Rosacea

rosacea · acne rosacea · rhinophyma · ocular rosacea

Central facial flushing with papules and no comedones - and the eyes are involved more often than anyone checks.

GPBand D

Red flags

Eye symptoms - ocular rosacea can cause keratitis and threaten vision; ask about grittiness, dryness and redness in every patient and refer if present
Rapid onset of facial papules with systemic features - reconsider lupus or a drug eruption
A butterfly rash sparing the nasolabial folds with systemic symptoms - consider lupus rather than rosacea
Severe rhinophyma causing airway or psychological problems
Long-term potent topical corticosteroid use on the face - steroid-induced rosacea, which will worsen while the steroid continues

Recognise

On light skin

Persistent central facial erythema with flushing, visible telangiectasia, and inflammatory papules and pustules without comedones.

On brown and black skin

Rosacea may affect 2 to 4% of Black, Asian, Pacific Islander and Hispanic or Latino populations, and its prevalence is likely underestimated precisely because diagnosis relies on phenotypic features - fixed erythema, flushing, telangiectasia - that are difficult to appreciate in more heavily pigmented skin. Its cardinal sign is the one that cannot be seen. Patients may describe flushing, burning and stinging that is entirely invisible to the examiner, and their symptom report should be believed rather than discounted. Look for the tone-independent findings: papules and pustules in a central facial distribution without comedones, a warm and swollen central face, and dryness or roughness. Telangiectasia may be detectable with dermoscopy or on close inspection with good light, or may not be visible at all. Granulomatous rosacea, with firm brown or skin-coloured papules, is described more often in darker skin. Where the visible signs fail, work from the minor and secondary criteria: burning or stinging, oedema, dryness, flushing, poor tolerance of over-the-counter products, symptoms with the classic triggers, family history and ocular symptoms - and ask the patient to help establish their own baseline skin tone during the examination. Post-inflammatory hyperpigmentation may be the presenting complaint.

In any skin tone

No comedones - this separates it from acne
Central facial distribution, symmetrical, sparing the skin around the eyes
Flushing and a history of triggers: heat, alcohol, spicy food, sunlight, stress
Burning or stinging rather than itch
Ocular rosacea - dry, gritty, red eyes and blepharitis - is common and is routinely missed because nobody asks
CKS's phenotype rule is what makes a diagnosis possible when you cannot see erythema: diagnose rosacea on at least one diagnostic feature - phymatous change or persistent erythema - or two major features: flushing or transient erythema, inflammatory papules and pustules, telangiectasia, or eye symptoms. Central facial papules and pustules plus ocular symptoms meet it with no visible redness at all
Rhinophyma - thickening of the nose - in longstanding disease, predominantly in men

Distribution

Central face - cheeks, nose, chin and forehead - sparing the periorbital skin. Symmetrical.

Photographs

Rosacea across the nose and cheek. Background erythema with visible telangiectatic vessels, and inflammatory papules and small pustules on top of it. **There are no comedones anywhere** - no blackheads, no whiteheads - and that absence is what separates rosacea from acne, which it is otherwise easily mistaken for. On brown and black skin the background redness is often invisible and rosacea is substantially underdiagnosed as a result; the papules, the pustules and a history of flushing to heat, alcohol or spice may be all you get. The only openly licensed photograph found for this entry shows light skin. **That is a limitation of this page, not of the disease** - a darker-skin photograph is still being sought.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · Sand M, Sand D, Thrandorf C, Paech V, Altmeyer P, Bechara FG · Wikimedia Commons - Rosacea 01.jpg · CC BY 2.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Acne vulgaris, and acne fulminans — Acne has comedones; rosacea does not. Both may coexist
Seborrhoeic dermatitis — Overlaps on the central face and frequently coexists; seborrhoeic disease scales
Contact dermatitis - allergic and irritant — A facial reaction to a cosmetic can look similar but follows application areas

What to do in the ED

Ask about the eyes in every patient with rosacea and examine them; refer to ophthalmology for anything more than mild dryness
Treat by phenotype, because the treatments are not interchangeable - this is CKS's structure, summarised; take doses from the BNF. Persistent erythema: consider topical brimonidine 0.5% gel once daily as required - it reduces erythema within 30 minutes, peaks at 3 to 6 hours and then wears off, so set that expectation. Transient flushing: consider oral propranolol 20 to 40 mg two or three times daily. Mild-to-moderate papules and pustules: topical ivermectin once daily for 8 to 12 weeks, with metronidazole 0.75% twice daily or azelaic acid 15% twice daily as alternatives where ivermectin is unavailable or inappropriate, for instance in pregnancy or breastfeeding - they are alternatives, not co-equal first-line. Moderate-to-severe: ivermectin plus oral doxycycline 40 mg modified-release once daily for 8 to 12 weeks
Stop any topical corticosteroid being used on the face - it is a common perpetuating cause
Advise on trigger avoidance and daily broad-spectrum sun protection, which is part of treatment and not an optional extra
In patients with brown or black skin, take the reported flushing and burning seriously even where you can see nothing, and treat on the symptoms - CKS says so itself, noting that in darker skin phototypes V and VI erythema may be difficult to detect visually. Use the two-major-feature route rather than waiting for redness you will not see
Refer to dermatology for resistant disease, rhinophyma, or diagnostic uncertainty

Disposition

Topical treatment and GP follow-up. Ophthalmology for ocular involvement and dermatology for resistant disease or rhinophyma.

Safety-netting

This is controllable but not curable, and it flares with known triggers - heat, alcohol, spicy food, sun and stress. Use sun protection daily. Do not use steroid creams on your face unless a doctor has specifically told you to. Return or see an optician or your GP promptly if your eyes become gritty, dry, red or painful, or if your vision changes.

Sources

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