Rosacea
Exam Tips
- Use phenotype criteria in OSCEs: 1 diagnostic feature or 2 major features confirms clinical diagnosis.
- Absence of comedones helps distinguish rosacea from acne vulgaris.
- Always ask about eyes; ocular rosacea can occur before, after, or without obvious skin lesions.
- In darker skin, erythema/telangiectasia may be subtle; rely on history (flushing, stinging) and consider dermoscopy.
- Red-flag eye symptoms (pain, photophobia, blurred vision) require same-day ophthalmology assessment.
Definition
Rosacea is a chronic relapsing inflammatory disorder of the pilosebaceous and neurovascular units, classically affecting the central convex face (cheeks, nose, chin, and central forehead). It is diagnosed clinically using a phenotype approach: either one diagnostic feature (persistent centrofacial erythema or phymatous change) or at least two major features (for example flushing, papules/pustules, telangiectasia, ocular involvement).
Pathophysiology
Rosacea is multifactorial, with interaction between genetic susceptibility and environmental triggers. Core mechanisms include innate immune overactivity (including increased cathelicidin/LL-37 signalling), neurovascular dysregulation causing flushing and persistent vasodilatation, and barrier dysfunction with heightened cutaneous reactivity. Demodex folliculorum overgrowth is strongly associated and may amplify inflammation, although causality is not absolute. Over time, repeated inflammatory and vascular episodes can progress to persistent erythema, telangiectasia, and in some patients tissue hypertrophy/fibrosis (phymatous rosacea, e. g. rhinophyma). Ocular disease reflects related meibomian and ocular surface inflammation (blepharitis, keratitis, conjunctival inflammation).
Risk Factors
- Fair skin phototypes (especially II-III); disease may be under-recognised in darker skin
- Age 30-60 years (often presenting in mid-adult life)
- Female sex for overall prevalence; male sex for severe phymatous disease
- Family history/genetic predisposition
- Ultraviolet exposure and photosensitive skin
- Heat, cold, hot drinks, spicy foods, alcohol
- Emotional stress and vigorous exercise
- Topical corticosteroid exposure (can trigger/worsen steroid-induced rosacea phenotype)
- Smoking (reported association)
- Demodex mite overdensity (associated risk marker)
Clinical Features
Symptoms
- Episodic flushing of the central face, often with warmth or burning
- Persistent facial redness with sensitivity/stinging
- Papules and pustules on central face (typically without comedones)
- Dry, rough, or tight-feeling skin
- Ocular symptoms: gritty/foreign-body sensation, dryness, burning, tearing, photophobia, intermittent blurred vision
Signs
- Persistent centrofacial erythema over convexities (cheeks, nose, chin, central forehead)
- Telangiectasia beyond the alar nose region (dermoscopy can help in darker skin)
- Inflammatory papules/pustules ± nodules in centrofacial distribution
- Phymatous change (skin thickening/sebaceous hyperplasia), especially rhinophyma
- Periocular signs: lid margin telangiectasia, blepharitis, conjunctival injection; severe cases may show keratitis/uveitis
- See clinical image references in dermatology atlases for centrofacial erythema, telangiectasia, and rhinophyma patterns
Investigations
Management
Lifestyle Modifications
- Educate that rosacea is chronic-relapsing; set realistic control goals rather than cure
- Identify and minimise personal triggers (UV, heat, alcohol, spicy food, stress, hot drinks, vigorous exertion)
- Daily broad-spectrum sunscreen (SPF 30-50), gentle non-soap cleanser, regular emollient, avoid irritant cosmetics
- Stop topical facial corticosteroids unless essential specialist indication
- Address psychosocial burden (anxiety, embarrassment, social impact) and offer support
Pharmacological Treatment
Topical anti-inflammatory therapy for papulopustular rosacea
- Ivermectin 1% cream: apply once daily to affected facial areas (up to ~4 months, then review)
- Metronidazole 0.75% gel/cream: apply twice daily (or 1% formulation once daily where used)
- Azelaic acid 15% gel: apply twice daily
First-line choices depend on phenotype, tolerability, and cost. Warn about local irritation/stinging; avoid contact with eyes/mucosa. Reassess response after 8-12 weeks.
Systemic antibiotics for moderate-severe inflammatory disease or topical failure
- Doxycycline modified-release 40 mg once daily in the morning (licensed for rosacea; typical 6-16 weeks)
- Doxycycline 100 mg once daily (off-label alternative in practice)
- Lymecycline 408 mg once daily (off-label alternative)
Avoid tetracyclines in pregnancy, breastfeeding, and children under 12 years. Counsel on photosensitivity and pill oesophagitis (take with water, stay upright, avoid before bed). Check interactions with antacids/iron.
Persistent erythema/flushing-targeted vasoconstrictor
- Brimonidine 0.33% gel once daily to affected facial erythema
Useful for transient erythema reduction, not for papules/pustules. Warn about rebound erythema/flushing. Avoid/seek specialist advice with severe cardiovascular disease; contraindicated with MAO inhibitors and caution with tricyclic/tetracyclic antidepressants.
Ocular rosacea adjuncts
- Preservative-free lubricating eye drops as needed
- Oral doxycycline regimens (e. g. 40 mg MR once daily) when significant lid/meibomian disease
Escalate urgently to ophthalmology for eye pain, photophobia, reduced vision, or suspected keratitis/uveitis.
Surgical / Interventional
- Vascular laser or intense pulsed light for persistent telangiectasia/erythema
- CO2 laser resurfacing, electrosurgery, or surgical debulking for rhinophyma/phymatous overgrowth
- Dermatology/plastic surgery referral for refractory phymatous disease or diagnostic uncertainty
Complications
- Psychological morbidity: anxiety, depression, low self-esteem, social withdrawal
- Ocular morbidity: chronic blepharitis, recurrent chalazia/hordeola, conjunctivitis
- Sight-threatening disease: keratitis, scleritis, anterior uveitis
- Rosacea fulminans (rare severe eruptive variant) with potential scarring
- Persistent facial lymphoedema (Morbihan disease), occasionally with ectropion
- Phymatous progression (rhinophyma), with rare association of basal cell carcinoma in affected tissue
Prognosis
Prognosis is variable: rosacea usually follows a chronic fluctuating course with remissions and relapses, and phenotypes may evolve over time. Many patients achieve partial control with trigger modification and phenotype-directed therapy, but complete remission may take years and some progress to ocular or phymatous complications without adequate treatment.
Sources & References
🏥BMJ Best Practice(2)
💊BNF Drug References(20)
- Alclometasone dipropionate[contraindications]
- Azelaic acid[management.pharmacological]
- Beclometasone dipropionate[contraindications]
- Betamethasone[contraindications]
- Brimonidine tartrate[management.pharmacological]
- Clobetasol propionate[contraindications]
- Clobetasone butyrate[contraindications]
- Erythromycin[management.pharmacological]
- Fludroxycortide[contraindications]
- Fluocinolone acetonide[contraindications]
- Fluocinonide[contraindications]
- Fluticasone[contraindications]
- Hydrocortisone[contraindications]
- Hydrocortisone butyrate[contraindications]
- Ivermectin[management.pharmacological]
- Mometasone furoate[contraindications]
- Oxytetracycline[management.pharmacological]
- Tetracycline[management.pharmacological]
- Tretinoin with clindamycin[contraindications]
- Tretinoin with erythromycin[contraindications]
✅NICE Guidelines(1)
- Rosacea[overview]
📖Textbook References(3)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1633)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 604)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 603, 604)[context]