A majority of rosacea patients have never heard of antibiotic resistance, results of a recent survey by the National Rosacea Society (NRS) show. Yet topical or oral antibiotics are among the most commonly prescribed treatments for rosacea. The NRS’s recently published standard management options for rosacea note that oral and topical therapies are often initially prescribed in combination, followed by long-term use of a single therapy to maintain remission.
“Dermatologists and rosacea patients can both practice antibiotic stewardship to help protect against resistance,” says James Q. Del Rosso, DO, 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.”

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.
There is strong clinical evidence supporting the use of low-dose doxycycline to treat the papules and pustules of rosacea, including a 40mg doxycycline modified-release capsule developed specifically for rosacea. The 40mg 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 explains. 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
“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 adds.