Understanding ivermectin, metronidazole & azelaic acid

Table of Content:
What are ivermectin, metronidazole & azelaic acid? | Is there a generic ivermectin, metronidazole & azelaic cream? | Do you need a prescription? | How get a prescription? | What is the price? | How to use it? | Side effects | What to avoid? | Who is it for? | FAQ

---

What are ivermectin, metronidazole & azelaic acid used for?

Dr. Ryan Trowbridge, board-certified dermatologist who offers online consultations via Miiskin says that ivermectin, metronidazole and azelaic acid are commonly used to treat rosacea. Each ingredient tackles a different part of the problem.

Ivermectin

• Targets Demodex mites (tiny skin mites linked to rosacea flares)
• Has anti-inflammatory effects (via direct anti-inflammatory effects and indirectly by reducing overgrowth of demodex mites)
• Primarily helps reduce papules and pustules over time; some minor evidence showing it could help marginally with flushing

Metronidazole

• Although classified as an anti-microbial, impact in rosacea is thought to be through reduction of inflammation by reducing reactive oxygen species
• Primarily reduces papules and pustules and redness/swelling associated with those lesions. 
• Long-time staple treatment for rosacea

Azelaic acid

• Reduces inflammation directly leading to reduction in papules and pustules and associated redness
• In rosacea treatment, primarily aids in reduction of papules and pustules and associated redness. 
• Can also help unclog pores and reduce mild hyperpigmentation, but these aren’t common factors contributing to rosacea

Is there a generic ivermectin, metronidazole & azelaic cream?

No, Dr. Trowbridge says there isn’t a branded or generic medication that combines ivermectin, metronidazole and azelaic acid into a single cream (although they are available individually). However, custom compounded versions of that triple combination can be made by a specialty pharmacy such as Foothills Pharmacy with a dermatologist’s prescription.

Do you need a prescription to buy ivermectin, metronidazole or azelaic cream?

Yes, you need a prescription to buy each cream individually or compounded cream that contains ivermectin, metronidazole, and azelaic acid.

How get a prescription for ivermectin, metronidazole & azelaic cream?

You can request a customized prescription for rosacea via Miiskin, if your dermatologist deems it adequate, they can issue a prescription for a customized formula that may include one or more ingredients, including ivermectin, metronidazole, and azelaic acid. You upload photos and describe your symptoms, and a dermatologist reviews your case; if the treatment is appropriate, they issue a prescription, which can then be filled by a Foothills pharmacy and delivered to you, once payment is processed. Consultation price is $59 and prescription renewals are $39.

What is the price of ivermectin, metronidazole & azelaic cream?

The price of most compounded formulas available via Foothills Pharmacy (including  ivermectin, metronidazole, and azelaic acid cream) is $48.99 for a 30 gram tube.

How to use ivermectin, metronidazole or azelaic?

Dr. Trowbridge says you should always follow your specific dermatologist’s recommendations (as we all have slight differences in how we may want the cream applied in  your specific case) but as a general rule, this is how the typical way to use of ivermectin, metronidazole or azelaic acid creams and gels looks like:

• Apply once daily, usually in the evening, to clean, dry skin
• Use a pea-sized amount for the whole face (or the amount prescribed) and spread a thin, even layer over affected areas
• Avoid the eyes, lips, and nostrils
• Let it absorb fully before applying moisturizer; if your skin is sensitive, you can moisturize before or after applying the cream
• Wash your hands after application

Dermatologist’s tips:

• Mild tingling, dryness, or redness can happen at first, this often settles within 1–2 weeks.
• Use daily sunscreen in the morning
• Results build gradually; improvement is usually seen after 4–8 weeks with consistent use

Potential side effects related to ivermectin, metronidazole or azelaic 

Common side effects

• Mild burning, stinging, or tingling
• Redness or flushing
• Dryness, peeling, or tightness
• Itching

Less common side effects

• Increased skin sensitivity
• Temporary worsening of redness or bumps at the start of treatment
• Contact dermatitis (rash or irritation)

What should I avoid when using ivermectin, metronidazole or azelaic cream?

When using ivermectin, metronidazole or azelaic acid, a few simple things can make a big difference in how well it works and how calm your skin stays.

Avoid combining with harsh products

• Retinoids (retinol, tretinoin) unless your clinician says it’s OK
• Exfoliating acids (AHA/BHA, glycolic, salicylic)
• Physical scrubs or cleansing brushes
• Alcohol-based toners or astringents
• Benzoyl peroxide
• In rare circumstances, nausea or vomiting can occur if consuming alcohol while using this product due to the presence of metronidazole

Lifestyle triggers to avoid for rosacea

• Excess sun exposure (use daily sunscreen SPF 50)
• Hot showers, saunas, and steam
• Spicy foods, hot drinks, and alcohol
• Extreme cold or wind

Other important tips

• Don’t layer multiple new products at once, introduce skincare slowly
• Use gentle, fragrance-free cleansers and moisturizers
• If irritation occurs, pause treatment and moisturize, then restart less frequently

Who is ivermectin, metronidazole or azelaic acid for?

Dr. Trowbridge says he usually prescribes ivermectin, metronidazole or azelaic acid for people who have rosacea that manifests with papules and pustules, especially when individual topical agents have been ineffective. 

It’s typically prescribed for adults with:

• Papulopustular rosacea (red bumps and pus-filled spots)
• Rosacea linked to Demodex mites
• Rosacea that hasn’t responded well to a single treatment

FAQ about ivermectin, metronidazole or azelaic acid

What do ivermectin, metronidazole & azelaic cream do?

Dr. Trowbridge says that these creams are usually prescribed for rosacea; they each work differently by reducing inflammation, bumps, pustules, and redness associated with these skin lesions. They all target factors that lead to inflammation, the primary driver of rosacea, with ivermectin additionally targeting Demodex mites which often contributes to inflammation (and in occasional scenarios is the sole driver). 

Can you apply ivermectin, metronidazole & azelaic cream together?

Yes. When prescribed by a dermatologist, or when they are compounded together.

What is the best time to apply ivermectin, metronidazole or azelaic creams and gels?

Dr. Trowbridge recommends applying these creams during the evening, primarily because ivermectin seems most effective then (demodex may be more active at nighttime).  

Will my rosacea come back if I stop using ivermectin, metronidazole or azelaic creams and gels?

Dr. Trowbridge says that rosacea is chronic, but can be relapsing and remitting.  So, symptoms may return if treatment is stopped. Many people use this cream as long-term maintenance or intermittently to prevent flares.  You can come up with a long-term treatment plan with your dermatologist that best works for you.

What can trigger rosacea?

Dr. Om says that rosacea triggers vary from person to person, but common ones include sun exposure, hot weather, spicy foods, alcohol (especially red wine), emotional stress, and harsh skin care products. Temperature extremes, hot drinks, and exercise can also cause flare-ups. Keeping a trigger journal can help identify what makes your symptoms worse, so you can avoid them more effectively.
Tretinoin can also potentially flare rosacea. If you are already using it, it should be used with caution during rosacea flares as it could exacerbate the condition.