alpha-agonists
  • oral isotretinoin.

The guideline cites research that demonstrates the successful use of 1% oxymetazoline cream for reducing persistent facial erythema and perilesional erythema in combination with topical metronidazole, topical azelaic acid, topical ivermectin, and oral doxycycline. In patients with severe papulopustular rosacea, subantibiotic dose doxycycline with azelaic acid may the preferred initial oral treatment due to the absence of bacterial selection pressure.

Also, the guideline update recommends oral azithromycin as an alternative approach if oral tetracycline is deemed ineffective or is poorly tolerated by the patient. Clinicians should counsel patients on the potential cardiac risks for tetracycline, especially if they have cardiovascular risk factors.

In cases of refractory disease, clinicians may wish to start oral isotretinoin and then transition to intermittent therapy after initial control of the disease.

Additional alternative topical therapies mentioned in the guideline include sulfacetamide-sulfur, calcineurin inhibitors, retinoids, and permethrin. The guideline cautions that limited data are available on these agents. Other options that may be useful for erythema include IPL, KTP, and pulsed dye laser, but the data on their efficacy for papulopustular lesions is limited.

Flushing Associated With Rosacea

In cases of acute or subacute intermittent vasodilation, the AARS emphasize the importance of prevention by avoiding known triggers such as sun exposure. There are currently limited data on the use of topical therapies to treat flushing. If treatment is indicated, the AARS recommends the use of low-dose oral agents that feature vasoconstrictive properties. These agents include mirtazapine, propranolol, and carvedilol.

The guideline update cites research suggesting intradermal botulinum toxin could be helpful for flushing, but limited data preclude a consensus-based recommendation for its use. In addition, the AARS guideline update points to data from small preliminary studies supporting the efficacy of niacinamide, licorice derivatives, chamomile, green tea, and parthenolide-free extracts of feverfew for improving facial redness and flushing in rosacea.

Granulomatous Rosacea

Evidence-based treatment for granulomatous rosacea, according to the AARS guideline update, include:

  • oral tetracyclines
  • topical pimecrolimus
  • oral isotretinoin
  • oral dapsone
  • intense pulsed-dye laser therapy
  • photodynamic therapy
  • topical brimonidine.

The evidence supporting these treatments is from small studies and case reports. Currently, however, there is no standard treatment for granulomatous rosacea.

Phymatous Rosacea

Recent evidence supports the use of carbon dioxide laser, erbium-doped yttrium aluminum garnet (YAG) laser, electrosurgery, and dermabrasion as potential treatment options for phymatous rosacea. Selection of treatment depends on the stage of disease development, such as early or fibrotic, as well as the extent of inflammation. The AARS guideline suggests oral isotretinoin may improve early soft phymatous changes caused by sebaceous hyperplasia.

Combination Approaches

The AARS notes in the guideline that there is little data to dictate the optimal use of combination strategies for rosacea. Despite this lack of data, the guideline states that the current evidence suggests that it “appears that rationally selected medical therapies can be utilized concurrently” in patients with rosacea.

Disclosure: Several guideline authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Del Rosso JQ, Tanghetti E, Webster G, Stein Gold L, Thiboutot D, Gallo RL. Update on the management of rosacea from the American Acne & Rosacea Society (AARS). J Clin Aesthet Dermatol. 2020;13(6 Suppl):17-24.