A Sequential Approach to the Treatment of Severe Papulopustular Rosacea Not Responding to Traditional Treatment

June 2016 | Volume 15 | Issue 6 | Case Reports | 769 | Copyright © June 2016

Thomas Dirschka MD,a,b Lutz Schmitz MD,a,c and Ágota Bartha MDa

aCentroDerm® Clinic Wuppertal, Germany
bFaculty of Health, University Witten-Herdecke, Witten, Germany
cRuhr-University Bochum, Department of Dermatology, Bochum, Germany

We report the case of a German female patient presenting with papulopustular rosacea (PPR) with a high count of facial inflammatory lesions and severe erythema who had not responded well to treatment with traditional therapies for a decade. In this patient, a sequential therapy consisting of oral modified-release doxycycline 40 mg (initially as monotherapy, then in combination with topical metronidazole), followed by topical ivermectin 10 mg/g was both rapidly active and effective. Following reduction of the inflammation with modified-release doxycycline 40 mg upfront and the disease becoming moderate in severity, the dose of this agent could be reduced and combination therapy with metronidazole 7.5 mg/g lotion started to continue decreasing inflammatory lesions count and erythema severity, before treatment with the recently approved agent ivermectin 10 mg/g was implemented to provide almost complete clearance. This sequential treatment was effective in reducing both the number of papules and pustules and the severity of erythema, with a good safety profile. In addition, a large improvement was documented in the patient’s DLQI score, contributing to her overall wellbeing.

J Drugs Dermatol. 2016;15(6):769-771.


Papulopustular rosacea (PPR) is characterized by the presence of persistent central facial erythema and central facial papules and/or pustules.1 There is now strong evidence to support that rosacea is a chronic inflammatory disease, with both innate and adaptive immune responses being activated in patients presenting with the PPR subtypes.2 In Germany, the approved therapies for the treatment of papules and pustules in patients with rosacea are3: topical azelaic acid gel (SKINOREN® 150 mg/g)4; modified-release oral doxycycline 40 mg hard capsules (ORAYCEA®)5; and metronidazole, as a topical gel, a cream or a lotion (METROGEL® 7.5 mg/g and METROCREAM® 7.5 mg/g and METROLOTION™ 7.5 mg/ml)6; and ivermectin 10 mg/g cream (SOOLANTRA®), which was approved for use in 2015.7


We report a case of facial PPR with severe erythema where traditional treatment options had not been effective over the course of a decade. The patient responded rapidly to a sequential approach targeting the inflammation, showing a striking reduction in redness and papules/pustules from baseline and a documented, important improvement in the patient’s quality of life.
A 45-year-old Caucasian woman presented to our department with severe erythema in the central facial region, as well as multiple papules and pustules, predominantly on the forehead, cheeks, and chin in December 2014 (Figure 1a). The patient, who indicated that she had suffered from PPR for 10 years, was currently not on any medication, did not have any existing medical conditions, was not a smoker and had no family history of rosacea. During this 10-year period, she had been prescribed metronidazole topical 7.5 mg/ml gel, 7.5 mg/ml cream and 7.5 mg/ml lotion, and although she had experienced intermittent periods of exacerbation and symptom improvement, over 40 facial papules and pustules were always present.
At presentation, the patient had a high lesion count of 122 inflammatory lesions (papules and pustules) and 2 nodules, as well as severe perilesional erythema (Figure 1a). In addition, the patient had a dermatology life quality index (DLQI) score of 25, indicative of an extremely important impact on her quality of life (scores range from 0 to 30).8 Following clinical diagnosis of PPR, a regimen of daily oral therapy with modified-release doxycycline 40 mg was initiated; no topical treatment was prescribed at this time.
The patient returned to our department 9 days later, showing a fast improvement in the severity of the disease. She had a lesion count of 39 inflammatory lesions (papules and pustules) and no nodules, and a DLQI score of 10 (moderate impact on her quality of life), although severe erythema was still present (Figure 1b). Daily oral therapy with modified-release doxycycline 40 mg was continued. One month later, in January 2015, the patient was assessed as having moderate erythema, with a lesion count of 18 (papules and pustules) and no nodules, and a DLQI score of 6 (moderate impact on her quality of life). Following this