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Basic Information ⬇

AUTHOR: Fred F. Ferri, MD

Definition

Rosacea is a common, chronic, heterogenous, inflammatory skin disease, seen most often in adults of both genders and all skin types. It predominantly involves the central face and is characterized by intermittent flares that present with transient findings (flushing, papules/pustules) and by persistence of some fixed clinical manifestations (telangiectasias, persistent facial erythema).

Synonym

Acne rosacea

ICD-10CM CODES
L71Rosacea
L71.9Rosacea unspecified
L71.1Rhinophyma
L71.8Other rosacea
L71.0Perioral dermatitis
Epidemiology & Demographics

  • Rosacea occurs in 1 in 20 Americans
  • Onset often between ages 30 and 50 yr
  • More common in people of Celtic origin; however, this disease may be overlooked in nonwhites because skin pigmentation results in atypical presentation
  • Female:male ratio of 3:1
Physical Findings & Clinical Presentation

  • Facial erythema, presence of papules, pustules, and telangiectasia (Fig. E1).
  • Excessive facial warmth and redness are the predominant presenting symptoms.
  • Itching is generally absent.
  • Comedones are absent (unlike acne).
  • Women are more likely to show symptoms on the chin and cheeks, whereas in men the nose is commonly involved.
  • Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.

Rosacea can be classified into four major subtypes (Table E1):

  1. Erythematotelangiectatic (vascular): Erythema in central part of face, telangiectasia, flushing
  2. Papulopustular (inflammatory): Presence of dome-shaped erythematous papules and small pustules, in addition to facial erythema, flushing, and telangiectasia
  3. Phymatosis/glandular rosacea (Fig. E2): Presence of thickened skin with prominent pores that may affect the nose (rhinophyma) (Fig. E3), chin (gnathophyma), forehead (metophyma), eyelids (blepharophyma), and ears (otophyma)
  4. Ocular: Conjunctival injection, sensation of foreign body in the eye, telangiectasia and erythema of lid margins, scaling

Figure E1 Papulopustular rosacea.

Courtesy Curt Samlaska, MD. From James WD et al: Andrews’ diseases of the skin, ed 12, Philadelphia, 2016, Elsevier.

Figure E2 Severe Rosacea

A, Note the Scattered Papules on the Face and the Confluent Involvement of the Nose. Alcohol Ingestion is Not Related to This Appearance. B, Note the Severe Inflammation with Confluent Redness and Significant Edema.

From White GM, Cox NH [eds]: Diseases of the skin: a color atlas and text, ed 2, St Louis, 2006, Mosby.

Figure E3 Glandular rosacea.

From James WD et al: Andrews’ diseases of the skin, ed 12, Philadelphia, 2016, Elsevier.

TABLE E1 Differential Diagnosis of the Four Subtypes of Rosacea∗

Rosacea Subtype and Differential DiagnosisDistinguishing Feature(s) From Rosacea
Erythematotelangiectatic rosacea
Actinic damage (telangiectatic photoaging)
  • Also characterized by facial telangiectasias and erythema, but the latter favors the lateral more than the central face
  • There tends to be less transient and nontransient erythema
  • Some patients have both disorders
Seborrheic dermatitis
  • Erythema with greasy scale in the eyebrows, nasolabial folds, auditory meatus, retroauricular sulcus, and scalp
  • Involvement of eyelid creases
  • Patients often have both disorders
Keratosis pilaris rubra
  • Onset usually during adolescence
  • Background erythema of the lateral cheeks with superimposed tiny follicular papules
Acute cutaneous lupus erythematosus
  • Absence of inflammatory papulopustules and ocular changes
  • At least 75%-80% of patients have systemic signs/symptoms of SLE
  • Often more well-demarcated edematous plaques with sparing of the nasolabial fold
Flushing (idiopathic or secondary)
  • Intermittent erythema and warmth
  • Flushing in patients with rosacea is usually limited to the face
  • Consider other common etiologies (e.g., menopause, anxiety disorder) or a tumor-related phenomenon (carcinoid syndrome, occult pheochromocytoma, mastocytosis) when additional anatomic sites are involved or there are associated symptoms such as tachycardia and sweating
Papulopustular rosacea
Acne (vulgaris)
  • Onset at a younger age
  • Comedones, both open and closed, and cysts
  • Greater involvement of the upper trunk
Steroid-induced rosacea
  • Clinical overlap with periorificial dermatitis
Demodicosis (Demodex folliculitis)
  • Patients often immunosuppressed (HIV infection, leukemia)
  • Involves face, especially the nose, and upper chest
  • Responds to topical permethrin ± oral ivermectin
Pityriasis folliculorum
  • See text
Tinea incognito, candidiasis
  • Both can mimic rosacea, especially if topical corticosteroids have been used
  • KOH examination demonstrates hyphae or budding yeasts
Papulopustular eruptions due to EGFR inhibitors
  • Occurs in up to 90% of patients on these drugs
  • Abrupt onset
  • May also involve scalp, neck, and trunk
Follicular mucinosis
  • Multiple papules but not pustules
Ocular rosacea
Seborrheic dermatitis
  • Involvement beyond the eyelid margin; may be accentuated in the eyelid creases
Drug-induced ocular rosacea
  • Eyedrops used to treat other ocular disorders, e.g., glaucoma
Phymatous rosacea
Lupus pernio (sarcoidosis)
  • Violaceous indurated plaque of the distal nose
Discoid lupus erythematosus
  • Erythema, scaling, follicular plugging, and tendency to scarring
Lupus vulgaris (cutaneous TB)
  • See “Lupus” chapter
Neoplasms
  • Basal cell carcinoma, lymphoma, angiosarcoma, cutaneous metastases (“clown nose”)

EGFR, Epidermal growth factor receptor; KOH, potassium hydroxide; SLE, systemic lupus erythematosus; TB, tuberculosis.

∗Occasionally, trichostasis spinulosa has associated erythema, but detection of multiple hairs within the follicular orifice by dermoscopy or microscopic examination of follicular contents establishes the diagnosis.

From Bolognia JL: Dermatology, ed 4, Philadelphia, 2018, Elsevier.

Etiology

  • The pathophysiology of rosacea is incompletely understood but believed to involve the vasculature.
  • Hot drinks, alcohol, and sun exposure may accentuate the erythema by causing vasodilation of the skin.
  • Flare-ups may also result from reactions to medications (e.g., simvastatin, ACE inhibitors, vasodilators, fluorinated corticosteroids), stress, extreme heat or cold, wind, humidity, strenuous exercise, spicy drinks, menstruation.

Diagnosis ⬆ ⬇

The presence of at least one of the following primary features in a central distribution of the face is generally sufficient to diagnose rosacea: Papules and pustules, telangiectasia, flushing (transient erythema), nontransient erythema.

Differential Diagnosis

  • Drug eruption
  • Acne vulgaris (Box 1)
  • Contact dermatitis
  • Systemic lupus erythematosus
  • Carcinoid flush
  • Idiopathic facial flushing
  • Seborrheic dermatitis
  • Facial sarcoidosis
  • Photodermatitis
  • Mastocytosis
  • Perioral dermatitis (Box 1)
  • Granulomas of the skin

Box 1 Differentiation of Acne Vulgaris, Periorificial Dermatitis, and Rosacea

Acne vulgaris
  • Commences at puberty
  • Comedones, pustules, cysts
  • Affects face and trunk
  • Can be a sign of androgen excess in females; side-effect of steroid use, including corticosteroids
Periorificial dermatitis
  • More common 14 yr old to 45 yr old (can occur at any age)
  • Female preponderance
  • Background erythema with studded erythematous papules and pseudopustules (no comedones)
  • Affects one or more of the mouth, nose, and eyelids
  • Spares the vermillion border
  • No systemic associations
  • May have a family history
  • Unknown initial trigger but made worse by topical corticosteroids and topical calcineurin inhibitors
Rosacea
  • Generally occurs in middle age
  • Caucasian skin predominantly
  • Female preponderance
  • Papules, telangiectasia, pustules (no comedones)
  • Centrofacial, often with rhinophyma, and blepharitis
  • No systemic disease associations
  • Facial flushing, especially with alcohol use

From Talley NJ et al: Essentials of internal medicine, ed 4, Chatswood, NSW, 2021, Elsevier Australia.

Workup

Diagnosis is based on clinical findings. Distinguishing features between acne and rosacea are the presence of telangiectasia and deep diffuse erythema and absence of comedones in rosacea.

Treatment ⬆ ⬇

Nonpharmacologic Therapy

  • Instruct patients to keep a diary to identify stimuli and triggers that exacerbate rosacea (e.g., spicy foods, drugs, cosmetics) and avoid identified triggers.
  • Avoid alcohol, excessive sun exposure, and hot drinks of any type.
  • Use of mild, nondrying soap or soap-free cleansers and nonoily moisturizers is recommended; local skin irritants should be avoided. General recommendations for skin care in patients with rosacea are summarized in Table 2.
  • Sunscreens are an important component of therapy and should be applied each morning.
  • Daily circular massage for several minutes of the central portion of the face is helpful in decreasing lymphedema and inflammation in this area.
  • Reassure patient that rosacea is completely unrelated to poor hygiene.
  • Vascular laser surgery is effective for telangiectasia.
  • Surgical options are available for telangiectasia and rhinophyma and include dermabrasion, laser ablation, heated scalpel, electrocautery, and radiofrequency electrosurgery.

Table 2 General Recommendations for Facial Skin Care and Education in Patients With Rosacea

Facial Skin Care
  • Wash with lukewarm water and use soap-free cleansers that are pH balanced.
  • Cleansers are applied gently with fingertips.
  • Use sunscreens with both UVA and UVB protection and an SPF ≥30.
  • Sunscreens containing the inorganic filters titanium dioxide and/or zinc oxide are usually well tolerated.
  • Use cosmetics and sunscreens that contain protective silicones.
  • Water-soluble facial powder containing inert green pigment helps to neutralize the perception of erythema.
  • Moisturizers containing humectants (e.g., glycerin) and occlusives (e.g., petrolatum) help to repair the epidermal barrier.
  • Avoid astringents, toners, and abrasive exfoliators.
  • Avoid cosmetics that contain alcohol, menthols, camphor, witch hazel, fragrance, peppermint, and eucalyptus oil.
  • Avoid waterproof cosmetics and heavy foundations that are difficult to remove without irritating solvents or physical scrubbing.
  • Avoid procedures such as glycolic peels or dermabrasion.
Patient Education
  • Reassure the patient about the benign nature of the disorder and the rarity of rhinophyma, particularly in women.
  • Emphasize the chronicity of the disease and the likelihood of exacerbations.
  • Direct patients to information websites such as those of the National Rosacea Society (http://www.rosacea.org/) or the American Academy of Dermatology (http://www.aad.org/).
  • Advise to avoid recognized triggers.
  • Explain the importance of compliance with topical regimens.
  • Educate on the importance of sun avoidance.

SPF, Sun protective factor; UVA, ultraviolet A; UVB, ultraviolet B.

Adapted from Del Rosso JQ, Baum EW: Comprehensive medical management of rosacea: an interim study report and literature review, J Clin Aesthet Dermatol 1:20-25, 2008; Powell FC: Rosacea, N Engl J Med 352:793-803, 2005; and Pelle MT et al: Rosacea: II. Therapy, J Am Acad Dermatol 51:499-512, 2004. In Bolognia J: Dermatology, ed 4, Philadelphia, 2018, Elsevier.

General Rx

  • Several classes of drugs are used in treatment of rosacea, including the metronidazole family, the tetracycline family, ivermectin cream, and azelaic acid.
  • Vascular rosacea: Topical therapy with metronidazole aqueous gel is effective as initial therapy for mild cases. Clindamycin lotion (Cleocin), sulfacetamide, or erythromycin 2% solution may also be effective. A 1.5% topical foam formulation of minocycline is also available for treatment of inflammatory lesions of rosacea in adults. Cost is a limiting factor. Brimonidine is a selective alpha2-adrenergic receptor agonist FDA-approved as a gel preparation for topical treatment of adults with persistent facial erythema of rosacea. Oxymetazoline 1% cream is also an FDA-approved selecting alpha1a-adrenergic receptor agonist for topical treatment of persistent facial erythema in adults. Neither brimonidine or oxymetazoline are indicated for the treatment of inflammatory lesions of rosacea.
  • Pustular and ocular rosacea: Systemic antibiotics (doxycycline 100 mg daily or tetracycline 250 mg qid until symptoms diminish, then taper off). Minocycline 50 to 100 mg is useful daily in resistant cases. Oral metronidazole (200 mg daily to bid) for 4 to 6 wk is also effective. A 1% cream formulation of the antiparasitic drug ivermectin is effective for papulopustular rosacea with minimal adverse effects. After 3 mo of therapy, it will produce clearing of rosacea lesions in up to 80% of patients with moderate to severe symptoms. Its mechanism of action is unknown, but it may be due to the combination of its antiinflammatory effects and its antiparasitic effects on the Demodex mite, which may contribute to the symptoms of rosacea.
  • Isotretinoin 0.5 to 1 mg/kg/day in two divided doses for 15 to 20 wk can be used for refractory papular and pustular rosacea; use of retinoids may, however, worsen erythema and telangiectasis.
  • Erythema and flushing may respond to low-dose clonidine (0.05 mg bid).
  • Treatment of phymatous rosacea: Oral tetracyclines, oral isotretinoin, ablative/pulsed dye laser therapy, electrosurgery.
  • Treatment of ocular rosacea: Topical or oral tetracyclines, artificial tears, and/or lid cleansing for eyelid hygiene. Medical and surgical therapies for rosacea are summarized in Table E3.
  • A 5% benzoyl peroxide cream (epsolay) has been FDA approved for treatment of inflammatory lesions of rosacea in adults. Cost and formulary are major barriers to its use, less expensive generic medications (metronidazole, azelaic acid) are preferred for initial treatment.

TABLE E3 Medical and Surgical Therapies for Rosacea∗

TreatmentComments and/or Doses
Erythematotelangiectatic
Facial skin care recommendations (see Table 2)Particularly useful as this subtype is prone to skin irritation and “sensitivity”
PhotoprotectionUVR may potentiate dermal matrix damage
Topical agents, e.g., azelaic acid, metronidazoleMay reduce erythema, but their use is often limited by their irritant effects
Topical brimonidine tartrate (0.33% gel)∗∗,†Selective α2-adrenergic agonist that improves erythema
Topical oxymetazoline HCl (1% cream)∗∗Selective αβ1A-adrenergic agonist that improves erythema
Laser therapy†Use of vascular lasers (e.g., pulsed dye, potassium titanyl phosphate) as well as intense pulsed light may improve grades 2 and 3
Papulopustular
Topical
Metronidazole (0.75% gel or cream; 1% cream)∗∗,† once or twice dailyCan be used as initial treatment to clear inflammatory lesions or as indefinite maintenance therapy
Ivermectin (1% cream)∗∗,† once dailyMore effective than placebo and slightly more effective than topical metronidazole in randomized controlled trials
Azelaic acid (15% gel)∗∗,† twice dailyAppears to be more effective than topical metronidazole but with more side effects, e.g., irritation
Azelaic acid (20% cream twice daily) is a non-FDA-approved alternative dose
Sodium sulfacetamide (10%) and sulfur (5%) in a cream or lotion∗once or twice dailyMay include 10% urea
Erythromycin (2% solution) twice dailyAlcohol in solution may reduce tolerance
Clindamycin (1% lotion) daily
Benzoyl peroxide 5% plus clindamycin 1% dailyMay cause skin irritation
Tretinoin (0.025% cream; 0.05% cream; 0.01% gel) dailyAlters epidermal keratinization and may improve photodamage
Poorly tolerated by some patients
Permethrin (5% cream) daily-weeklyShown to be as effective as topical metronidazole for the treatment of papules and erythema
May have future role in combination with antibiotics, but further studies needed
Pimecrolimus (1% cream) or tacrolimus (0.03%, 0.1% ointment) twice dailySome studies have shown improvement in erythema, but there have been case reports of exacerbations, so further studies needed
Systemic
Doxycycline∗∗,†40 mg daily (30 mg immediate release and 10 mg delayed release) for 4-8 wk
As effective as the 100 mg dose but with fewer adverse effects
Doxycycline50-100 mg once or twice daily for 4-8 wk
Minocycline50-100 mg twice daily or sustained action formula (1 mg/kg) daily for 4-8 wk∗∗∗
Tetracycline†250-500 mg twice daily for 4-8 wk
Erythromycin250-500 mg once or twice daily for 4-8 wk
Azithromycin250-500 mg (5-10 mg/kg) thrice weekly for 4-8 wk
Metronidazole200 mg once or twice daily for 4-8 wk
Isotretinoin†0.3 mg/kg/day
Phymatous
IsotretinoinMay reduce nasal volume and halt the progression of rhinophyma
Surgical excisionCan effectively debulk and resculpt the nose
Electrosurgery
CO2 laser
Ocular
Eyelid hygiene and artificial tearsFrequently used to treat mild disease
Useful for maintaining remission following treatment of grades 2 and 3 disease with systemic antibiotics
Fusidic acid
Metronidazole gel
Cyclosporine 0.5% ophthalmic emulsion†More effective than artificial tears in treatment of ocular rosacea
Systemic antibiotics (see above section)For grade 2-3 disease

CO2; Carbon dioxide; FDA, U.S. Food and Drug Administration; HCl, hydrochloride; UVR, ultraviolet radiation.

∗If moderate to severe flushing persists despite avoidance of triggers, β-blockers (e.g., carvedilol, nadolol) can be tried.

∗∗FDA-approved treatments for rosacea (evidence-based support = 1).

∗∗∗In a 16-wk trial, minocycline 100 mg daily was noninferior to doxycycline 40 mg daily.

† In a Cochrane review of randomized controlled trials conducted for moderate to severe rosacea, these were the treatments shown to be effective.

From Bolognia JL: Dermatology, ed 4, Philadelphia, 2018, Elsevier.

Disposition

  • Rosacea is often resistant to initial treatment and recurrent. Periods of remission and relapse are common.
  • The progression of rosacea is variable. Typical stages include:
    1. Facial flushing
    2. Erythema and/or edema and ocular symptoms
    3. Papules and pustules
    4. Rhinophyma

Pearls & Considerations ⬆ ⬇

Comments

  • The course of the disease is typically chronic, with remissions and relapses.
  • Patients with resistant cases may have Demodex folliculorum mite infestation or tinea infection (diagnosis can be confirmed with potassium hydroxide examination); the role of D. folliculorum in rosacea is unclear. These mites can sometimes be found in large numbers in the lesions; however, their numbers do not generally decline with treatment.
  • Rosacea can result in emotional and social stigmas, especially because many people associate rosacea and rhinophyma with alcohol abuse.
  • Early consultation with an ophthalmologist is recommended in patients with suspected ocular involvement.
Related Content

Rosacea (Patient Information)

Suggested Readings ⬆

    1. Del Rosso J.Q. : Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 1Cutis. ;92:234-240, 2013.
    2. Del Rosso J.Q. : Management of facial erythema of rosaceaJ Am Acad Dermatol. ;69:S44-S56, 2013.
    3. van Zuuren E.J. : RosaceaN Engl J Med. ;377:1754-1764, 2017.