Topical Preparations for Moderate to Severe Rosacea Treatment: A Systematic Review and Network Meta-Analysis

Area of Science:

• Dermatology
• Clinical Pharmacology

Background:

• Topical therapies for rosacea, especially novel agents like encapsulated benzoyl peroxide, require comparative efficacy and tolerability data.
• Current characterization of treatment effectiveness for moderate to severe rosacea is incomplete.

Purpose of the Study:

• To conduct a systematic review and network meta-analysis of randomized clinical trials (RCTs).
• To compare the efficacy and tolerability of various topical treatments for moderate to severe rosacea.

Main Methods:

• Systematic search of multiple databases (CENTRAL, MEDLINE, Web of Science, Embase) up to August 2025.
• Inclusion of 32 RCTs involving 11,399 adults with moderate to severe rosacea.
• Network meta-analysis using random-effects models, assessing risk of bias and certainty of evidence.

Main Results:

• Topical ivermectin and encapsulated benzoyl peroxide demonstrated superior reductions in lesion count and higher Investigator Global Assessment (IGA) success rates compared to metronidazole.
• Discontinuation rates due to adverse events were similar across treatments, but higher with encapsulated benzoyl peroxide versus metronidazole.
• Limited data prevented robust synthesis of patient-reported outcomes and erythema.

Conclusions:

• Topical ivermectin and encapsulated benzoyl peroxide are more efficacious than metronidazole for moderate to severe rosacea.
• Encapsulated benzoyl peroxide's efficacy is offset by a higher rate of adverse event-related discontinuation.
• Future research should focus on long-term outcomes, tolerability, and standardized patient-reported measures.