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(Acne Rosacea)


Jonette E. Keri

, MD, PhD, University of Miami, Miller School of Medicine

Reviewed/Revised Feb 2022 | Modified Sep 2022
Topic Resources

Rosacea is a chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and, in severe cases, rhinophyma. Diagnosis is based on the characteristic appearance and history. Treatment depends on severity and includes topical metronidazole, topical and oral antibiotics, topical ivermectin, rarely isotretinoin, and, for severe rhinophyma, surgery.

Rosacea most commonly affects patients aged 30 to 50 with fair complexions, most notably those of Irish and Northern European descent, but it affects and is probably under-recognized in darker-skinned patients.

Etiology of Rosacea

The etiology of rosacea is unknown, but some proposed associations include

  • Abnormal vasomotor control

  • Impaired facial venous drainage

  • Increased follicle mites (Demodex folliculorum)

  • Increased angiogenesis, ferritin expression, and reactive oxygen species

  • Dysfunction of antimicrobial peptides (eg, cathelicidin)

Diet plays no consistent role, but some agents (eg, amiodarone, topical and nasal corticosteroids, high doses of B6 and B12) may worsen rosacea.

Symptoms and Signs of Rosacea

Rosacea is limited to the face and scalp and manifests in 4 phases:

  • Pre-rosacea

  • Vascular

  • Inflammatory

  • Late

In the pre-rosacea phase, patients describe embarrassing flushing and blushing, often accompanied by uncomfortable stinging. Common reported triggers for these flares include sun exposure, emotional stress, cold or hot weather, alcohol, spicy foods, exercise, wind, cosmetics, and hot baths or hot drinks. These symptoms persist throughout other phases of the disorder.

In the vascular phase, patients develop facial erythema and edema with multiple telangiectases, possibly as a result of persistent vasomotor instability.

An inflammatory phase often follows, in which sterile papules and pustules (leading to the designation of rosacea as adult acne) develop.

The late phase (developing in some patients), is characterized by coarse tissue hyperplasia of the cheeks and nose (rhinophyma) caused by tissue inflammation, collagen deposition, and sebaceous gland hyperplasia.

The phases of rosacea are usually sequential. Some patients go directly into the inflammatory stage, bypassing the earlier stages. Treatment may cause rosacea to return to an earlier stage. Progression to the late stage is not inevitable.

Ocular rosacea often precedes or accompanies facial rosacea and manifests as some combination of blepharoconjunctivitis, iritis, scleritis, and keratitis, causing itching, foreign body sensation, erythema, and edema of the eye.

Diagnosis of Rosacea

  • Clinical evaluation

Diagnosis of rosacea is based on the characteristic appearance; there are no specific diagnostic tests. The age of onset and absence of comedones help distinguish rosacea from acne.

Treatment of Rosacea

  • Avoidance of triggers

  • Consideration of topical or oral antibiotics or topical azelaic acid or ivermectin

  • For flushing or persistent erythema, consideration of topical brimonidine or oxymetazoline

  • For recalcitrant cases, consideration of oral isotretinoin

  • For rhinophyma, consideration of dermabrasion, laser ablation, and tissue excision

  • For telangiectasia, consideration of laser or electrocautery treatment

Primary initial treatment of rosacea involves avoidance of triggers (including use of sunscreen). Antibiotics and/or azelaic acid may be used for inflammatory disease. The objective of treatment is control of symptoms, not cure. See the Canadian 2016 clinical practice guidelines for rosacea.

Metronidazole cream (1%), lotion (0.75%), or gel (0.75%) and azelaic acid 20% cream, applied 2 times a day, are equally effective; 2.5% benzoyl peroxide in any form (eg, gel, lotion, cream), applied once a day or 2 times a day, can be added for improved control. Less effective alternatives include sodium sulfacetamide 10%/sulfur 5% lotion; clindamycin 1% solution, gel, or lotion; and erythromycin 2% solution, all applied 2 times a day. Minocycline 1.5% foam can also be applied once a day. Many patients require indefinite treatment for long-term control. Topical ivermectin 1% cream also has efficacy in the treatment of inflammatory lesions of rosacea.

Oral antibiotics are indicated for patients with multiple papules or pustules and for those with ocular rosacea; options include doxycycline 50 to 100 mg 2 times a day, tetracycline 250 to 500 mg 2 times a day, minocycline 50 to 100 mg 2 times a day, erythromycin 250 to 500 mg 2 times a day, and azithromycin 250 mg once a day or various alternate-day or pulse dose regimens. Dose should be reduced to the lowest one that controls symptoms once a beneficial response is achieved. Subantimicrobial doses of doxycycline (40 mg once a day in a preparation containing 30 mg of immediate-release and 10 mg of sustained-release doxycycline) are effective for acne and rosacea.

Persistent erythema or flushing may be treated with the topical alpha-2-selective adrenergic agonist brimonidine 0.33% gel applied once a day or with the primarily alpha-1a agonist oxymetazoline hydrochloride 1% cream applied once a day (1 Treatment reference Rosacea is a chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and, in severe cases, rhinophyma. Diagnosis is based on the characteristic... read more Treatment reference ).

Recalcitrant cases may respond to oral isotretinoin.

Techniques for treatment of rhinophyma include dermabrasion, laser ablation, and tissue excision; cosmetic results are good.

Techniques for treatment of telangiectasia include laser and electrocautery.

Treatment reference

  • 1. Baumann L, Goldberg DJ, Stein Gold L, et al: Pivotal trial of the efficacy and safety of oxymetazoline cream 1.0% for the treatment of persistent facial erythema associated with rosacea: Findings from the second REVEAL trial. J Drugs Dermatol 17(3):290–298, 2018. PMID: 29537447

Key Points

  • Consider rosacea if patients have facial flushing and blushing, with or without stinging, often triggered by sun exposure, emotional stress, cold or hot weather, alcohol, spicy foods, exercise, wind, cosmetics, or hot baths or hot drinks.

  • Diagnose rosacea by its typical appearance (eg, central facial erythema and edema with or without pustules, papules, or multiple telangiectases).

  • Treat rosacea with avoidance of triggers; treat inflammation, depending on severity, with topical antibiotics and/or azelaic acid, oral antibiotics, isotretinoin, or topical ivermectin.

  • Consider brimonidine or oxymetazoline for persistent erythema or flushing.

  • Dermabrasion, laser ablation, and tissue excision for rhinophyma give good cosmetic results.

  • Consider laser or electrocautery for telangiectasia.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

Drug Name Select Trade
Flagyl, Flagyl ER, Flagyl RTU, LIKMEZ, MetroCream, MetroGel, MetroGel Vaginal, MetroLotion, Noritate, NUVESSA, Nydamax, Rosadan, Rozex, Vandazole, Vitazol
Sklice, Soolantra, Stromectol
Absorica, Absorica LD, Accutane, Amnesteem , Claravis , MYORISAN, Sotret, ZENATANE
Cordarone, Nexterone, Pacerone
Azelex, Finacea, Finacea Plus, Finevin
Alphagan, Alphagan P, LUMIFY, Mirvaso
12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
Acne Medication, Acne-10, Acneclear, Benprox , Benzac AC, Benzac W, Benzac-10, Benzac-5, Benzagel, Benzagel-10 , Benzagel-5, BenzaShave, BenzEFoam, BenzEFoam Ultra , BenzePrO, Benziq, Benziq LS, BP Cleanser, BP Cleansing Lotion, BP Foaming Wash, BP Gel, BP Topical , BP Wash, BP Wash Kit, BPO, BPO Creamy Wash, BPO Foaming Cloth, Brevoxyl-4, Brevoxyl-8, Clean&Clear Persa-Gel, Clearplex , Clearplex X, Clearskin, Clinac BPO, Del Aqua, Delos, Desquam-E, Desquam-X, EFFACLAR, Enzoclear, EPSOLAY, Ethexderm BPW, Inova Easy Pad, Lavoclen-4 , Lavoclen-8, NeoBenz Micro, NeoBenz Micro Cream Plus Pack, NeoBenz Micro SD, NeoBenz Micro Wash Plus Pack, Neutrogena Acne Cream, OC8, Oscion, Pacnex, Pacnex HP, Pacnex LP, Pacnex MX, PanOxyl, PanOxyl 10 Maximum Strength, PanOxyl 5, PanOxyl AQ, PanOxyl Aqua, PanOxyl-10, PanOxyl-5, PanOxyl-8, Peroderm, RE Benzoyl Peroxide , Riax, SE BPO, Seba, Seba-Gel, Soluclenz Rx , Theroxide, TL BPO MX, Triaz, True Marker Lintera, Zaclir, Zoderm Cleanser , Zoderm Cream, Zoderm Gel, Zoderm Redi-Pads , Zoderm Wash
AK-Sulf , Bleph-10, Carmol, Cetamide, Klaron, Mexar, Ocu-Sul , Ovace, Ovace Plus, RE-10 , Rosula NS, Seb-Prev, Sodium Sulamyd, Sulf-10
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
A/T/S, Akne-mycin, E.E.S., Emcin Clear , EMGEL, E-Mycin, ERYC, Erycette, Eryderm , Erygel, Erymax, EryPed, Ery-Tab, Erythra Derm , Erythrocin, Erythrocin Lactobionate, Erythrocin Stearate, Ilosone, Ilotycin, My-E, PCE, PCE Dispertab , Romycin, Staticin, T-Stat
Amzeeq, Arestin, Dynacin, Minocin, minolira, Myrac, Solodyn, Ximino, Zilxi
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs
Emtet-500, Panmycin, Sumycin
Azasite, Zithromax, Zithromax Powder, Zithromax Single-Dose , Zithromax Tri-Pak, Zithromax Z-Pak, Zmax, Zmax Pediatric
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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