Rationale for Use of Combination Therapy in Rosacea

October 2020 | Volume 19 | Issue 10 | Original Article | 929 | Copyright © October 2020

Published online October 2, 2020

Linda Stein Gold MD,a Hilary Baldwin MD,b Julie C. Harper MDc

aDepartment of Dermatology, Henry Ford Health System, Detroit, MI bDepartment of Dermatology, Acne Treatment & Research Center, Morristown, NJ cDermatology and Skin Care Center of Birmingham, Birmingham, AL

Background: Rosacea is a chronic skin condition characterized by primary and secondary manifestations affecting the centrofacial skin. The primary diagnostic phenotypes for rosacea are fixed centrofacial erythema with periodic intensification, and phymatous changes. Major phenotypes, including papules and pustules, flushing, telangiectasia, and ocular manifestations, may occur concomitantly or independently with the diagnostic features. The phenotypes of rosacea patients may evolve between subtypes and may require multiple treatments concurrently to be effectively managed. We report the proceedings of a roundtable discussion among 3 dermatologists experienced in the treatment of rosacea and present examples of rosacea treatment strategies that target multiple rosacea symptoms presenting in individual patients.
Methods: Three hypothetical cases describing patients representative of those commonly seen by practicing dermatologists were developed. A roundtable discussion was held to discuss overall and specific strategies for treating rosacea based on the cases. Results/Discussion: With few exceptions, the dermatologists recommended combination therapy targeting each manifestation of rosacea for each case. These recommendations are in agreement with the current American Acne and Rosacea Society treatment guidelines for rosacea and are supported by several studies demonstrating beneficial results from combining rosacea treatments. Conclusions: Rosacea is an evolving condition; care should take into account all clinical signs and symptoms of rosacea that are present in an individual patient, understanding that symptoms may change over time, and utilize combination therapy when applicable to target all rosacea symptoms.

J Drugs Dermatol. 2020;19(10): 929-934. doi:10.36849/JDD.2020.5367


Rosacea is a chronic, multifactorial condition associated with various phenotypes affecting the centrofacial skin.1 The primary diagnostic phenotypes for rosacea, as defined by the National Rosacea Society, include fixed centrofacial erythema with periodic intensification, and phymatous changes.2 Major phenotypes, which may occur concomitantly or independently with the diagnostic features, are papules and pustules, flushing, telangiectasia, and ocular manifestations. Secondary signs and symptoms also may occur with the diagnostic or major phenotypes; these may include burning or stinging sensations, facial edema, and a dry appearance of central facial skin.

The presentations of patients with rosacea often involve different combinations of phenotypes or evolve between phenotypes over time and require treatments with different mechanisms of action to manage their disease.1,2 Vascular changes resulting in chronic vasodilation are central to the pathophysiology of rosacea, potentially affecting all of the phenotypes3; therefore, treatments that control vasodilation may lead to overall disease improvement. Guidelines from the American Acne and Rosacea Society (AARS) recommend a phenotype-centered approach to treatment of all rosacea features that a patient displays at any given time.4,5

Three hypothetical cases describing representative patients seen by practicing dermatologists were developed. A teleconference was held among dermatologists experienced in the study and treatment of rosacea (the authors) to discuss treatment strategies for the hypothetical cases. This article reports the roundtable discussion proceedings and provides strategies and recommendations for treating rosacea based on the cases.


Hypothetical Case 1: MJ is a 35-year-old female with Fitzpatrick Skin Type I presenting with diffuse facial erythema that persists between episodes of intense facial flushing that are triggered by hot weather, hot water from a shower/bath, and spicy food. She has papules, pustules, and telangiectasia on her cheeks, and her facial skin appears dry and often is irritated by cosmetics. MJ has tried over-the-counter acne cleansers and, most recently, adapalene, without improvement. Her skin became more inflamed and irritated.

Initial treatment recommendations
We identified this patient’s most prominent rosacea manifestations as background redness, telangiectasia, and papules and pustules, and agreed that the patient displayed combination rosacea. Dr. Stein Gold felt that this patient made a common misdoi: