Papulopustular rosacea formula guide
How to use the prescribed topical ivermectin, metronidazole and niacinamide compounded gel without confusing it with oral ivermectin.
Papulopustular rosacea formula guide
How to use the prescribed topical ivermectin, metronidazole and niacinamide compounded gel without confusing it with oral ivermectin.
- READ TIME
- 2 min read
- PATHWAY
- Compounded spot formula
- DOSE RANGE
- Pea-sized, once daily → Once daily
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How to use
- What it is and how it works
The validated non-comedogenic gel contains topical ivermectin 1%, metronidazole 0.75% and niacinamide 2% for inflammatory papules and pustules. It is not oral ivermectin and must never be replaced with ivermectin tablets.
- Apply it as prescribed
Apply a thin layer once daily to clean, dry skin over the prescribed area. Avoid the eyes, lips, mucosa, broken skin and the breast area, and wash your hands afterwards. Use only the labelled 30 g gel supplied by the pharmacy.
- Skin care and interactions
Do not add oral ivermectin, another metronidazole product or another facial medicine without clinical review. Tell the prescriber about anticoagulants or blood disorders. Use gentle cleansing, moisturiser and daily sunscreen, and track personal rosacea triggers.
First 8 weeks. Photograph your face in the same light at the start, 4 weeks and 8 weeks, and count papules and pustules. A short-lived increase in spots in the first 2 weeks is expected and is not a reason to stop. Burning, itching or dryness are the most common effects; use a bland moisturiser and SPF 50+.
Ongoing. Stop and ask for review for a spreading rash, facial swelling or blistering. If there is no improvement at 8 weeks, tell your doctor; the diagnosis and oral options are reconsidered. Store the compounded gel as the pharmacy label says and discard it after the stated shelf life.
Treatment pathway
- Pea-sized, once dailyWeeks 1-2
- Once dailyWeeks 3-8
- Once dailyWeeks 9-12
Reviews happen through your account chat; send photos in the same light each time.
See the full decision pathway
Your spot formula pathway
Weeks 1-12
Spot formula once daily
Pea-sized amount spread thinly over affected areas, with a gentle cleanser, moisturiser and SPF 50+.
At 8 weeks, have papules and pustules clearly reduced on your photos?
Yes
Complete the course
Finish 3 months, then maintenance with azelaic acid, metronidazole or ivermectin as agreed with your doctor.
No
Doctor review
Your doctor may add oral doxycycline, reconsider the diagnosis, or refer for in-person care.
Weeks 1-12After the course
Clear or nearly clear
Maintenance
Topical maintenance keeps remission longer; in the ATTRACT extension, relapse after ivermectin came at a median of 115 days.
Partial response
Combine with an oral option
Modified-release doxycycline 40 mg has moderate to high-certainty evidence for papules and pustules.
Reviews happen through your account chat; send photos in the same light each time.
Dose schedule
| Dose | When | Note |
|---|---|---|
| Pea-sized, once daily | Weeks 1-2 | A brief flare can occur as Demodex mites die off; do not stop. |
| Once daily | Weeks 3-8 | Lesions reduce steadily from week 4 in the ivermectin trials. Photo review at 8 weeks. |
| Once daily | Weeks 9-12 | Complete the 3-month course; maintenance plan agreed at review. |
How it compares
| Rosacea treatments compared | How it works | Best suited for | How often | Judged at | Product type |
|---|---|---|---|---|---|
| Azelaic acid 15% | Reduces inflammation and follicular signals behind papules and pustules | Papulopustular rosacea; first-line; sensitive skin | Twice daily | 12 weeks | EU-authorised medicine |
| Compounded redness formula | Metronidazole and azelaic acid calm inflammation; niacinamide and allantoin repair the barrier | Persistent background redness with a mild inflammatory component | Once daily | 12 weeks | Pharmacy-compounded to prescription |
| Compounded spot formula | Ivermectin acts on Demodex and inflammation; metronidazole adds anti-inflammatory effect | Moderate papules and pustules, or after azelaic acid alone is not enough | Once daily | 12 weeks | Pharmacy-compounded to prescription |
Evidence certainty from van Zuuren 2019 (BJD): high for azelaic acid and ivermectin, moderate for metronidazole, for papules and pustules. Compounded combinations have not been trialled as products.
Side effects
Local irritation
Mild redness, dryness, stinging or peeling can occur, especially at the start. Use a gentle moisturiser and follow the prescribed adjustment plan. Stop and seek advice if the reaction is marked or persistent.
Inflammation or allergy
Burning, itching or redness can occur. Stop and seek advice for marked swelling, a spreading rash, blistering or symptoms that do not settle after a short pause.
Do not use if
- You are allergic to ivermectin, metronidazole, niacinamide or the final vehicle
- You are pregnant, trying to conceive or breastfeeding and the formula has not been individually reviewed
- The skin is broken or severely inflamed, or the labelled preparation does not match the prescribed topical formula
When to contact your doctor
- Facial swelling, breathing difficulty, widespread blistering, eye pain, light sensitivity or altered vision: seek urgent medical care
- You become pregnant, plan a pregnancy or are breastfeeding: stop and request an individual review
- There is no satisfactory response at the 6–12-week review or papules and pustules are worsening
Storage
Keep the compounded preparation in its labelled container, out of children's reach. Follow the pharmacy's storage conditions and beyond-use date; these depend on the final vehicle. Do not transfer it to another container.
What to expect
Inflammatory lesions should improve gradually during the 3-month course. The 6–12-week review confirms whether the diagnosis, adherence and formula remain appropriate; do not substitute tablets or change the formula yourself.
Sources
Questions while you're on treatment?
Message your doctor in your private chat about side effects, doses or anything that worries you. Replies in under 2 hours on average.
- Follow up on your skin treatment in the chat
- Download your e-prescription
- Renewals reviewed by your doctor
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