Rosacea
Chronic centrofacial inflammatory dermatosis with flushing, persistent erythema, telangiectasias, papules/pustules, and ocular involvement.
Also known as: rosacea, acne rosacea, rhinophyma, ocular rosacea
Overview
A chronic relapsing inflammatory disorder of the centrofacial skin characterized by flushing, fixed erythema, telangiectasias, inflammatory papules and pustules, and phymatous changes; may involve the eye.
Epidemiology
Prevalence ~5% of US adults. Peak onset ages 30-50. Female predominance for erythematotelangiectatic and papulopustular subtypes; male predominance for phymatous disease (rhinophyma). More common in fair-skinned individuals of northern European descent.
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Risk factors
- Fair skin (Fitzpatrick I-II), Celtic/northern European ancestry
- Family history of rosacea
- Chronic UV exposure
- Demodex folliculorum mite overgrowth
- Helicobacter pylori (controversial)
- Triggers: hot beverages, spicy food, alcohol (red wine), heat, cold wind, emotional stress, sun exposure, vasodilators
Pathophysiology
Multifactorial: dysregulated innate immunity (elevated cathelicidin LL-37 and kallikrein-5), neurovascular dysfunction (TRPV1/TRPA1 receptor sensitization), Demodex-driven inflammation, and impaired skin barrier. Chronic inflammation drives vascular ectasia, sebaceous gland hyperplasia, and dermal fibrosis (phyma).
Clinical presentation
Symptoms
- Episodic flushing in response to triggers, lasting minutes
- Persistent centrofacial erythema (cheeks, nose, chin, central forehead) — spares periocular skin
- Burning, stinging, dryness, sensitivity to topicals
- Ocular: foreign body sensation, dryness, blurred vision, burning, photophobia
Signs / physical exam
- Erythematotelangiectatic (ETR): fixed erythema and telangiectasias
- Papulopustular (PPR): small dome-shaped papules and pustules WITHOUT comedones
- Phymatous: thickened, bulbous nose (rhinophyma); less commonly chin (gnathophyma), forehead (metophyma), ear (otophyma), eyelid (blepharophyma)
- Ocular rosacea: blepharitis, meibomian gland dysfunction, chalazia, conjunctival injection, corneal neovascularization (vision-threatening)
Classic findings
Centrofacial distribution sparing periocular and perioral skin; absence of comedones distinguishes from acne.
Differential diagnosis
- Acne vulgaris — Comedones present; younger age; truncal involvement common
- Seborrheic dermatitis — Greasy yellow scale on scalp, eyebrows, nasolabial folds; often co-occurs with rosacea
- Lupus (acute cutaneous) — Malar rash sparing nasolabial folds, photosensitivity, systemic symptoms, positive ANA
- Perioral dermatitis — Papules around mouth sparing vermilion border, often steroid-induced
- Carcinoid syndrome — Episodic flushing + diarrhea, wheezing; elevated 24-hr urinary 5-HIAA
- Steroid-induced rosacea — History of chronic topical steroid use to face; rebound erythema and papules on withdrawal
- Demodicosis — Pityriasis folliculorum with sandpaper texture; numerous Demodex on skin scraping
Diagnostic workup
Diagnostic criteria
ROSCO 2017 phenotype-based criteria. Diagnostic: persistent centrofacial erythema OR phymatous changes. Major: flushing, telangiectasia, papules/pustules, ocular findings (lid margin telangiectasia, conjunctival injection, keratitis).
Labs
- Clinical diagnosis — no laboratory testing required
- Consider ANA if photosensitive malar rash or systemic features suggest lupus
Imaging
- Not indicated
Diagnostic algorithm
| Subtype | Hallmark Features | Preferred Therapy |
|---|---|---|
| Erythematotelangiectatic | Persistent erythema, telangiectasias, flushing | Trigger avoidance, brimonidine/oxymetazoline, pulsed dye laser/IPL |
| Papulopustular | Papules and pustules, no comedones | Topical ivermectin/metronidazole/azelaic acid; oral doxycycline 40 mg MR |
| Phymatous | Thickened sebaceous skin, rhinophyma | Isotretinoin (early); surgical debulking, CO2 laser |
| Ocular | Blepharitis, chalazia, keratitis | Lid hygiene, artificial tears, oral doxycycline, ophthalmology |
Treatment
First-line
- General: trigger avoidance, daily broad-spectrum sunscreen SPF ≥30, gentle non-soap cleansers, fragrance-free moisturizer
- Persistent erythema: topical alpha-agonists — brimonidine 0.33% gel daily or oxymetazoline 1% cream daily (rebound erythema possible)
- Telangiectasias: pulsed dye laser, KTP laser, or intense pulsed light (IPL)
- Papulopustular (mild-moderate): topical metronidazole 0.75-1%, azelaic acid 15%, ivermectin 1% cream daily
- Papulopustular (moderate-severe): add oral doxycycline — sub-antimicrobial 40 mg modified-release daily (anti-inflammatory dose) preferred; doxycycline 100 mg daily acceptable
- Ocular rosacea: warm compresses, lid hygiene, artificial tears, topical cyclosporine 0.05%, oral doxycycline; ophthalmology referral if keratitis
Phymatous (rhinophyma)
- Early: oral isotretinoin 0.3-0.5 mg/kg/day may slow progression
- Established: surgical debulking — electrocautery, dermabrasion, CO2 laser, or cold-steel excision
Severe / refractory papulopustular
- Oral isotretinoin 0.25-0.5 mg/kg/day (lower dose than acne) for 4-6 months
Second-line / adjunct
- Topical minocycline 1.5% foam
- Encapsulated benzoyl peroxide 5% cream (recently FDA-approved for rosacea)
- Sulfacetamide-sulfur 10%/5% lotion or cleanser
- Oral erythromycin or azithromycin if doxycycline contraindicated
Complications
- Permanent telangiectasias and dermal thickening
- Rhinophyma — disfigurement and psychosocial impact
- Ocular complications: corneal neovascularization, ulceration, scarring, vision loss
- Anxiety, depression, body image disturbance
PANCE pearls
- Absence of comedones is the single best clue to distinguish rosacea from acne.
- Topical corticosteroids should NEVER be used for rosacea — they cause rebound flares and steroid-induced rosacea.
- Ocular rosacea can precede skin findings — ask about gritty/burning eyes in any patient with facial flushing.
- Sub-antimicrobial doxycycline 40 mg MR is anti-inflammatory without selecting resistance and is preferred over 100 mg dosing for long-term use.
- Phymatous rosacea is more common in men despite female predominance in other subtypes.
References
- AAD 2020 — Guidelines of Care for the Management of Rosacea (Thiboutot et al., J Am Acad Dermatol 2020)
- ROSCO 2017 — Updating the Diagnosis, Classification and Assessment of Rosacea — Recommendations by the Global ROSacea COnsensus Panel (Tan et al., Br J Dermatol 2017)
- NRS Standard — Standard Classification and Pathophysiology of Rosacea — National Rosacea Society Expert Committee (Gallo et al., J Am Acad Dermatol 2018)
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