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:
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
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.
Differential diagnosis of rosacea includes acne vulgaris Diagnosis Acne vulgaris is the formation of comedones, papules, pustules, nodules, and/or cysts as a result of obstruction and inflammation of pilosebaceous units (hair follicles and their accompanying... read more , systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more , sarcoidosis Sarcoidosis Sarcoidosis is an inflammatory disorder resulting in noncaseating granulomas in one or more organs and tissues; etiology is unknown. The lungs and lymphatic system are most often affected, but... read more , photodermatitis, drug eruptions Drug Eruptions and Reactions Drugs can cause multiple skin eruptions and reactions. The most serious of these are discussed elsewhere in THE MANUAL and include Stevens-Johnson syndrome and toxic epidermal necrolysis, hypersensitivity... read more (particularly caused by iodides and bromides), granulomas of the skin, and perioral dermatitis Perioral Dermatitis Perioral dermatitis is an erythematous, papulopustular facial eruption that resembles acne and/or rosacea but typically starts around the mouth. Diagnosis is by appearance. Treatment includes... read more .
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 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 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. 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 and 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 ).
Recalcitrant cases may respond to oral isotretinoin.
Techniques for treatment of rhinophyma include dermabrasion and tissue excision; cosmetic results are good.
Techniques for treatment of telangiectasia include laser and electrocautery.
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.
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.
Consider rosacea if patients have 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 and tissue excision for rhinophyma give good cosmetic results.
Consider laser or electrocautery for telangiectasia.