A systematic review and network meta-analysis of 32 RCTs (n=11,399 adults) compared the efficacy and tolerability of 10 topical therapies for moderate to severe rosacea, with most studies spanning 8–16 weeks of follow-up.
Compared with metronidazole, both ivermectin (MD −4.17 lesions; 95% CI, 1.85–6.48) and encapsulated benzoyl peroxide (MD −4.14 lesions; 95% CI, 0.62–7.66) reduced lesion counts more effectively and achieved higher IGA success rates (+10.31% and +15.51%, respectively). However, encapsulated benzoyl peroxide had significantly more discontinuations due to adverse events than metronidazole (MD +8.33%; 95% CI, 0.45–16.22).
- Follow-up was mostly 8–16 weeks, leaving long-term efficacy and tolerability unknown. - Limited data prevented robust synthesis of patient-reported outcomes and erythema endpoints. - Network meta-analysis relies on indirect comparisons, which may introduce uncertainty.
For moderate to severe rosacea, topical ivermectin offers better lesion reduction and IGA response than metronidazole with a similar tolerability profile, making it a strong first-line topical option. Encapsulated benzoyl peroxide is also more efficacious but carries a higher risk of treatment discontinuation due to side effects — counsel patients accordingly before prescribing.
