Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Patients may have facial erythema, flushing, telangiectasia, papules, pustules, phymatous changes, and ocular manifestations. The diagnosis is clinical. Management includes avoidance of triggers, gentle skincare, topical (and/or oral) antibiotics, and laser (or surgical) therapies.

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  • Worldwide incidence: > 5%
  • Age of presentation: 30–50 years old
  • Women > men
  • More common in fair-skinned people


The exact etiology is not understood, but the following may be associated with rosacea:

  • Genetic predisposition
  • Infections:
    • Demodex mites
    • Helicobacter pylori
  • Ultraviolet radiation
  • Vascular hyperactivity causing prolonged flushing: 
    • Exercise 
    • Hot weather
    • Spicy food
    • Alcohol use
    • Stress


The precise mechanism is unknown. There are 2 proposed theories:

  • Environmental exposure → vasoactive peptides are upregulated → capillary hyperreactivity → erythema and flushing
  • Microbial exposure → immune system activation and inflammation

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Clinical Presentation and Diagnosis

Clinical presentation

Rosacea may present as 1 of 4 clinical subtypes. These subtypes are not mutually exclusive, and patients may have features of multiple subtypes with varying symptoms over time.

  • Erythematotelangiectatic rosacea: 
    • Often the earliest manifestation
    • Persistent centrofacial (nose and medial cheeks) erythema
    • Intermittent facial flushing of the nose and cheeks
    • Telangiectasia (enlarged cutaneous blood vessels)
    • Occurs when exposed to triggers
  • Papulopustular rosacea: 
    • Eruptive papules and pustules
    • Similar in appearance to acne vulgaris, but lacks comedones.
  • Phymatous rosacea:
    • Often a late manifestation, but can occur with no prior skin changes
    • Fibrosis and hypertrophy of sebaceous glands
    • Appears as thickened skin and irregular contours
    • Commonly affected areas:
      • Nose → rhinophyma (most common in men)
      • Forehead → glabellophyma
      • Chin → gnathophyma
      • Cheeks
  • Ocular rosacea (seen in > 50% of cases):
    • May precede facial symptoms in 20% of patients
    • Conjunctivitis
    • Blepharitis
    • Iritis
    • Keratitis
    • Chalazion or hordeola
    • Lid margin telangiectasia
Rosacea erythema and telangiectasia

Cutaneous findings of rosacea:
Erythema and telangiectasia are seen over the cheeks, nasolabial area, and nose. Inflammatory papules and pustules can be observed over the nose. The absence of comedones is a helpful tool to distinguish rosacea from acne vulgaris.

Image: “Rosacea erythema and telangiectasia” by Department of Dermatology and Allergology, Dermatologic Surgery Unit, Ruhr-University Bochum, Gudrunstr 56, 44791 Bochum, Germany. License: CC BY 2.0


Rosacea is a clinical diagnosis.

Diagnostic criteria (National Rosacea Society Expert Committee):

  • Any 1 of the following:
    • Fixed centrofacial erythema 
      • Has a characteristic pattern
      • May periodically intensify
    • Phymatous changes
  • OR 2 of the following:
    • Flushing
    • Papules and pustules
    • Telangiectasia
    • Ocular manifestations

Management and Prognosis


  • General measures:
    • Identify and avoid triggers
    • Broad-spectrum ultraviolet protection
    • Gentle skin cleansing
    • Keep skin moisturized.
    • Avoid irritating topical products and exfoliation.
  • Therapy for erythema and flushing:
    • Topical agents (induce and maintain remission):
      • Brimonidine
      • Oxymetazoline
    • Laser therapy to reduce telangiectasia
    • Avoid steroids (as they may worsen the condition).
  • Therapy for pustules and papules:
    • Topical treatments:
      • Metronidazole
      • Azelaic acid
      • Ivermectin
    • Oral antibiotics: 
      • Doxycycline
      • Minocycline
      • Tetracycline
    • Isotretinoin
  • Therapy for phymatous changes:
    • Isotretinoin
    • Laser ablation
    • Surgery
  • Ocular therapy:
    • Ophthalmologists should evaluate patients.
    • Artificial tears
    • Topical antibiotics:
      • Erythromycin
      • Metronidazole
    • Oral antibiotics:
      • Doxycycline 
      • Metronidazole


  • Rosacea is a lifelong condition and requires long-term care.
  • Rosacea is not a life-threatening condition.
  • If untreated, permanent scarring can develop.
  • Patients may develop anxiety or depression.

Differential Diagnosis

  • Acne vulgaris: the most common skin disease, which results from obstruction and inflammation of hair follicles and sebaceous glands. Acne can present as open (or closed) comedones, papules, pustules, nodules, or cysts. The diagnosis is clinical. Management depends on the severity and may include topical therapies, antibiotics, and retinoids.
  • Seborrheic dermatitis: a common chronic, relapsing skin disorder that presents as erythematous plaques with greasy yellow scales in susceptible areas (scalp, face, and trunk). This condition can be seen in the nasolabial folds. The diagnosis is clinical. Steroids, calcineurin inhibitors, and antifungal agents are used in the management of this condition.
  • Systemic lupus erythematosus (SLE): a chronic, autoimmune, multisystem, inflammatory condition. Cutaneous findings can include a malar rash (which spares the nasolabial folds). Multiple systemic symptoms may also be present, including arthritis, nephritis, serositis, cytopenia, thromboembolic disease, seizures, and/or psychosis. The diagnosis is made by meeting clinical criteria, which include antinuclear and SLE-specific antibodies. Management involves corticosteroids, hydroxychloroquine, and immunosuppressants. 


  1. Dahl, V.M. (2020). Rosacea: Pathogenesis, clinical features, and diagnosis. UpToDate. Retrieved on February 15, 2021, from
  2. Maier, L.E. (2021). Management of rosacea. In Oforoi, A.O. (Ed.), UpToDate. Retrieved February 18, 2021, from
  3. Banasikowska, A.K., and Bolton, D. (2020). Rosacea. In James, W.D. (Ed.), Medscape. Retrieved February 18, 2021, from
  4. Farshchian M., Daveluy S. (2020). Rosacea. [online] StatPearls. Retrieved February 18, 2021, from
  5. Keri, J.E. (2020). Rosacea. [online] MSD Manual Professional Version. Retrieved February 18, 2021, from

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