Rosacea- resistant for treatments

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 woman 42yo, skin type III

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Dear colleagues, I’d be grateful for your thoughts and recommendations

Case Summary
Female patient, 42 years old, under observation for over 12 months. No significant medical history except recently diagnosed ADHD, currently managed by her primary care physician.

Current Medications:

• Estradiol patch (low dose)

• Testosterone gel

• Progesterone 200 mg

• Lisdexamfetamine (generic Vyvanse) 40 mg

Patient’s Report:

“Currently using on face:
AM: Paula’s Choice Calm Cleanser, Obagi Toner, spot treatment with 2.5% benzoyl peroxide, SkinBetter Alto Defense, SkinBetter Mineral SPF.
PM: Cleanse, tone, rosacea cream with ivermectin, tretinoin 0.05% gel with hyaluronic acid on non-red areas, and De La Cruz 10% sulfur mask (helps somewhat but doesn’t resolve the issue).

After washing with warm (not hot) water, skin appears blotchy and red (see last picture). The skin is smoother than it looks but remains covered with persistent dark red, flat spots.

Azelaic acid 15% and niacinamide products worsen redness. 0.05% ivermectin formulations caused little improvement and possible irritation. Prescription rosacea cream with ivermectin led to a bumpy, rash-like texture long-term.

Pure beta-glucan serum is tolerated but not significantly effective. Only mineral sunscreens and mineral-based makeup are used; patient avoids fragrance entirely.

Tretinoin is well tolerated on the forehead and outer cheeks but avoided on red areas. Vanicream Vitamin C serum is tolerated but provides no visible benefit.”

Treatment History:

• Broadband Light (BBL 260 vascular) showed improvement for 2–3 weeks, followed by recurrence of redness.

Consultation Question:
I’m seeking expert suggestions regarding the possible underlying cause of this treatment resistance and recommendations for more effective management strategies.