Rosacea
Summary
Rosacea is a chronic inflammatory skin condition primarily affecting the central face (Cheeks, Nose, Forehead, Chin). It is characterised by facial erythema (Redness), telangiectasia (Visible blood vessels), papules and pustules (But NO comedones – unlike acne), and flushing. It typically affects adults aged 30-60, with fair-skinned individuals of Celtic/Northern European ancestry being most susceptible. The condition is classified into four subtypes: Erythematotelangiectatic (Flushing/Redness), Papulopustular (Inflammatory papules/pustules), Phymatous (Tissue hypertrophy – classically Rhinophyma of the nose), and Ocular (Affecting eyes – blepharitis, keratitis). Management involves trigger avoidance (Sun, Heat, Alcohol, Spicy food), topical treatments (Metronidazole, Azelaic Acid, Ivermectin), and oral antibiotics (Doxycycline) for moderate-severe disease. Rosacea is NOT contagious and is NOT caused by poor hygiene. [1,2,3]
Clinical Pearls
"No Comedones": Key differentiator from Acne Vulgaris. Rosacea has papules/pustules BUT NO blackheads/whiteheads.
"Central Face": Rosacea affects the Convexities of the face (Cheeks, Nose, Forehead, Chin). Spares periocular and perioral areas (Unlike seborrhoeic dermatitis).
"Ocular Rosacea Can Threaten Vision": Keratitis can cause corneal scarring. Always ask about eye symptoms. Refer to Ophthalmology if corneal involvement.
"Rhinophyma ≠ Alcoholism": Rhinophyma (Bulbous nose) is a complication of rosacea, NOT caused by alcohol. This is a common misconception.
Demographics
| Factor | Notes |
|---|---|
| Age | 30-60 years. Rare in children. |
| Sex | Female > Male (Erythematotelangiectatic/Papulopustular). Male > Female (Phymatous/Rhinophyma). |
| Race | Fair-skinned individuals (Celtic, Northern European – "Curse of the Celts"). Can affect any skin type. |
| Prevalence | ~5-10% in fair-skinned populations. |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Fair Skin (Fitzpatrick I-II) | Strongest risk factor. |
| Family History | Genetic component. |
| UV Exposure | Exacerbating factor. |
| Demodex Mites | Higher density on rosacea skin. Role in pathogenesis debated. Ivermectin targets this. |
Mechanisms
| Factor | Notes |
|---|---|
| Vascular Instability | Abnormal flushing response. Increased blood vessel reactivity. |
| Innate Immune Dysregulation | Upregulation of Cathelicidin (Antimicrobial peptide) and Kallikrein 5. Causes inflammation. |
| Demodex Folliculorum | Mite that lives in hair follicles. Higher density in rosacea patients. May trigger inflammation. |
| Neurogenic Inflammation | Transient Receptor Potential (TRP) channel dysfunction. Triggers flushing with heat/spice. |
| UV Damage | Chronic sun damage contributes to telangiectasia and skin changes. |
| Subtype | Features | Notes |
|---|---|---|
| Erythematotelangiectatic (ETR) | Facial redness (Centrofacial erythema), Flushing, Visible telangiectasia. | Most common. "Red face." May have burning/stinging. |
| Papulopustular (PPR) | Inflammatory papules and pustules on erythematous base. | Resembles acne but NO comedones. Central face. |
| Phymatous (PHY) | Skin thickening, Irregular nodular texture. Rhinophyma (Nose) most common. | Also Gnathophyma (Chin), Metophyma (Forehead). More common in men. |
| Ocular (OCR) | Eye involvement: Blepharitis, Conjunctivitis, Meibomian gland dysfunction, Keratitis. | Can occur with or without skin findings. Keratitis = Urgent referral. |
| Condition | Key Features |
|---|---|
| Rosacea | Central facial erythema, Telangiectasia, Papules/Pustules, NO comedones. |
| Acne Vulgaris | Comedones (Blackheads/Whiteheads), Papules, Pustules, Nodules. Younger age. |
| Seborrhoeic Dermatitis | Greasy scales, Nasolabial folds, Scalp, Eyebrows, Ears. |
| Lupus (SLE/Discoid) | Malar rash (Butterfly), Spares nasolabial folds, Systemic features. |
| Perioral Dermatitis | Papules/Pustules around mouth, Spares vermillion border. Often steroid-induced. |
| Contact Dermatitis | Eczematous, Itchy, History of exposure/topicals. |
| Carcinoid Syndrome | Episodic flushing, Diarrhoea, Wheeze. Rare. Check 5-HIAA. |
Symptoms
| Symptom | Notes |
|---|---|
| Facial Redness | Persistent erythema, Often worse with triggers. |
| Flushing | Transient episodes of intense redness. Triggered by heat, alcohol, spicy food, stress. |
| Papules/Pustules | Inflammatory lesions. Central face. |
| Burning/Stinging | Skin often feels sensitive. |
| Dryness/Roughness | Skin texture changes. |
| Ocular Symptoms | Gritty eyes, Burning, Dry eyes, Blepharitis. |
Triggers
| Trigger | Notes |
|---|---|
| Sun/UV Exposure | Most common. |
| Heat/Hot Drinks | Flushing trigger. |
| Alcohol (Red Wine) | Classic trigger. |
| Spicy Food | Capsaicin activates TRP channels. |
| Stress/Emotion | Neurogenic flushing. |
| Hot Baths/Showers | |
| Certain Skincare Products | Irritants, Alcohol-based. |
| Topical Steroids | Can worsen rosacea ("Steroid Rosacea"). AVOID. |
Examination Findings
| Finding | Subtype |
|---|---|
| Centrofacial Erythema | ETR, PPR |
| Telangiectasia | ETR |
| Papules/Pustules (No Comedones) | PPR |
| Rhinophyma (Bulbous nose) | PHY |
| Blepharitis/Meibomian Gland Dysfunction | OCR |
Diagnosis
- Clinical Diagnosis: Based on typical features. No specific diagnostic test.
- Biopsy: Rarely needed. May be considered if diagnosis uncertain or to exclude lupus.
Investigations If Doubt
| Test | Indication |
|---|---|
| ANA, Anti-dsDNA | If lupus suspected (Malar rash, Systemic symptoms). |
| Skin Biopsy | If atypical features or alternative diagnosis considered. |
| Slit Lamp Examination | If ocular rosacea suspected. Refer to Ophthalmology. |
Management Algorithm
ROSACEA DIAGNOSIS
(Central facial erythema, Papules/Pustules, No comedones)
↓
GENERAL MEASURES (All Patients)
- Trigger avoidance (Sun, Heat, Alcohol, Spicy food)
- Sun protection (High SPF, Physical sunscreens)
- Gentle skincare (Avoid irritants, fragrance-free)
- AVOID topical steroids
↓
CLASSIFY SUBTYPE
┌────────────────┴────────────────────────────────┐
ERYTHEMA/TELANGIECTASIA PAPULOPUSTULAR OCULAR
↓ ↓ ↓
Topical Brimonidine Topical First-Line Lid hygiene
(For flushing/redness) Lubricants
Laser/IPL for Oral Doxycycline
persistent telangiectasia Ophthalmology if
keratitis
↓
PAPULOPUSTULAR ROSACEA TREATMENT LADDER
┌──────────────────────────────────────────────────────────┐
│ MILD: │
│ - Topical Metronidazole 0.75% gel/cream BD │
│ OR Topical Azelaic Acid 15% gel BD │
│ OR Topical Ivermectin 1% cream OD │
│ │
│ MODERATE: │
│ - Add Oral Doxycycline 40mg MR OD (Subantimicrobial) │
│ OR Doxycycline 100mg OD for 6-12 weeks │
│ - Continue topical │
│ │
│ SEVERE / REFRACTORY: │
│ - Oral Isotretinoin (Low dose: 0.25-0.5mg/kg) │
│ - Specialist referral │
└──────────────────────────────────────────────────────────┘
↓
PHYMATOUS ROSACEA (Rhinophyma)
- CO2 Laser ablation
- Surgical reshaping
- Prevention: Treat rosacea early before phymatous changes
Topical Treatments
| Treatment | Notes |
|---|---|
| Metronidazole 0.75% Gel/Cream | First-line. Anti-inflammatory. Apply BD. |
| Azelaic Acid 15% Gel | Alternative first-line. Anti-inflammatory + Antimicrobial. |
| Ivermectin 1% Cream (Soolantra) | Targets Demodex mites. OD application. Highly effective for PPR. |
| Brimonidine 0.33% Gel (Mirvaso) | Alpha-agonist. Causes vasoconstriction. Reduces redness for ~12h. For ETR. |
| Oxymetazoline 1% Cream (Rhofade) | Similar to Brimonidine. Not yet widely available UK. |
Systemic Treatments
| Treatment | Notes |
|---|---|
| Doxycycline 40mg MR OD (Efracea) | Subantimicrobial dose. Anti-inflammatory without antibiotic effects. Long-term use possible. |
| Doxycycline 100mg OD | For more severe disease. 6-12 week courses. |
| Isotretinoin (Low Dose) | For severe refractory rosacea. Reduces sebum, Anti-inflammatory. Specialist only. |
Ocular Rosacea Management
| Treatment | Notes |
|---|---|
| Lid Hygiene | Warm compresses, Lid scrubs. |
| Lubricating Eye Drops | Artificial tears. |
| Oral Doxycycline | Effective for ocular rosacea. |
| Ophthalmology Referral | If keratitis (Corneal involvement). Vision-threatening. |
Telangiectasia Management
| Treatment | Notes |
|---|---|
| Laser (Pulsed Dye, Nd:YAG) | Destroys visible blood vessels. Multiple sessions needed. |
| IPL (Intense Pulsed Light) | Alternative to laser. Reduces redness and vessels. |
| Complication | Notes |
|---|---|
| Rhinophyma | Phymatous changes of nose. Bulbous, Pitted, Thickened skin. Cosmetically distressing. |
| Ocular Complications | Keratitis → Corneal scarring → Vision loss. Chronic blepharitis. |
| Psychological Impact | Significant. Embarrassment, Anxiety, Depression. Social avoidance. |
| Steroid Rosacea | Worsening/Rebound from inappropriate topical steroid use. |
| Factor | Notes |
|---|---|
| Chronic Condition | Rosacea is chronic and relapsing. No cure. |
| Control is Possible | With treatment and trigger avoidance, symptoms can be well controlled. |
| Phymatous Changes | Irreversible tissue thickening. Requires procedural intervention. |
| Early Treatment | Prevents progression to more severe subtypes. |
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Rosacea Management | BAD (British Association of Dermatologists) | Stepwise treatment. Topical first-line. Doxycycline for moderate-severe. |
| Global Rosacea Consensus | Rosacea International Expert Group (ROSCO) | Phenotype-based approach. Individualized treatment. |
Evidence Points
- Ivermectin vs Metronidazole: RCTs show Ivermectin superior for PPR at 12 weeks.
- Subantimicrobial Doxycycline: Effective without promoting antibiotic resistance. Can be used long-term.
What is Rosacea?
Rosacea is a common skin condition that causes redness, flushing, and sometimes spots on the face. It mainly affects the cheeks, nose, forehead, and chin. It is NOT contagious and is NOT caused by poor hygiene.
What causes it?
We don't know exactly, but it involves blood vessels being overly reactive and inflammation in the skin. It runs in families and is more common in fair-skinned people.
What makes it worse?
Common triggers include:
- Sun exposure
- Hot drinks and spicy food
- Alcohol (Especially red wine)
- Stress
- Hot baths
Keeping a diary can help identify your triggers.
Is there a cure?
There is no cure, but rosacea can be well controlled with treatment. Avoiding triggers, using gentle skincare, and applying prescribed creams can make a big difference. For more stubborn cases, tablets may be needed.
What about the redness and veins?
Visible blood vessels (Telangiectasia) can be treated with laser or IPL. This doesn't cure the rosacea but can significantly improve appearance.
What is Rhinophyma?
In some people (Usually men), the skin on the nose can thicken and become bulbous. This is called Rhinophyma. It is NOT caused by alcohol (Despite the myth). It can be treated with laser or surgery.
Primary Sources
- van Zuuren EJ, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262. PMID: 25919144.
- Two AM, et al. Rosacea: Part I. Introduction, Categorization, Histology, Pathogenesis, and Risk Factors. J Am Acad Dermatol. 2015;72(5):749-758. PMID: 25890455.
- Gallo RL, et al. Standard classification and pathophysiology of rosacea. J Am Acad Dermatol. 2018;78(3 Suppl 1):S16-S21. PMID: 29471918.
Common Exam Questions
- Key Differential from Acne: "How do you differentiate Rosacea from Acne Vulgaris?"
- Answer: No Comedones in Rosacea. Acne has blackheads/whiteheads.
- First-Line Topical: "What is first-line topical treatment for Papulopustular Rosacea?"
- Answer: Topical Metronidazole OR Azelaic Acid OR Ivermectin.
- Eye Involvement: "What is the vision-threatening complication of Ocular Rosacea?"
- Answer: Keratitis (Corneal involvement → Scarring).
- Rhinophyma: "Is Rhinophyma caused by alcohol?"
- Answer: NO. This is a myth. Rhinophyma is a complication of rosacea.
Viva Points
- Steroid Rosacea: Topical steroids WORSEN rosacea. Never prescribe steroids for facial redness.
- Brimonidine Rebound: Brimonidine can cause rebound redness when it wears off.
- Demodex and Ivermectin: Higher Demodex mite density in rosacea. Ivermectin is acaricidal.
- Subtypes Can Overlap: Patients may have features of multiple subtypes.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.