What's on this rung
- Ivermectin 1% (Soolantra) — Evidence A for inflammatory lesions
- Metronidazole 0.75% — long-standing first-line topical (Evidence B)
- Microencapsulated benzoyl peroxide 5% (Epsolay) — FDA-approved for inflammatory lesions (2022)
- Brimonidine / oxymetazoline — temporary redness reduction (Type 1). Brimonidine can cause rebound redness worse than baseline in some users — discuss with your clinician
- Topical cyclosporine drops — used off-label for ocular involvement (Type 4)
What to expect
Meaningful improvement in papulopustular and erythematous rosacea over 8–12 weeks. Often combined with Rung 2.
When to climb
If topicals aren't enough, oral therapy (Rung 4) is the next evidence-backed step.