Papulopustular rosacea is notoriously a challenge to treat, and treatment options are scarce. Only limited data exist on the use of azithromycin in treatment of papulopustular rosacea. However, the unique pharmacokinetics of azithromycin may have several indications in the treatment of papulopustular rosacea. We here report a case of hard-to-treat papulopustular rosacea which was successfully treated with pulsed oral azithromycin in addition to maintenance isotretinoin.