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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Question 1DermatologyMedium
A 45-year-old woman has worsening facial flushing, inflammatory papules, and telangiectasias across her nose and cheeks that flare with sun exposure, alcohol, and spicy foods. No comedones are present. Which of the following is the most likely diagnosis?
ARosacea
BAcne vulgaris
CLupus malar rash
DSeborrheic dermatitis
Reveal answer & full explanation
Correct answer: A — Rosacea
ARosacea✓
BAcne vulgaris
CLupus malar rash
DSeborrheic dermatitis
Why Rosacea is correct
Chronic inflammatory facial dermatosis with flushing, telangiectasias, and inflammatory papules triggered by sun, alcohol, and spicy foods
The absence of comedones is the key feature distinguishing rosacea from acne vulgaris
Why the others are wrong
Acne vulgaris — defined by comedones (open and closed), which are absent here; choosing it ignores the discriminating negative finding (premature closure on the most common facial papular eruption)
Lupus malar rash — a butterfly-distribution flat erythema that spares the nasolabial folds and lacks telangiectasias and papulopustules, with systemic lupus features (anchoring on 'photosensitive facial rash')
Seborrheic dermatitis — greasy, yellowish scales in the nasolabial folds and scalp rather than flushing and telangiectasias (confused-with-rosacea trap by central-face location)
Additional high-yield points
Subtypes: erythematotelangiectatic (brimonidine gel or laser); papulopustular (topical metronidazole, azelaic acid, or ivermectin first-line; oral doxycycline for moderate-to-severe); phymatous (rhinophyma)
Avoid topical corticosteroids, which worsen rosacea over time
Question 2DermatologyEasy
A 44-year-old fair-skinned woman of Irish descent presents with a 1-year history of facial redness that flares after hot coffee, red wine, and time in the sun. On examination there is persistent erythema and fine telangiectasias across the cheeks, nose, and central forehead, along with several small dome-shaped papules and pustules; the skin around her eyes and the area immediately around her mouth are spared. No comedones are seen. She also reports a gritty, burning sensation in both eyes. Which of the following is the most likely diagnosis?
AAcne vulgaris
BTinea faciei
CAtopic eczema
DAcne rosacea
Reveal answer & full explanation
Correct answer: D — Acne rosacea
AAcne vulgaris
BTinea faciei
CAtopic eczema
DAcne rosacea✓
Why Acne rosacea is correct
Persistent centrofacial erythema with telangiectasias plus dome-shaped papules and pustules and NO comedones is the classic papulopustular/erythematotelangiectatic picture.
Trigger-induced flushing (hot beverages, red wine, sun) plus gritty, burning eyes (ocular rosacea) strongly support the diagnosis.
Sparing of the periocular and perioral skin and the absence of comedones are the key discriminators; ROSCO 2017 criteria make persistent centrofacial erythema diagnostic on its own.
Why the others are wrong
Acne vulgaris is defined by comedones, tends to occur in younger patients, and commonly involves the trunk; comedones are absent here and flushing is not a feature.
Tinea faciei produces an annular, scaly, advancing plaque that is KOH-positive for hyphae; it does not cause trigger-induced flushing or symmetric centrofacial telangiectasias.
Atopic eczema causes pruritic, ill-defined erythema with lichenification at flexural sites and a personal/family atopic history; it lacks telangiectasias, pustules, and the flushing triggers seen here.
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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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