Meta-analysis: Topical Ivermectin, Encapsulated BPO Show Strongest Efficacy in Rosacea
Key Takeaways
- A network meta-analysis of 32 randomized clinical trials indicated topical ivermectin and encapsulated benzoyl peroxide (E-BPO) outperformed metronidazole in reducing inflammatory lesions and improving Investigator Global Assessment (IGA) success in moderate to severe rosacea.
- E-BPO showed efficacy comparable to ivermectin but was associated with a higher rate of treatment discontinuation due to adverse events compared with metronidazole.
- The investigators suggested the need for longer-term trials and standardized patient-reported outcome measures to better define the comparative benefits and tolerability of topical rosacea therapies.
A systematic review and network meta-analysis of randomized clinical trials suggests that topical ivermectin and encapsulated benzoyl peroxide (E-BPO) provide greater efficacy than metronidazole for adults with moderate to severe rosacea.
The analysis included 32 randomized clinical trials involving 11,399 adults and evaluated 10 topical therapies for rosacea. Investigators searched CENTRAL, MEDLINE, Embase, and Web of Science through August 6, 2025. Most studies followed patients for 8 to 16 weeks.
Network Meta-analysis Compares 10 Topical Rosacea Therapies
Compared with metronidazole, ivermectin produced greater reductions in inflammatory lesion count (mean difference [MD] = 4.17; 95% CI, 1.85 to 6.48) and improved Investigator Global Assessment (IGA) success (MD = 10.31; 95% CI, 2.85-17.77). Encapsulated benzoyl peroxide demonstrated similar efficacy, with greater lesion count reduction (MD = 4.14; 95% CI, 0.62 to 7.66) and higher IGA success rates (MD = 15.51; 95% CI, 2.35 to 28.68).
Overall discontinuation rates due to adverse events were similar across topical therapies; however, E-BPO was associated with a higher frequency of discontinuation than metronidazole (MD = 8.33; 95% CI, 0.45 to 16.22). The investigators noted that evidence for patient-reported outcomes and clinician-assessed erythema was insufficient for robust quantitative analysis.
"Topical ivermectin and encapsulated benzoyl peroxide were more efficacious than metronidazole for rosacea, although encapsulated benzoyl peroxide was also associated with higher discontinuation due to adverse events," the authors wrote. "Future trials should evaluate long-term efficacy, tolerability, and standardized patient-reported outcomes."
Source
Amstutz AV, et al. JAMA Dermatology 2026. Doi:10.1001/jamadermatol.2026.2062