Acne Rosacea



  • Rosacea is a chronic condition characterized by recurrent episodes of facial flushing, erythema (due to dilatation of small blood vessels in the face), papules, pustules, and telangiectasia (due to increased reactivity of capillaries) in a symmetric, central facial distribution; sometimes associated with ocular symptoms (ocular rosacea)
  • Four subtypes:
    • Erythematotelangiectatic rosacea (ETR)
    • Papulopustular rosacea (PPR)
    • Phymatous rosacea
    • Ocular rosacea
  • System(s) affected: skin/exocrine
  • Synonym(s): rosacea

Geriatric Considerations

  • Chronic inflammatory dermatosis with middle-age onset
  • Effects of aging might increase the side effects associated with oral isotretinoin used for treatment (at present, data are insufficient due to lack of clinical studies in elderly patients aged ≥65 years).



  • Predominant age of onset: 30 to 50 years
  • Predominant sex: female > male. However, males are at greater risk for progression to later stages.
  • More common in Fitzpatrick skin types I and II

Etiology and Pathophysiology

  • No proven cause
  • Possibilities include the following:
    • Thyroid and sex hormone disturbance
    • Alcohol, coffee, tea, spiced food overindulgence (unproven)
    • Demodex follicular parasite (suspected)
    • Exposure to cold, heat
    • Emotional stress
    • Dysfunction of the GI tract (possible association with Helicobacter pylori)


  • People of Northern European and Celtic background commonly afflicted
  • Associated with three human leukocyte antigen (HLA) alleles: HLA-DRB1, HLA-DQB1, and HLA-DQA1 (MHC class II)

Risk Factors

  • Exposure to spicy foods, hot drinks
  • Environmental factors: sun, wind, cold, heat

General Prevention

No preventive measures known

Commonly Associated Conditions

  • Seborrheic dermatitis of scalp and eyelids
  • Keratitis with photophobia, lacrimation, visual disturbance
  • Corneal lesions
  • Blepharitis
  • Uveitis



  • Usually have a history of episodic flushing with increases in skin temperature in response to heat stimulus in mouth (hot liquids), spicy foods, alcohol, sun exposure
  • Acne may have preceded onset of rosacea by years; nevertheless, rosacea usually arises de novo without preceding history of acne or seborrhea.
  • Excessive facial warmth and redness are the predominant presenting complaints. Itching is generally absent.

Physical Exam

  • Rosacea has four subtypes:
    • The rosacea diathesis: episodic erythema, “flushing and blushing”
    • ETR: persistent erythema with telangiectases
    • PPR: persistent erythema, telangiectases, papules, pustules
    • Phymatous: persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent “solid” edema of the central part of the face (phymatous)
  • Progression from one subtype to another is hypothetical.
  • Facial erythema, particularly on cheeks, nose, and chin. At times, entire face may be involved.
  • Inflammatory papules are prominent; pustules and telangiectasia may be present.
  • Comedones are absent (unlike acne vulgaris).
  • Women usually have lesions on the chin and cheeks, whereas the nose is commonly involved in men.
  • Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.

Differential Diagnosis

  • Drug eruptions (iodides and bromides)
  • Granulomas of the skin
  • Cutaneous lupus erythematosus
  • Carcinoid syndrome
  • Acne vulgaris
  • Seborrheic dermatitis
  • Steroid rosacea (abuse)
  • Systemic lupus erythematosus
  • Lupus pernio (sarcoidosis)

Diagnostic Tests & Interpretation

  • Diagnosis is based on physical exam findings.
  • A recent change in classification has been proposed based on the phenotype that reflects the clinical presentation and to better focus treatment options, which are targeted to address the main clinical presentation (1).

Test Interpretation
Histology of affected skin may reveal:

  • Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
  • Absence of comedones and blocked ducts
  • Vascular dilatation and dermal lymphocytic infiltrate
  • Granulomatous inflammation


General Measures

  • Proper skin care and photoprotection are important components of management plan (1)[B]. Use of mild, nondrying soap is recommended; local skin irritants should be avoided.
  • Avoidance of triggers
  • Reassurance that rosacea is completely unrelated to poor hygiene
  • Treat psychological stress if present.
  • Topical steroids should not be used because they may aggravate rosacea.
  • Avoid oil-based cosmetics:
    • Others are acceptable and may help women tolerate symptoms.
  • Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
  • Possible evolving laser therapy
  • Support physical fitness.


First Line

  • Topical metronidazole preparations once (1% formulation) or twice (0.75% formulations) daily for 7 to 12 weeks was significantly more effective than placebo in patients with moderate to severe rosacea. A rosacea treatment system (cleanser, metronidazole 0.75% gel, hydrating complexion corrector, and sunscreen SPF 30) may offer superior efficacy and tolerability to metronidazole (2)[A].
  • Azelaic acid (Finacea) is very effective as initial therapy; azelaic acid topical alone is effective for maintenance (3)[A].
  • Topical ivermectin 1% cream (2)[A]
    • Recently found to be more effective than metronidazole for treatment of PPR
  • Topical brimonidine tartrate 0.5% gel is effective in reducing erythema associated with ETR (4)[A].
    • α2-Adrenergic receptor agonist; potent vasoconstrictor
  • Oxymetazoline 1% cream, an α1A-adrenergic receptor agonist recently approved for the treatment of persistent erythema associated with rosacea in adults (5)[B]
  • Doxycycline 40-mg dose is at least as effective as 100-mg dose and has a correspondingly lower risk of adverse effects but is much more expensive (6)[A].
  • Precautions: Tetracyclines may cause photosensitivity; sunscreen is recommended.
  • Significant possible interactions:
    • Tetracyclines: Avoid concurrent administration with antacids, dairy products, or iron.
    • Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; however, this finding has only been confirmed with rifampin; consider adding barrier method.

Second Line

  • Topical erythromycin
  • Topical timolol maleate 0.5%
  • Topical clindamycin (lotion preferred)
    • Can be used in combination with benzoyl peroxide; commercial topical combinations are available.
  • Possible use of calcineurin inhibitors (tacrolimus 0.1%; pimecrolimus 1%). Pimecrolimus 1% is effective to treat mild to moderate inflammatory rosacea.
  • Permethrin 5% cream; similar efficacy compared to metronidazole for severe cases, oral isotretinoin at 0.3 mg/kg for a minimum of 3 months

Pediatric Considerations
Tetracyclines: not for use in children <8 years

Pregnancy Considerations

  • Tetracyclines: not for use during pregnancy
  • Isotretinoin: teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception; requires registration with iPLEDGE program

Additional Therapies

Cyclosporine 0.05% ophthalmic emulsion may be more effective than artificial tears for ocular rosacea.

Surgery/Other Procedures

Laser treatment is an option for progressive telangiectasias or rhinophyma.

  • Pulsed dye laser (585 nm or 595 nm) is effective in treating telangiectases and erythema.
  • CO2 fractional ablative laser can be used to treat rhinophyma.

Ongoing Care

Follow-up Recommendations

Outpatient treatment

Patient Monitoring

  • Occasional and as needed
  • Close follow-up and laboratory assessment for patients using isotretinoin per prescribing instructions and iPLEDGE program guidance
  • Consider ophthalmology evaluation in patients with ocular symptoms.


Avoid alcohol and hot drinks of any type.


  • Slowly progressive
  • Subsides spontaneously (sometimes)


  • Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
  • Conjunctivitis
  • Blepharitis
  • Keratitis
  • Visual deterioration

Additional Reading

  • Al Mokadem SM, Ibrahim ASM, El Sayed AM. Efficacy of topical timolol 0.5% in the treatment of acne and rosacea: a multicentric study. J Clin Aesthet Dermatol. 2020;13(3):22–27. [PMID:32308793]
  • Liu RH, Smith MK, Basta SA, et al. Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Arch Dermatol. 2006;142(8):1047–1052. [PMID:16924055]
  • Mikkelsen CS, Holmgren HR, Kjellman P, et al. Rosacea: a clinical review. Dermatol Reports. 2016;8(1):6387. [PMID:27942368]
  • van Zuuren EJ, Arents BWM, van der Linden MMD, et al. Rosacea: new concepts in classification and treatment. Am J Clin Dermatol. 2021;22(4):457–465. [PMID:33759078]

See Also

Algorithm: Acne



  • L71.8 Other rosacea
  • L71.9 Rosacea, unspecified


  • 200933006 Ocular rosacea (disorder)
  • 257006 Acne rosacea, erythematous telangiectatic type (disorder)
  • 371097007 Rosacea blepharoconjunctivitis
  • 398909004 Rosacea (disorder)
  • 75867005 Acne rosacea, papular type (disorder)

Clinical Pearls

  • Rosacea usually arises de novo without any preceding history of acne or seborrhea.
  • Rosacea may cause chronic eye symptoms, including blepharitis.
  • Avoid alcohol, sun exposure, and hot drinks.
  • Medication treatment resembles that of acne vulgaris, with oral and topical antibiotics.


Shane L. Larson, MD


Figure 1-14

Descriptive text is not available for this image

Rosacea. As seen here, rosacea is characterized by inflammatory papules and pustules and telangiectasias located on the central third of the face.


  1. Schaller M, Almeida LMC, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465–471. [PMID:27861741]
  2. van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;2015(4):CD003262. [PMID:30585305]
  3. 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. [PMID:23839181]
  4. Fowler J Jr, Jackson M, Moore A, et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013;12(6):650–656. [PMID:23839181]
  5. Oxymetazoline cream (Rhofade) for rosacea. Med Lett Drugs Ther. 2017;59(1521):84–86. [PMID:28520699]
  6. Del Rosso JQ, Webster GF, Jackson M, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56(5):791–802. [PMID:17367893]

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