Dermatology · PANCE / PANRE

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

Phenotype-based rosacea subtypes and first-line therapy.

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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