Best Treatment for Rosacea and Facial Redness Over 40

The best rosacea treatment after 40 depends on which kind of redness you have. For red bumps, ivermectin 1% cream cleared more of them than metronidazole cream in a 962-person trial. For constant background redness, oxymetazoline or brimonidine cream fades the color for several hours a day. If perimenopause hot flushes are part of the picture, estrogen therapy generally calms menopausal flushing, and flushing can make rosacea worse. Many women in their 40s and 50s have more than one of these on the same face, so the answer is often two treatments, not one.

What kind of rosacea redness do I have?

Rosacea comes in four main types:

• Constant redness with visible blood vessels
• Red bumps and pus spots
• Thickened skin, often on the nose
• Eye rosacea

The most common sign is redness across the center of your face that stays there between flares. Only some women also get bumps, according to a review of redness treatments.

That constant redness comes from more blood vessels near the surface of your skin, and from those vessels being wider. They still respond to signals that tighten them. A cream that narrows them can fade the color.

Rosacea bumps can pass for adult acne. One clue helps tell them apart: acne usually comes with blackheads or whiteheads, and rosacea does not.

A study of 59 women with rosacea aged 45 to 55 found that every one of them had constant redness, and 71.2% had moderate to severe redness. Another 57.6% also had bumps. That overlap is why one product often is not enough. Rosacea wears on women, too. In the same group, 45.8% had anxiety and 40% had depression.

What works best for rosacea bumps?

Ivermectin 1% cream is the bump treatment that beat metronidazole in a head-to-head trial. Hot or Nothing does not sell these treatments. Ask the clinician who treats your skin about them.

Ivermectin's edge goes beyond the bump count. Side effects were about as common as with metronidazole, and the skin tolerated ivermectin better. More ivermectin users also rated their improvement as good or excellent.

The doxycycline in that combination is a low dose of 40 mg. At that dose, it is used to calm inflammation rather than as a full antibiotic course.

What helps the redness that never goes away?

Two creams are FDA-approved for constant rosacea redness in adults:

• Brimonidine 0.33% gel (Mirvaso), approved in 2014
• Oxymetazoline 1% cream (Rhofade), approved in 2017

You use each one once a day. Both shrink the blood vessels near the surface so the red fades. In their phase III trials, the late-stage studies used for approval, both creams beat the same cream base without the drug at lowering redness by at least two grades on clinician and patient scales. Side effects were most often mild and stayed on the skin.

Think of them like a color corrector you apply once. The redness fades for several hours, then comes back to about where it started by 12 hours. They suit days when you want the red turned down for work, a dinner or photos.

Brimonidine has a catch. Between 10 and 20% of people using it get redder. That can happen soon after putting it on, when it wears off or after they stop using it. The reaction goes away, but it can be enough to make people stop. Trials of oxymetazoline suggested little to no risk of this rebound redness, though real-world experience was still early when the review was written. Ask whoever prescribes either cream what to watch for.

These creams calm the color. They are the only medical treatments shown to reduce redness caused by permanently widened surface vessels. They are not the creams that clear bumps, so if you have both, you may need one of each.

Is perimenopause making my rosacea worse?

It can. Menopausal flushing is known to make rosacea worse or even set it off. Very little research has looked at menopause and rosacea directly. About 75% of women in perimenopause and menopause get flushing, and the flushing generally responds to estrogen therapy.

A small study of 59 women aged 45 to 55 found that women with lower estradiol had more severe constant redness. Estradiol is the main form of estrogen before menopause. Women with bumps also had lower estradiol. The study only observed the women at one point in time. It suggests an early link, not proof that estrogen treats rosacea.

Estrogen therapy has risks that your clinical team will weigh with you. They include blood clots, breast cancer and endometrial cancer, which is cancer of the uterine lining. Reviewers generally consider these risks low and outweighed by the benefits.

If hot flushes are part of your redness, our clinical team can look at whether bioidentical estrogen fits your plan for the flushing. Keep your rosacea creams for the bumps and the background red.

Which rosacea treatment fits me?

• Mostly red bumps: Ask about ivermectin 1% cream, the option that beat metronidazole head to head. Give it at least a few weeks. In the trial, the gap showed by week 3, and results were measured at 16 weeks.
• Moderate or stubborn bumps: A low anti-inflammatory dose of doxycycline (40 mg once a day) is often paired with a cream, especially at the start.
• Mostly constant red with no bumps: Ask about oxymetazoline or brimonidine for days you want the red toned down. The effect lasts several hours.
• Redness that spikes with hot flushes: Flushing from perimenopause generally responds to estrogen therapy, so bring it up with your clinical team.
• Eye symptoms or a thickening nose: These are separate rosacea types. Get them looked at in person rather than treating them with face creams.

If perimenopause hot flushes are making your face flare, take the quiz to start a plan with our clinical team. They can look at whether bioidentical estrogen fits your goal.