New Analysis Finds Radiofrequency Microneedling Superior for Rosacea Erythema and Patient Satisfaction

Laser and energy-based devices (EBDs) are firmly established in clinical practice for managing the vascular symptoms of rosacea.¹ However, comparative evidence across device classes remains limited. A new systematic review and network meta-analysis provides the first comprehensive comparative assessment of laser and EBD therapies for rosacea.²

Methods & Materials

A preregistered search of MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science identified randomized controlled trials evaluating any laser or EBD for rosacea up until November 23, 2023. The trial registers, including WHO Trials Registry and Clinicaltrials.gov, were also searched up to December 25, 2023.

Eligible studies (n = 25) assessed pulsed dye laser (PDL), intense pulsed light (IPL), potassium titanyl phosphate (KTP), Nd:YAG lasers, radiofrequency microneedling (RFMN), and combination regimens including topical oxymetazoline or niacinamide. These trials featured a total of 843 patients with a mean age of 46.9 years. Approximately 66% of all participants were female. Most trials evaluated Fitzpatrick skin types, phenotypes of rosacea, persistent facial erythema or telangiectasia, interventions, outcomes, and any withdrawals related to adverse events.

The primary outcomes were patient satisfaction, investigator-assessed improvement in erythema and telangiectasia, and long-term adverse events such as post-inflammatory hyperpigmentation and scarring. Secondary outcomes of short-term adverse effects, like crusts, swelling, and erythema, were also noted. Due to heterogeneity in assessment tools, outcomes were standardized on a 1 to 5 (clear to severe) visual analog scale.

Results

For patient-reported satisfaction, RFMN was significantly superior to PDL (MD –1.32; 95% CI –1.89 to –0.76). Combination therapies incorporating vasoconstrictors—niacinamide + PDL and oxymetazoline + PDL—ranked next. The least promising approach was no treatment (MD 1.16; 95 % CI 0.59 to 1.72).

Regarding erythema improvement, RFMN again ranked highest (MD –1.44; 95% CI –1.96 to –0.91 versus PDL). All active treatments outperformed no treatment, which consistently ranked lowest. For telangiectasia, oxymetazoline + PDL demonstrated the greatest efficacy (MD –0.58; 95% CI –1.03 to –0.14), followed by KTP laser (MD –0.30; 95% CI –0.55 to –0.05). Topical oxymetazoline alone and no treatment were the least effective.

“This ranking is based on available RCT data and may not reflect broader clinical experience or long-term outcomes,” the investigators noted. “KTP lasers have long been established as highly effective and well-tolerated in routine practice, with high clearance rates and strong patient satisfaction.”

Safety & Limitations

Short-term adverse events such as transient erythema, swelling, crusting, and occasional blistering were commonly reported and generally resolved within days. Long-term reactions were uncommon but included post-inflammatory hyperpigmentation, atrophic scarring (notably with a 585-nm yellow laser), and persistent dysesthesia after IPL in isolated cases. Furthermore, discontinuation rates were low and did not differ meaningfully between devices. Any reported dropouts were primarily attributed to pain, swelling, or treatment-related anxiety.

It is worth noting that the evidence base is limited by small sample sizes, nonstandardized outcome measures, heterogeneity in device parameters, and generally unclear risk of bias. Moreover, the long-term durability of vascular clearance and recurrence rates remains insufficiently studied. Diverse representation of darker skin phototypes was also minimal. To combat this, the authors recommend further well-designed investigations with a large, more varied population, especially when testing combination therapy approaches.

Clinical Advice

Laser and EBDs remain valuable tools for managing rosacea-associated erythema and telangiectasia, yet the comparative evidence supporting specific device choices is still evolving. The researchers recommend establishing clear expectations between patient and provider, especially since laser treatment typically involves several sessions to achieve sustained results. This includes frequent and aligned conversations on the healing process, therapy course, and any potential risks or complications associated with the particular device. Additionally, clinicians must remember that most laser- and energy-based treatments used for treating rosacea are less suitable for darker skin types, as the absorption of melanin in these types may be too high.

“As with other chronic conditions, the primary goal of treatment extends beyond achieving a cure to include effective symptom, thereby positively influencing the disease's overall course. Future research should focus on optimizing treatment parameters, intervals, patient-specific factors, and combination therapies to enable more personalized and effective therapeutic approaches,” the authors concluded.

References

1. van Zuuren EJ, Fedorowicz Z, Tan J, et al. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. Br J Dermatol. 2019;181(1):65-79. doi:10.1111/bjd.17590

2. Nguyen L, Sorbe C, Seeber N, Schneider SW, Herberger K. Laser and energy-based devices for treating rosacea - a systematic review and network meta-analysis. J Dtsch Dermatol Ges. Published online November 21, 2025. doi:10.1111/ddg.15961