What it is
Persistent facial redness with bumps runs on two engines: an overactive inflammatory response in the skin, and Demodex mites, which live in everyone's follicles but are implicated in higher numbers in redness-prone skin. Metronidazole 0.75% and 1% is the decades-old first-line topical: an anti-inflammatory cream or gel that beats vehicle over 12 to 16 week trials and costs very little as a generic.
Ivermectin 1% cream attacks both engines at once: it is anti-inflammatory and it kills Demodex. In ATTRACT, a 962-patient randomized investigator-blinded trial, it beat metronidazole 0.75% head to head: 83.0% versus 73.7% reduction in inflammatory lesions at week 16, with separation visible from week 3 and better local tolerability. A generic now exists, which cut the cash price by roughly three quarters.
Know what these creams do not do. They target the bumps and calm the inflammatory component of redness; they do not close visible vessels or stop flushing, which respond to a vascular laser instead. And if erythema is the main complaint, azelaic acid 15% beat metronidazole on redness in a 20-study systematic review, so it is a real alternative worth asking about.
Who this is for
- Central-face redness that has stuck around for months, with small red bumps or pustules
- Flares triggered by heat, sun, alcohol, spicy food, or hard workouts
- Bumps that look like acne but never respond to acne products
- Redness-relief serums that work for an evening and change nothing by morning
- Mostly flushing and visible vessels: that pattern points at a vascular laser instead, and the visit sorts out which you need
How the online flow works
- 1
Intake and photos
Complete the questionnaire and upload daylight photos of the affected areas.
- 2
Video visit
Talk through triggers, prior treatments, and budget with Dr. Mueller on a live video visit; creams need no in-person step.
- 3
Pharmacy
The prescription goes to the pharmacy you pick, and both drugs now have generics.
- 4
Follow-up
A photo follow-up lands at 12 to 16 weeks, where the trials measured full effect, with an earlier check if nothing has moved by week 6.
Side effects and limits
Honest list, not fine print. Every one of these is part of the consent conversation at your video visit.
- Metronidazole: mild local irritation; systemic effects are negligible at topical doses.
- Ivermectin: better local tolerability than metronidazole in the head-to-head trial, though early stinging or dryness is still possible.
- Neither cream closes vessels or prevents flushing; expecting that leads to disappointment, and a vascular laser is the tool for that job.
- Redness of this pattern tends to run long; plan on maintenance rather than a one-time fix.
The evidence
- ATTRACT randomized investigator-blinded trial, 962 patients (Br J Dermatol 2015): ivermectin 1% beat metronidazole 0.75%, 83.0% versus 73.7% inflammatory lesion reduction at week 16, P<0.001; IGA success 84.9% versus 75.4%.
- Systematic review of azelaic acid in rosacea, 20 studies (J Cosmet Dermatol 2023): azelaic acid 15% superior to metronidazole 0.75% on erythema and inflammatory lesion counts.
- Topical metronidazole: effective versus vehicle across 12 to 16 week rosacea trials, the basis of its decades-long first-line position.
Straight answers
- Which cream will I get, metronidazole or ivermectin?
- Decided live on the visit. Ivermectin won the head-to-head trial, 83.0% versus 73.7% lesion reduction at week 16, but generic metronidazole costs a fraction as much and has decades of use behind it. Pattern, budget, and prior response drive the call.
- Will these stop my flushing and visible veins?
- No. They act on inflammatory bumps and the redness that rides along with them. Visible vessels and flush reactions are plumbing, not inflammation, and a vascular laser is the tool for those; that route starts with an in-person exam.
- Isn't ivermectin a deworming drug?
- Same molecule, different job. In the skin it kills Demodex mites, which are implicated in this redness pattern, and it has direct anti-inflammatory effects. The 1% cream is applied once daily.
- How long before I see anything?
- The trial curves separated from week 3, and full benefit was measured at week 16. Give it 6 weeks before judging; the follow-up visit exists to change course if the photos show nothing.
- What does it cost?
- The online prescription visit is $79 and follow-ups are $39, itemized on the pricing page; nothing is added at checkout. The cream is a separate pharmacy cost, and both drugs have generics; figures are in the facts above.
- Can I add a vascular laser, or does other acne medication block it?
- The combination is common: cream for the bumps, laser for the vessels. The 2017 ASDS consensus permits vascular lasers even during isotretinoin under physician judgment, so overlapping medication rarely rules it out; sequencing is set at the in-person exam.