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Acne Rosacea
Daniel R. DiBlasi, DO
Shane L. Larson, MD
image BASICS
  • Rosacea is a chronic condition characterized by recurrent episodes of facial flushing, erythema (due to dilatation of small blood vessels in the face), papules, pustules, and telangiectasia (due to increased reactivity of capillaries) in a symmetric, central facial distribution. Sometimes associated with ocular symptoms (ocular rosacea).
  • Four subtypes:
    • Erythematotelangiectatic rosacea (ETR)
    • Papulopustular rosacea (PPR)
    • Phymatous rosacea
    • Ocular rosacea
  • System(s) affected: skin/exocrine
  • Synonym(s): rosacea
Geriatric Considerations
  • Uncommon >60 years of age
  • Effects of aging might increase the side effects associated with oral isotretinoin used for treatment (at present, data are insufficient due to lack of clinical studies in elderly patients ≥65 years).
  • Predominant age: 30 to 50 years
  • Predominant sex: female > male. However, males are at greater risk for progression to later stages.
  • No proven cause
  • Possibilities include the following:
    • Thyroid and sex hormone disturbance
    • Alcohol, coffee, tea, spiced food overindulgence (unproven)
    • Demodex follicular parasite (suspected)
    • Exposure to cold, heat
    • Emotional stress
    • Dysfunction of the GI tract
People of Northern European and Celtic background commonly afflicted
  • Exposure to spicy foods, hot drinks
  • Environmental factors: sun, wind, cold, heat
No preventive measures known
  • Seborrheic dermatitis of scalp and eyelids
  • Keratitis with photophobia, lacrimation, visual disturbance
  • Corneal lesions
  • Blepharitis
  • Uveitis
  • Rosacea has typical stages of evolution:
    • The rosacea diathesis: episodic erythema, “flushing and blushing”
    • Stage I: persistent erythema with telangiectases
    • Stage II: persistent erythema, telangiectases, papules, tiny pustules
    • Stage III: persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent “solid” edema of the central part of the face (phymatous)
  • Facial erythema, particularly on cheeks, nose, and chin. At times, entire face may be involved.
  • Inflammatory papules are prominent; pustules and telangiectasia may be present.
  • Comedones are absent (unlike acne vulgaris).
  • Women usually have lesions on the chin and cheeks, whereas the nose is commonly involved in men.
  • Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.
  • Drug eruptions (iodides and bromides)
  • Granulomas of the skin
  • Cutaneous lupus erythematosus
  • Carcinoid syndrome
  • Deep fungal infection
  • Acne vulgaris
  • Seborrheic dermatitis
  • Steroid rosacea (abuse)
  • Systemic lupus erythematosus
  • Lupus pernio (sarcoidosis)
Diagnosis is based on physical exam findings.
Test Interpretation
  • Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
  • Absence of comedones and blocked ducts
  • Vascular dilatation and dermal lymphocytic infiltrate
  • Proper skin care and photoprotection are important components of management plan (1)[B]. Use of mild, nondrying soap is recommended; local skin irritants should be avoided.
  • Avoidance of triggers
  • Reassurance that rosacea is completely unrelated to poor hygiene
  • Treat psychological stress if present.
  • Topical steroids should not be used, as they may aggravate rosacea.
  • Avoid oil-based cosmetics:
    • Others are acceptable and may help women tolerate symptoms
  • Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
  • Possible evolving laser therapy
  • Support physical fitness.

First Line
  • Topical metronidazole preparations once (1% formulation) or twice (0.75% formulations) daily for 7 to 12 weeks was significantly more effective than placebo in patients with moderate to severe rosacea. A rosacea treatment system (cleanser, metronidazole 0.75% gel, hydrating complexion corrector, and sunscreen SPF 30) may offer superior efficacy and tolerability to metronidazole (2)[A].
  • Azelaic acid (Finacea) is very effective as initial therapy; azelaic acid topical alone is effective for maintenance (3)[A].
  • Topical ivermectin 1% cream (2)[A]
    • Recently found to be more effective than metronidazole for treatment of PPR
  • Topical brimonidine tartrate 0.5% gel is effective in reducing erythema associated with ETR (4)[A].
    • α2-Adrenergic receptor agonist; potent vasoconstrictor
  • Doxycycline 40-mg dose is at least as effective as 100-mg dose and has a correspondingly lower risk of adverse effects but is much more expensive (5)[A].
  • Precautions: Tetracyclines may cause photosensitivity; sunscreen is recommended.
  • Significant possible interactions:
    • Tetracyclines: Avoid concurrent administration with antacids, dairy products, or iron.
    • Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier method is recommended.
Second Line
  • Topical erythromycin
  • Topical clindamycin (lotion preferred)
    • Can be used in combination with benzoyl peroxide; commercial topical combinations are available
  • Possible use of calcineurin inhibitors (tacrolimus 0.1%; pimecrolimus 1%). Pimecrolimus 1% is effective to treat mild to moderate inflammatory rosacea (6)[A].
  • Permethrin 5% cream; similar efficacy compared to metronidazole (7)[B]. For severe cases, oral isotretinoin at 0.3 mg/kg for a minimum of 3 months.
Pediatric Considerations
Tetracyclines: not for use in children <8 years
Pregnancy Considerations
  • Tetracyclines: not for use during pregnancy
  • Isotretinoin: teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception; requires registration with iPLEDGE program
Cyclosporine 0.05% ophthalmic emulsion may be more effective than artificial tears for ocular rosacea.
Laser treatment is an option for progressive telangiectasias or rhinophyma.
Outpatient treatment
Patient Monitoring
  • Occasional and as needed
  • Close follow-up and laboratory assessment for women using isotretinoin per prescribing instructions and iPLEDGE program guidance.
Avoid alcohol, excessive sun exposure, and hot drinks of any type.
  • Slowly progressive
  • Subsides spontaneously (sometimes)
1. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies. Cutis. 2014;93(1):18-28.
2. van Zuuren EJ, Fedorowicz Z, Carter BR, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262. doi:10.1002/14651858. CD003262.pub5.
3. Thiboutot DM, Fleischer AB, Del Rosso JQ, et al. A multicenter study of topical azelaic acid 15% gel in combination with oral doxycycline as initial therapy and azelaic acid 15% gel as maintenance monotherapy. J Drugs Dermatol. 2009;8(7):639-648.
4. Fowler J Jr, Jackson JM, Moore A, et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013;12(6):650-656.
5. Del Rosso JQ, Webster GF, Jackson M, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56(5):791-802.
6. Kim MB, Kim GW, Park HJ, et al. Pimecrolimus 1% cream for the treatment of rosacea. J Dermatol. 2011;38(12):1135-1139. doi:10.1111/j.1346-8138.2011.01223.x.
7. Koçak M, Yağli S, Vahapoğlu G, et al. Permethrin 5% cream versus metronidazole 0.75% gel for the treatment of papulopustular rosacea. A randomized double-blind placebo-controlled study. Dermatology. 2002;205(3):265-270.
Additional Reading
  • Leyden JJ. Efficacy of a novel rosacea treatment system: an investigator-blind, randomized, parallel-group study. J Drugs Dermatol. 2011;10(10):1179-1185.
  • Liu RH, Smith MK, Basta SA, et al. Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Arch Dermatol. 2006;142(8):1047-1052.
See Also
  • Acne Vulgaris; Blepharitis; Dermatitis, Seborrheic; Lupus Erythematosus, Discoid; Uveitis
  • Algorithm: Acne
  • L71.9 Rosacea, unspecified
  • L71.8 Other rosacea
Clinical Pearls
  • Rosacea usually arises de novo without any preceding history of acne or seborrhea.
  • Rosacea may cause chronic eye symptoms, including blepharitis.
  • Avoid alcohol, sun exposure, and hot drinks.
  • Medication treatment resembles that of acne vulgaris, with oral and topical antibiotics.