Dear colleagues,

I would like to ask for your professional opinion regarding a challenging rosacea case.

Patient: Female, 34 years old.

Main concerns: persistent erythema and facial hyperpigmentation.

During flare-ups, the patient develops papules, which respond well to topical ivermectin.

However, after resolution of inflammatory lesions, the persistent erythema remains a major concern.

We have attempted treatment with IPL and yellow Vbeam laser, using very mild parameters, yet no clinical improvement was achieved. On several occasions, the patient even experienced mild flare-ups following these procedures.

Trials with topical tranexamic acid and azelaic acid also failed to produce meaningful improvement in erythema.

I would appreciate your insights and recommendations regarding further management strategies for such cases — particularly any experience with systemic or combination therapies that might help address treatment-resistant erythema.

Thank you in advance for your expertise and suggestions.