Topical Calcineurin Inhibitors in Rosacea: Potential Benefit in Selected Clinical Settings and Risk of Rosaceiform Dermatitis

Rosacea is a chronic inflammatory skin disorder characterized by persistent erythema, flushing, papules, pustules, and telangiectasia, predominantly affecting the central face. Topical calcineurin inhibitors (TCIs), including tacrolimus and pimecrolimus, are approved for atopic dermatitis(AD) but have also been used off-label in rosacea and other facial inflammatory dermatoses. Evidence for their use in rosacea is limited and mixed. Some small uncontrolled studies have reported clinical improvement, particularly with pimecrolimus. In contrast, rosaceiform dermatitis has been reported during treatment with both tacrolimus and pimecrolimus, including cases with increased Demodex density. These reports highlight the need to distinguish primary rosacea from steroid-induced rosacea-like dermatitis(SIRD) and other rosaceiform eruptions associated with topical therapies. Tacrolimus and pimecrolimus have also been studied in different clinical settings, and the available evidence does not support treating them as interchangeable. Current guidelines and consensus statements provide no consistent recommendation for TCI use in primary rosacea. This review summarizes the clinical evidence for the potential benefits and adverse effects of TCIs in rosacea and discusses their possible role in selected clinical settings.