Rosacea is a common but often misunderstood inflammatory skin condition. At its worst can affect well-being and confidence of sufferers. Whilst there’s no cure, management generally centres around skincare and lifestyle changes to control symptoms. There are also a few treatments that can help reduce flare-ups and treat active skin lesions. One of these medications is topical metronidazole skin creams, gels or lotions. In this article, we’re going to take a closer look at metronidazole for rosacea. We’ll review how it works, who it’s suitable for and other uses of metronidazole in dermatology.
What is Rosacea?
This is a chronic inflammatory skin condition that primarily affects the face. The most common symptoms of rosacea are persistent redness, visible blood vessels and sometimes small, red, pus-filled bumps. Often it can be easy to confuse it for similar looking skin conditions like acne, seborrheic dermatitis or even eczema. However, there are certain features that can help diagnose rosacea. These include facial flushing, a feeling of heat or burning on the face and swelling. It can also affect the eyes (ocular rosacea) leading to dryness, irritation and swollen eyelids.
Although the exact cause of rosacea remains unknown, several factors are likely to contribute to its development such as genetic predisposition, abnormalities in facial blood vessels and the presence of a microscopic mite on the skin called Demodex folliculorum. People with a family history of rosacea are also more likely to develop the condition. Additionally, certain environmental and lifestyle factors can trigger or worsen symptoms. These vary from person to person but common ones include sun exposure, stress, hot or cold weather, alcohol consumption, spicy foods and hot drinks. Living with rosacea can be challenging. The visible nature of the symptoms can lead to embarrassment, social anxiety and even depression.
How Does Metronidazole Work?
Metronidazole is an antibiotic and antiprotozoal medication with decades of use, both orally and topically. It is commonly used to treat variety of diseases including gut, oral, genital, pelvic and skin infectious and inflammatory conditions. Metronidazole works through a number of mechanisms. The main one is by inhibiting the synthesis of microbial DNA which then reduces the population of bacteria and parasites that can contribute to inflammation. Metronidazole also inhibits the production of reactive oxygen species (ROS) and other mediators which ultimately reduces inflammation. With regards to the skin, metronidazole also helps to strengthen the skin barrier by repairing damaged and preventing further irritation. These actions have made metronidazole a useful treatment in dermatology.
Benefits of Metronidazole for Rosacea Skin
Topical metronidazole has been used in dermatology for rosacea treatment since the 1980s. It remains an important option for managing papulopustular (acne) rosacea. Numerous studies have shown that metronidazole skin cream can reduce both the number and severity of inflammatory lesions in rosacea. It may also help improve redness associated with these lesions, although its impact on background erythema alone tends to be modest. Despite these benefits, we don’t fully understand the exact way metronidazole works for skin conditions like rosacea. However, researchers generally suspect that metronidazole’s skin benefits are likely down to a combination of the following actions:
- Anti-inflammatory action: Metronidazole appears to suppress the production of reactive oxygen species and other inflammatory mediators in the skin.
- Antimicrobial effects: Whilst rosacea isn’t caused by infection, there’s evidence that certain microbes such as Demodex mites and associated bacteria may trigger or worsen inflammation. Metronidazole’s antimicrobial action may help reduce this burden.
Thanks to these dual effects, metronidazole is thought to help calm down inflammation. This then reduces redness and irritation. These actions also help reduce the papules as well pustules (small bumps and spots) often seen with rosacea.
Who is Metronidazole Suitable for?
Metronidazole skin creams and other forms are prescription only medicine. So, your dermatologist or healthcare provider will need to weigh up whether it is safe and effective for you. As a general rule, topical metronidazole may be a good option in the following rosacea skin concerns:
- Papulopustular rosacea: This is the form of rosacea associated with acne like spots and bumps
- People who experienced sensitive skin or irritation with other treatments
- Those looking for a maintenance treatment to prevent flare-ups
Topical metronidazole may not be the best choice if your main rosacea symptoms are flushing or redness without bumps. It’s also unlikely to be suitable if you’ve already tried and not responded to metronidazole in the past.
Other Uses of Topical Metronidazole in Dermatology
Whilst rosacea is by far the most common indication, topical metronidazole is also sometimes used off-license in dermatology for other inflammatory skin conditions. These include:
- Perioral Dermatitis: This is a condition that causes red, bumpy rashes around the mouth, nose or eyes. Like rosacea, perioral dermatitis is not purely infectious but may respond well to the anti-inflammatory and antimicrobial effects of metronidazole.
- Seborrhoeic Dermatitis: Although not a standard treatment, some dermatologists may consider metronidazole for seborrhoeic dermatitis. This is usually if there’s evidence of associated secondary infection or irritation.
How to Use Metronidazole for Rosacea
Topical metronidazole is available as a cream, gel or lotion by prescription only in countries like the UK and USA. Metronidazole creams tend to suit dry or sensitive skin whilst gels are generally better for oily or acne-prone skin. In the UK, metronidazole is licensed for the treatment of rosacea under brand names like Rozex® and Metrogel®. These are both 0.75% strength and usually used twice a day. Metronidazole 1% treatments (e.g. Noritate®) are also available and are typically once daily. Metronidazole is also available as a compounded treatment. These are specifically made for each patient by specialist pharmacists and allow customisation in terms of concentration, base or addition of other rosacea ingredients.
Regardless of your metronidazole formula, you should always follow your prescriber’s instructions carefully. Pay specific attention to dosage, frequency and application protocol. As a general tip, try to gently cleanse your skin with a mild non-irritating cleanser. Always pat dry before applying a thin layer of metronidazole to the affected areas as directed by your doctor. Also allow the treatment to absorb fully before using moisturisers, sunscreen or makeup. remember to use your metronidazole cream or gel consistently and be patient as rosacea treatments can take several weeks to yield results.
Side Effects & Safety of Metronidazole for Skin
Although topical metronidazole is generally well-tolerated, as with any medication, side effects can occur. The most common ones include:
- Stinging or burning sensation at the application site
- Skin dryness or irritation
- Redness or itching
These side effects often improve as your skin adjusts. If irritation persists, it’s important to discuss this with your doctor, as they may recommend switching to a different formulation or treatment. Rarely, more serious side effects like allergic reactions and systemic side effects like headaches, nausea or palpitations can occur. Always seek medical help if you experience any unusual symptoms after starting a new medication.
Alternatives to Metronidazole for Rosacea
What if metronidazole doesn’t work for your rosacea or if you experience irritation or other problems? Thankfully there are other topical options for treating rosacea. Your doctor may in fact choose these before considering metronidazole skin cream. These medications may include:
- Ivermectin: Targets inflammation and Demodex mites with similar actions to metronidazole.
- Azelaic Acid: Offers anti-inflammatory and keratolytic actions.
- Brimonidine or Oxymetazoline: Reduce persistent redness (erythema) through vasoconstriction.
In some cases, your doctor may recommend oral antibiotics like doxycycline or other treatments like laser or surgery. This is especially likely for severe rosacea and rhinophyma.
Metronidazole is a tried-and-tested topical treatment for rosacea in dermatology. Thanks to its anti-inflammatory and antimicrobial properties, it can help reduce flare-ups and keep symptoms under control. It also has minimal side effects if used correctly under medical supervision. As with most chronic skin conditions, nothing works over night. Even with appropriate treatment, a lot of consistency and patience is required.
At City Skin Clinic, we are super passionate about personalised skincare. We offer safe and effective compound skincare treatments with prescription-strength ingredients. These include Ivermectin, Metronidazole, Azelaic acid, Tretinoin and Hydroquinone where appropriate through online skin clinic. Our doctors treat a range of conditions such as rosacea, acne, hyperpigmentation, melasma and skin ageing. To start your personalised skincare plan, book a virtual video consultation or use our online consultation form. The journey towards great skin starts here.
