Metronidazole for rosacea: Dosage, uses, and side effects

In this article:

• Understanding rosacea
• Will metronidazole treat rosacea?
• Is metronidazole cream or gel better for rosacea?
• How long does it take to work?
• Side effects and risks
• Do you need antibiotics for rosacea acne?
• Alternatives to metronidazole for rosacea

In this article

• Understanding rosacea
• Will metronidazole treat rosacea?
• Is metronidazole cream or gel better for rosacea?
• How long does it take to work?
• Side effects and risks
• Do you need antibiotics for rosacea acne?
• Alternatives to metronidazole for rosacea

Metronidazole is a prescription medication used to treat bacterial and parasitic infections. It is available in a tablet, as an injection, or topically as a cream or gel. Metrogel, Metrocream, and Metrolotion are brand-name versions of metronidazole, which is also available in generic preparations. Topical metronidazole is approved to treat rosacea, an inflammatory skin condition that affects blood vessels in the face. In this article, learn about metronidazole, how it’s used for rosacea, and alternatives that your healthcare provider may consider.

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Understanding rosacea

Rosacea is a skin condition that affects the blood vessels of the face. It’s a chronic inflammatory disease that tends to come and go over time. Rosacea causes long-term redness (erythema), enlarged blood vessels, and lesions on the skin, which could lead to scarring and ocular rosacea, which affects the eyes.

In order to get the right treatment, healthcare providers diagnose rosacea clinically by ruling out other conditions. “There is no specific test to diagnose rosacea. Instead, a dermatologist will review a patient’s signs and symptoms along with their medical history,” says Long Ly, MD, board-certified dermatologist at MetroDerm in Atlanta, Georgia. “Because rosacea can resemble other conditions, your doctor may consider things like acne, seborrheic dermatitis, contact dermatitis, or perioral dermatitis. These have similar symptoms, but also important differences. For example, acne often involves blackheads and whiteheads, while rosacea does not,” Dr. Ly adds.

Rosacea causes

For people with rosacea, the body’s immune system is activated, causing inflammation in the blood vessels of the face. This leads to the symptoms of rosacea, discussed below. It’s not clear what exactly causes rosacea, but there are risk factors for developing the condition:

• Being 30 years or older
• Being female
• Being fair-skinned and having blonde hair and blue eyes
• Having a family history of rosacea
• Having a personal history of chronic or severe acne
• Being in menopause or perimenopause

Possible triggers for this immune system activation and inflammation are still being studied. These triggers increase the risk of developing rosacea:

• Presence of high amounts of Demodex mites, microscopic mites that commonly live on skin
• Bacterial infection from H. pylori
• Environmental triggers that cause blood vessel dilation, including extreme temperatures, spices, and alcohol consumption
• Inflammation due to ultraviolet (UV) exposure

Rosacea symptoms

Symptoms of rosacea can resemble those of other conditions. The following are some signs and symptoms that a person with rosacea might notice:

• A tendency to flush easily, causing color changes on the skin, along with a warm feeling
• Flushing that lasts for weeks, months, or longer
• Long-term flushing (red or violet) appears on the chin, forehead, ears, neck, upper chest, or scalp
• Acne-like breakouts: papules (bumps) and pustules (bumps filled with pus)
• Visible blood vessels (telangiectasia)
• Eye changes: gritty, dry, tearing, burning, or sore 
• Thickening skin around the nose, chin, ears, foreheads, or eyelids
• Darkening of skin (hyperpigmentation)
• Burning or stinging when putting anything on the face
• Irritated skin: rough, scaly, burning, stinging, tight, or itchy skin 

Will metronidazole treat rosacea?

Yes, metronidazole can treat rosacea symptoms. It’s approved by the Food and Drug Administration (FDA) to treat lesions (the papules and pustules) of rosacea. It works as an anti-inflammatory that helps calm redness and reduce papules and pustules over time.

Metronidazole cream, gel, or lotion may be recommended to treat acne-like breakouts, redness, and bacteria on the skin. In clinical trials, topical metronidazole has been found to reduce redness, itching, pain, soreness, and stinging. Topical metronidazole is more effective than placebo in people with moderate to severe rosacea. 

However, metronidazole creams or gels may be only one part of your rosacea treatment. Though it can be used alone, it’s often combined with other medications such as tetracycline and procedures like laser or light treatment to further control symptoms in some patients. In a study where people with rosacea were successfully treated with tetracycline and metronidazole gel initially, using metronidazole topical gel alone helped prevent redness, papules, and pustules. 

Healthcare providers and dermatology specialists create treatment plans tailored to your individual symptoms with the goal of reducing the signs of rosacea, preventing it from worsening, and easing your discomfort from skin inflammation. Your treatment plan may also change with your symptoms, so it’s important to continue following up with your healthcare provider to get ongoing care tailored to you. 

Is metronidazole cream or gel better for rosacea?

Choosing between a cream or gel version of topical metronidazole may depend on your skin type. Metronidazole is available in either a gel or a cream in concentrations of 0.75% or 1%. Your healthcare provider may recommend a topical metronidazole product based on your skin and how it responds to treatment. Some people may find that gels feel lighter, while creams offer more hydration.  

Gels contain more water in the formulation and may be better for people who have oily, acne-prone skin. Creams have higher oil content, which can be helpful for people with dry or itchy skin. Eleonora Fedonenko, MD, Medical Director of Your Laser Skin Care Center in Los Angeles, California, shares, “I prefer using the gel formulation for patients with oily skin, and the cream formulation for those with dry skin. The active ingredient in both (metronidazole) is the gold standard for long-term maintenance therapy.”

How long does metronidazole take to work for rosacea?

“Typically, patients will experience a 50% reduction in redness and bumps within approximately four to six weeks when utilizing either the 0.75% or 1% formulations of topical metronidazole,” Dr. Fednonenko says. In clinical trials, significant reductions in rosacea symptoms were seen after 4 weeks of 0.75% metronidazole gel treatment. Some patients want the clearing of the increased blood vessels and pustules. But it’s important to be patient, as the condition did not come overnight and will not resolve overnight.  

As for long-term treatment, the American Academy of Dermatology Association (AAD) recommends skincare basics (e.g., gentle skincare products and sun protection), lifestyle modifications (e.g., managing triggers), and maintaining results using a single treatment. As mentioned, topical metronidazole has been shown to prevent future flare-ups of rosacea symptoms, so patients should expect to use it for long-term to maintain remission. 

Metronidazole for rosacea: Side effects and risks

The most common side effects for rosacea involve skin discomfort around the site of application, which may be sensitive due to the inflammation from rosacea to begin with. These include:

• Burning
• Stinging
• Redness
• Skin irritation
• Itchiness
• Worsening of rosacea 
• Dryness

Other side effects of topical metronidazole include:

• Metallic taste
• Tingling or numbness of fingers and toes (peripheral neuropathy)
• Nausea 
• Tearing of the eyes 
• Flu-like symptoms

Topical metronidazole can also cause an allergic reaction when it’s in contact with the skin. Healthcare providers may also use metronidazole with caution in people with a history of blood-related disorders, as there’s a potential for interaction with normal blood cell development. 

If you experience any of the above, especially symptoms related to tingling, numbness, or an allergic reaction, contact your healthcare provider right away.

Do you need antibiotics for rosacea acne?

No, antibiotics aren’t always needed for acne-like breakouts from rosacea. “Rosacea-related acne is typically treated with topical antibiotics like metronidazole or azelaic acid,” Dr. Ly says. 

Topical antibiotics like metronidazole and oral antibiotics like tetracycline are only some of the treatments available for rosacea acne. While antibiotics aim to control bacterial causes of breakouts on the skin, alternatives that aim to reduce inflammation can also help. Other non-antibiotic treatments approved by the FDA for acne-like breakouts include topical azelaic acid and benzoyl peroxide. Newer treatments like ivermectin cream and laser therapy can also help manage symptoms of rosacea-related acne, shares Dr. Ly.

Alternatives to metronidazole for rosacea

Healthcare professionals may consider various topical and oral treatments for rosacea. Commonly-used alternatives to topical metronidazole include:

• Azelaic acid, foam/gel (15%) or cream (20%)
• Ivermectin cream (1%) (e.g., Soolantra)
• Benzoyl peroxide cream (5%)
• Minocycline foam (1%/4.5%) (e.g., Amzeeq)
• Low-dose oral doxycycline (e.g., Oracea)
• Brimonidine tartrate gel (0.33%)
• Oxymetazoline hydrochloride cream (1%) (e.g., Rhofade) 
• Laser therapy or intense pulsed-light (IPL) therapy 

The AAD emphasizes that medication works best when paired with daily skin care and trigger management. Gentle cleansing, regular moisturizing, and broad-spectrum sunscreen daily are foundations for managing symptoms of rosacea. In addition, avoiding triggers such as heat, alcohol, spicy foods, and sun exposure can reduce the risk of flares and help maintain long-term control.

Because rosacea varies widely from person to person, it’s important to work with a healthcare provider or dermatologist. “Your dermatologist will help create a personalized treatment plan based on your medical history, symptoms, skin type, and lifestyle,” Dr. Ly says. 

The bottom line

Topical metronidazole comes in varying strengths and forms of gels and creams. It is commonly used to treat rosacea. It can be used on its own or with other treatments to control rosacea symptoms and prevent future flare-ups. It’s generally safe to use metronidazole, but there are some risks to keep in mind. The most common side effect of topical metronidazole is skin irritation, which can be bothersome for some people with rosacea who already have inflamed skin. Consult with your healthcare provider for individualized treatment, but more importantly, for a maintenance plan to manage this chronic condition.