Can Hydroxychloroquine Help Rosacea? A Pharmacological Analysis

October 7, 2025 •

4 min read

Affecting an estimated 5.46% of the global adult population, rosacea is a common chronic inflammatory skin condition. For those with treatment-resistant forms, a key question arises: Can hydroxychloroquine help rosacea?

Quick Summary

Hydroxychloroquine, an immunomodulatory drug, is an emerging off-label therapy for rosacea, particularly for treatment-resistant cases. Studies show it can be effective for erythema and inflammatory lesions.

Key Points

Off-Label Use: Hydroxychloroquine is not FDA-approved for rosacea but is used off-label as an alternative for treatment-resistant cases.
Anti-Inflammatory Action: Its benefit comes from its immunomodulatory effects, which reduce the activity of mast cells and inflammatory cytokines involved in rosacea.
Comparable to Doxycycline: A pilot study found that a specific regimen of hydroxychloroquine had noninferior efficacy compared to a specific regimen of doxycycline for papulopustular rosacea after 8 weeks.
Mandatory Eye Exams: The most serious potential side effect is irreversible retinal toxicity, making baseline and regular eye exams essential for anyone taking the medication long-term.
Not a First-Line Therapy: It is considered a second or third-line option after standard treatments like topical medications and oral antibiotics have failed.
Potential for Specific Subtypes: There is emerging data supporting its role in treating papulopustular (PPR), erythematotelangiectatic (ETR), and granulomatous rosacea.
Pregnancy Consideration: Because it is generally considered safe during pregnancy, it may be a potential option for pregnant patients with rosacea, though more research is needed.

Understanding Rosacea and Its Challenges

Rosacea is a chronic inflammatory disease that primarily affects the facial skin, causing symptoms like persistent redness, flushing, visible blood vessels, papules, and pustules. A global study found its prevalence to be around 5.46% in the general population. The condition is typically categorized into four main subtypes: erythematotelangiectatic (redness and visible blood vessels), papulopustular (bumps and pimples), phymatous (skin thickening, often on the nose), and ocular (affecting the eyes).

Standard first-line treatments are often effective and include topical agents like metronidazole, azelaic acid, and ivermectin, as well as oral antibiotics such as doxycycline and minocycline, which are used for their anti-inflammatory properties. However, some patients have recalcitrant or resistant rosacea that does not respond adequately to these conventional therapies, prompting dermatologists to explore alternative, off-label options.

What is Hydroxychloroquine?

Hydroxychloroquine (HCQ) is a medication originally developed as an antimalarial drug. It was FDA-approved for lupus in 1955 and is now widely used to treat various autoimmune diseases, including rheumatoid arthritis and systemic lupus erythematosus. Its primary function in these conditions is as an immune modulator; it interferes with the communication of immune cells and reduces the production of pro-inflammatory cytokines. This anti-inflammatory and immunomodulatory activity is the basis for its potential use in treating rosacea.

Hydroxychloroquine as an Off-Label Rosacea Treatment

Emerging evidence suggests that hydroxychloroquine may be a valuable second- or third-line treatment for rosacea, especially for papulopustular (PPR), erythematotelangiectatic (ETR), and granulomatous subtypes. Its use for rosacea is considered "off-label," meaning it is not officially approved by the FDA for this specific indication.

Mechanism of Action in Rosacea

The therapeutic effects of HCQ in rosacea are believed to stem from its broad anti-inflammatory properties. Research indicates that HCQ works by:

Inhibiting Mast Cell Infiltration: Mast cells play a key role in the inflammation and immune dysregulation seen in rosacea. HCQ helps prevent the infiltration of these cells into skin tissue and reduces their long-term survival.
Reducing Pro-Inflammatory Factors: Studies in mouse models have shown that HCQ significantly inhibits the expression of rosacea-related inflammatory factors like TNF-α, IL-1β, and IL-6.
Suppressing Mast Cell Activation: HCQ can suppress the activation of mast cells induced by the antimicrobial peptide LL-37, which is implicated in rosacea's development. This includes inhibiting the release of inflammatory agents and cell degranulation.

One study identified that HCQ may exert its effects by inhibiting KCa3.1-mediated calcium signaling, a pathway involved in mast cell activation.

Clinical Evidence and Efficacy

Several clinical studies have investigated HCQ's effectiveness for rosacea, with promising results. A key pilot study involving 66 patients with papulopustular rosacea compared a specific regimen of hydroxychloroquine to a specific regimen of doxycycline. After 8 weeks, the study found that hydroxychloroquine demonstrated noninferior efficacy to doxycycline in reducing inflammatory lesions and erythema.

Another study noted that a course of HCQ of a specific duration resulted in satisfactory therapeutic effects on both erythema and inflammatory lesions in rosacea patients. Due to its general safety profile during pregnancy, some researchers suggest it could be a viable option for pregnant patients with rosacea, although more research is needed.

Comparing Rosacea Treatments: Hydroxychloroquine vs. Doxycycline


Feature	Hydroxychloroquine	Doxycycline
Primary Use	Malaria, Lupus, Rheumatoid Arthritis	Bacterial Infections
Rosacea Use	Off-label, for resistant or specific subtypes	FDA-approved, first-line oral treatment
Mechanism	Anti-inflammatory, immunomodulatory	Anti-inflammatory (at sub-antimicrobial doses)
Typical Dosage	Varies by patient and condition	Varies by patient and condition
Key Side Effects	Potential retinal toxicity, GI upset, dizziness	GI upset, photosensitivity
Monitoring	Mandatory baseline and regular eye exams	Generally not required for low doses

Safety, Side Effects, and Necessary Precautions

While HCQ is generally well-tolerated, it carries potential risks that require careful management. Common, milder side effects include nausea, diarrhea, abdominal pain, and headaches.

The most significant risk associated with long-term HCQ use is irreversible retinal toxicity. This risk increases with higher doses, duration of use (especially over 5 years), underlying kidney disease, and age over 60. Because of this risk, it is mandatory for patients to undergo a baseline ophthalmologic exam within the first year of starting HCQ and then periodic screenings (e.g., annually after five years of use) to monitor for any retinal changes. Any vision changes should be reported to a doctor immediately.

Other rare but serious side effects can include heart problems (like cardiomyopathy or rhythm changes), low blood sugar, muscle weakness, and mood changes.

Conclusion: A Promising but Cautious Option

Hydroxychloroquine is emerging as a promising off-label therapeutic option for patients with moderate to severe rosacea, especially those who have not found success with standard treatments. Its potent anti-inflammatory and immunomodulatory effects can effectively reduce erythema and inflammatory lesions, with an efficacy comparable to a standard oral antibiotic regimen in some studies.

However, its use is not without significant considerations. The risk of retinal toxicity necessitates a strong commitment to regular ophthalmological monitoring. Therefore, the decision to use hydroxychloroquine for rosacea should be made by a dermatologist after a thorough evaluation of the patient's condition and a detailed discussion of the potential benefits and risks. It remains a second or third-line choice, reserved for specific and challenging cases of this chronic skin condition. An authoritative source on rosacea is the National Rosacea Society.

Frequently Asked Questions

Symptom improvement can begin within one to two months, but it may take up to six months to see the full benefits of the medication. Studies on rosacea specifically have often assessed efficacy at 8 weeks.

Long-term use increases the risk of side effects, most notably irreversible retinal damage. The risk is low in the first 5 years but increases with continued use. This is why regular eye monitoring is mandatory for long-term treatment.

The most common side effects are gastrointestinal issues like nausea, diarrhea, and abdominal pain. In one study comparing it to doxycycline for rosacea, the most common events were dry skin, dry eye, and dizziness.

You need regular eye exams because hydroxychloroquine can, in rare cases, cause irreversible damage to the retina, the light-sensitive tissue at the back of the eye. Exams can detect early changes before vision is affected.

Doxycycline is an FDA-approved antibiotic used for its anti-inflammatory effects in rosacea. Hydroxychloroquine is an off-label immunomodulatory drug that works differently by altering immune cell function. While a study showed comparable efficacy, their side effect and monitoring profiles differ, with HCQ requiring eye exams.

No, there is no cure for rosacea. Hydroxychloroquine, like other treatments, is used to manage and control the signs and symptoms of the chronic condition, particularly in cases that are resistant to other therapies.

The dosage is typically determined by a physician based on the patient's individual needs, weight, and the severity of their condition. It's crucial to follow the prescribed regimen.