Overview
Rosacea
1. Clinical Overview
Summary
Rosacea is a chronic inflammatory facial skin condition characterised by transient or persistent central facial erythema, telangiectasia, papules, pustules, and in severe cases, phymatous changes. It typically affects adults over 30 years and follows a relapsing-remitting course.
Key Facts
| Aspect | Detail |
|---|---|
| Peak Age | 30-50 years |
| Gender | More common in women (but more severe in men) |
| Skin Type | Fair-skinned individuals (Fitzpatrick I-II) |
| Distribution | Central face: cheeks, nose, chin, forehead |
| Key Feature | Flushing + persistent erythema |
Clinical Pearls
- Not Acne: No comedones (blackheads/whiteheads) - distinguishes from acne vulgaris
- Eye Involvement: 50% have ocular symptoms - always ask about dry, gritty eyes
- Trigger Avoidance: Critical part of management - sunlight, alcohol, spicy food
- Rhinophyma: Phymatous nose - almost exclusively in men
2. Epidemiology
Prevalence & Demographics
| Population | Prevalence |
|---|---|
| Global | 1-10% (varies by ethnicity) |
| Fair-skinned populations | Up to 10% |
| Celtic/Northern European ancestry | Highest prevalence |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Fair skin | Fitzpatrick types I-II |
| Family history | Genetic predisposition |
| Female sex | More common, but males more severe |
| Age 30-50 | Peak onset |
| UV exposure | Major trigger |
3. Pathophysiology
Proposed Mechanisms
Genetic Predisposition + Environmental Triggers
↓
Innate Immune Dysregulation
(Cathelicidin/LL-37 overexpression)
↓
Neurovascular Dysregulation
(TRPV channels, vasodilation)
↓
Inflammation + Angiogenesis
↓
ROSACEA (Erythema, papulopustules, telangiectasia)
Key Factors
| Factor | Role |
|---|---|
| Cathelicidin LL-37 | Antimicrobial peptide - elevated in rosacea |
| Demodex mites | Increased density in rosacea skin |
| Vascular reactivity | Enhanced vasodilation response |
| UV damage | Inflammation, vascular changes |
4. Clinical Presentation
Rosacea Subtypes
| Subtype | Features |
|---|---|
| Erythematotelangiectatic (ETR) | Flushing, persistent erythema, telangiectasia |
| Papulopustular (PPR) | Papules and pustules on erythematous base |
| Phymatous | Skin thickening, rhinophyma (nose) |
| Ocular | Dry eyes, blepharitis, conjunctivitis, keratitis |
Symptoms by Subtype
| Symptom | Subtype |
|---|---|
| Flushing | ETR |
| Burning/stinging | ETR, PPR |
| Dryness | ETR |
| Papules/pustules | PPR |
| Thickened skin | Phymatous |
| Gritty eyes | Ocular |
Common Triggers
| Category | Examples |
|---|---|
| Temperature | Hot drinks, hot weather, saunas |
| Diet | Alcohol (especially red wine), spicy food |
| Emotional | Stress, embarrassment |
| Environmental | Sun exposure, wind |
| Medications | Topical steroids, vasodilators |
| Skincare | Harsh products, fragranced cosmetics |
5. Clinical Examination
Key Findings
| Finding | Description |
|---|---|
| Central facial erythema | Cheeks, nose, chin, forehead |
| Telangiectasia | Visible dilated vessels |
| Papules | Inflammatory, dome-shaped |
| Pustules | Pus-filled lesions |
| Absence of comedones | Differentiates from acne |
| Rhinophyma | Bulbous, thickened nose |
Ocular Examination
| Finding | Significance |
|---|---|
| Lid margin inflammation | Blepharitis |
| Conjunctival injection | Conjunctivitis |
| Corneal changes | Keratitis (refer urgently) |
| Meibomian gland dysfunction | Evaporative dry eye |
Differential Diagnosis
| Condition | Distinguishing Features |
|---|---|
| Acne vulgaris | Comedones present, younger age |
| Seborrheic dermatitis | Scale, nasolabial folds |
| Lupus (malar rash) | Spares nasolabial folds, systemic features |
| Perioral dermatitis | Perioral distribution, often topical steroid history |
6. Investigations
Diagnosis
- Clinical diagnosis - no specific tests required
When to Investigate
| Indication | Test |
|---|---|
| Uncertain diagnosis | Skin biopsy |
| Systemic symptoms | ANA, complement if lupus suspected |
| Ocular involvement | Ophthalmology referral |
7. Management
General Measures (All Subtypes)
| Measure | Details |
|---|---|
| Trigger avoidance | Identify and avoid personal triggers |
| Sun protection | SPF 30+, physical blockers preferred |
| Gentle skincare | Fragrance-free, non-irritating products |
| Temperature | Avoid extremes |
Treatment by Subtype
Erythematotelangiectatic Rosacea
| Treatment | Notes |
|---|---|
| Topical brimonidine | Alpha-agonist vasoconstrictor |
| Topical oxymetazoline | Alternative vasoconstrictor |
| Laser/IPL | For persistent telangiectasia |
Papulopustular Rosacea
| Treatment | First/Second Line |
|---|---|
| Topical metronidazole 0.75% | First-line |
| Topical ivermectin 1% | First-line (anti-Demodex) |
| Topical azelaic acid 15% | Alternative |
| Oral doxycycline 40mg MR | Moderate-severe (anti-inflammatory dose) |
| Oral isotretinoin | Severe, refractory cases |
Ocular Rosacea
| Treatment | Notes |
|---|---|
| Lid hygiene | Warm compresses, lid massage |
| Artificial tears | Lubricant eye drops |
| Oral doxycycline | If moderate-severe |
| Ophthalmology referral | If keratitis suspected |
Phymatous Rosacea
| Treatment | Notes |
|---|---|
| Oral isotretinoin | May reduce early changes |
| Surgical/laser ablation | For established rhinophyma |
| CO2 laser or electrosurgery | Tissue remodelling |
8. Complications
| Complication | Notes |
|---|---|
| Ocular keratitis | Vision-threatening - urgent referral |
| Rhinophyma | Disfiguring, difficult to treat |
| Psychological impact | Embarrassment, social anxiety |
| Steroid-induced rosacea | Worsening with topical steroids |
9. Prognosis & Outcomes
| Factor | Outlook |
|---|---|
| Course | Chronic, relapsing-remitting |
| With treatment | Good control achievable |
| ETR subtype | Often persistent |
| PPR subtype | Usually responds well to treatment |
| Phymatous | May progress without treatment |
10. Evidence & Guidelines
| Organisation | Key Points |
|---|---|
| BAD Guidelines (2021) | Topical ivermectin or metronidazole first-line for PPR |
| Cochrane | Doxycycline 40mg MR effective, fewer side effects than higher doses |
| AAD | Emphasises trigger avoidance and sun protection |
11. Patient / Layperson Explanation
For Patients
What is rosacea? Rosacea is a common skin condition causing redness on the face, often with spots and visible blood vessels. It tends to come and go and affects adults over 30.
What causes it? The exact cause is unknown but involves overactive blood vessels, inflammation, and sometimes tiny mites that live on the skin (Demodex). It's not contagious and not caused by poor hygiene.
What triggers it? Common triggers include:
- Sun exposure
- Hot drinks and spicy foods
- Alcohol (especially red wine)
- Temperature extremes
- Stress and embarrassment
How is it treated?
- Trigger avoidance: Keep a diary to identify your triggers
- Sun protection: Use SPF 30+ daily
- Gentle skincare: Fragrance-free products
- Medications: Creams (metronidazole, ivermectin) or tablets (doxycycline)
- Laser treatment: For visible blood vessels
What about the eyes? Up to half of people with rosacea get eye symptoms (dryness, grittiness, redness). Tell your doctor if your eyes are affected.
Will it go away? Rosacea is usually a long-term condition, but with proper treatment and avoiding triggers, most people keep it well controlled.
12. References
- Gallo RL, et al. Rosacea. Nat Rev Dis Primers. 2018;4:17026.
- BAD Guidelines: Management of Rosacea. 2021.
- van Zuuren EJ. Rosacea. NEJM. 2017;377(18):1754-1764.
- Two AM, et al. Rosacea: Pathogenesis & Therapeutic Correlates. JAAD. 2015.