Topical metronidazole for rosacea

By Dr Magnus Lynch MA(Cantab) DPhil(Oxon) MRCS FRCP
Consultant Dermatologist & Dermatological Surgeon

Metronidazole is one of the most frequently used topical treatments for rosacea. It helps reduce inflammation, papules and pustules, and can calm background redness in some people.

When should I use topical metronidazole?

I advise applying at night before bed. Do not apply at the same time as other active ingredients

How long should I use it?

Onset: If it is effective, you should expect to see a noticeable improvement in 4–8 weeks; maximal benefit can take up to 12 weeks.
Maintenance: Many patients continue once-daily maintenance long-term to keep inflammation controlled. Others step down to a few times per week once stable.
When to stop: If you’re consistently clear for several months, you can trial a gradual reduction. If flares recur, restart regular use and/or add in other treatments.

What should I do if metronidazole stops working after a few months?

Rosacea is chronic and can fluctuate. If benefit wears off or flares break through:

Repair skin barrier: Use a bland, fragrance-free moisturiser such as Cetaphil or Cerave to help the skin barrier to heal.
Switch or add another topical: Options include ivermectin (often very effective for inflammatory lesions) or azelaic acid. These can be rotated or combined.
Consider oral therapy for flares: A 6-12 week course of low-dose an antibiotic such as lymecycline can be very effective for settling flares..
For persistent redness/visible vessels: Topicals help less with fixed redness and telangiectasia; vascular laser or IPL is often required.
Re-evaluate the diagnosis: If there’s no response at all, consider alternatives such as periorificial dermatitis, seborrhoeic dermatitis or acne - all of which can co-exist with rosacea.

What if topical metronidazole doesn't work?

Topical metronidazole is often prescribed as a first line treatment but is not always effective and if things don't improve you can switch to or combine with other options such as topical ivermectin (Soolantra) or azelaic acid.

Is gel or cream better?

Gel tends to suit oilier or combination skin; cream/lotion can be more comfortable for dry or sensitive skin.

Can I use it with azelaic acid, niacinamide or ivermectin?

Yes. A common plan is metronidazole in the morning and azelaic acid or ivermectin at night. Niacinamide may help the skin barrier.

How to combine with moisturiser or sunscreen?

After cleansing, apply metronidazole first, allow it to absorb for a minute or two, then moisturiser. In the morning finish with a broad-spectrum SPF 30–50. If stinging occurs, try moisturiser first, then metronidazole.

How much should I use?

Use a pea-sized amount for the whole face. Using more can increase the risk of irritation.

What side-effects should I expect?

Most people tolerate it well. Possible effects include mild dryness, tightness, or transient stinging. Allergy is uncommon. Always the read the product information leaflet for a full list of potential side effects.

Do I need to avoid alcohol like with the tablet?

Metronidazole can cause serious adverse reaction with alcohol when taken as a tablet. When used topically, a small amount can be absorbed through the skin so the risks are less, but the safest thing is to avoid alcohol altogether.

Can I use it long-term? Will it cause resistance?

Yes—many people use it safely for maintenance. It has anti-inflammatory activity more than classic antibiotic effects, and bacterial resistance with topical use is not a major concern..

Is it safe in pregnancy or breastfeeding?

Metronidazole is generally considered safe in pregnancy and breastfeeding

How quickly should it work?

Expect gradual improvement over 4–8 weeks. If there’s no benefit at 12 weeks, consider alternatives.

What if my main issue is persistent redness rather than spots?

Metronidazole can help some background redness, but fixed redness and visible vessels respond best to vascular laser or IPL. Brimonidine or oxymetazoline creams can temporarily reduce redness in some patients but I do not recommend them due to the risk of rebound flares.

Dr. Magnus Lynch, Consultant Dermatologist

About Dr Magnus Lynch

I am a London-based Consultant Dermatologist and Dermatological Surgeon. My NHS practice is at Guy's Hospital and is focused on Mohs micrographic surgery and the treatment of complex skin cancers. My private practice additionally focuses on laser treatments, regenerative dermatology, rosacea, acne, pigmentation and scarring. I have particular expertise in the diagnosis and treatment of skin cancer, including minimally-invasive techniques, Mohs micrographic surgery, and facial reconstructive surgery. I studied at the Universities of Cambridge and Oxford, and completed my dermatology training and Mohs fellowship at the prestigious St John’s Institute of Dermatology. I graduated from medical school in 2003 and have worked exclusively in Dermatology since 2012.

I lead a research team at King’s College London investigating the molecular biology of skin cancer and skin cancer diagnostics, and I constantly aim to translate the latest findings into better patient care. You can learn more about my Research.

In recent years I have been involved in Media Appearances, including the Channel 5 series 'Skin A&E', where I perform skin surgeries and treat various skin conditions. Filming for the next series has recently completed and the series will be released later in 2025.

How I can help

If you’re struggling with rosacea I can offer a tailored treatment plan including topicals (metronidazole, azelaic acid, ivermectin), tablet treatments (e.g. low-dose doxycycline) and vascular laser treatments.

I consult with private patients at several well-appointed and conveniently located sites across central London:

London Bridge Hospital: Conveniently situated within The Shard, next to London Bridge station.
Skin55 Ltd: Located at 55 Harley Street, this beautiful Edwardian building houses one of the largest private dermatology facilities in the UK with a comprehensive laser suite.
OneWelbeck: Located close to Bond Street underground station. Mohs surgery, lasers, and other skin surgeries are performed in the state-of-the-art surgical suite here.

A new consultation is £250, a follow up consultation is £220. For more information on fees, please visit Prices.