Rosacea !
Rosacea is a long-term skin condition that causes facial flushing, redness and pimples, and sometimes eye irritation or a thickened nose.
Updated 2026-11-01
Structures involved
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Why it happens
- Chronic inflammation: causes, cells and features
- Skin blood flow
- Hair follicles, sebaceous and sweat glands, nails
What it is
A chronic, relapsing inflammatory disease of the central face characterised by flushing, persistent redness, telangiectasias and inflammatory papules and pustules without comedones. It can also affect the eyes and cause thickening of the skin (phymas).
Who gets it
Common in adults aged 30–50, more often diagnosed in women, while rhinophyma occurs mostly in men. Classically described in fair skin, it is under-recognised in darker skin types common in Latin America, where redness is harder to see.
Causes
- Dysregulated innate immunity (excess cathelicidin and toll-like receptor 2 activity)
- Neurovascular dysregulation with exaggerated vasodilation
- Overgrowth of Demodex folliculorum mites and changes in skin microbes
- Genetic predisposition
Risk factors
- Fair skin, family history
- Age 30–50
- Triggers: sun exposure, heat, hot drinks, spicy food, alcohol, exercise, emotional stress
- Topical corticosteroid use on the face
Pathophysiology
Triggers activate toll-like receptor 2 and kallikrein-5, which cleaves cathelicidin into the inflammatory peptide LL-37. This drives vasodilation, new vessel formation and leukocyte recruitment. Repeated flushing leaves fixed redness and telangiectasias, and long-standing inflammation with fibrosis and sebaceous hyperplasia can produce phymas such as rhinophyma.
Classification
- Diagnostic phenotypes: fixed centrofacial erythema or phymatous changes
- Major features: flushing, papules and pustules, telangiectasias, ocular signs
- Older subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular
Symptoms and signs
- Episodes of facial flushing and persistent redness of the cheeks, nose, chin and forehead
- Telangiectasias (visible small vessels)
- Papules and pustules without comedones (unlike acne)
- Burning, stinging and sensitive skin
- Ocular rosacea: gritty, red, dry eyes, blepharitis, recurrent styes or chalazia
- Rhinophyma: thickened, bulbous nose with large pores
Diagnosis
- Clinical
- Clinical, based on fixed centrofacial redness or phymas, or on two major features (flushing, papules-pustules, telangiectasias, ocular signs). Absence of comedones helps separate it from acne. Slit-lamp exam if eye symptoms.
- Tests
- No specific test. ANA if lupus is suspected; biopsy only for atypical presentations.
- Imaging
- Not needed.
Differential diagnosis
- Acne vulgaris (comedones present, younger patients)
- Seborrheic dermatitis (greasy scale in nasolabial folds and scalp)
- Systemic lupus erythematosus malar rash (spares nasolabial folds, no pustules)
- Perioral dermatitis and steroid-induced dermatitis
- Contact dermatitis; carcinoid syndrome flushing
Goal of treatment
Control redness and inflammatory lesions, reduce flares by avoiding triggers, protect the eyes, and correct phymas; treatment is tailored to the features each person shows.
Treatment
- Lifestyle
- Identify and avoid personal triggers, daily broad-spectrum sunscreen, gentle non-irritating skin care; avoid topical corticosteroids on the face.
- Medical
- Topical metronidazole, azelaic acid or ivermectin for papules and pustules; topical alpha-adrenergic agonists (brimonidine, oxymetazoline) for persistent redness.
- Medical
- Oral tetracyclines (doxycycline at anti-inflammatory levels) for moderate-severe papulopustular or ocular rosacea; oral isotretinoin in refractory or phymatous cases.
- Procedure
- Vascular laser or intense pulsed light for telangiectasias; ablative laser or surgical reshaping (decortication) for rhinophyma.
- Conservative
- Ocular rosacea: eyelid hygiene and warm compresses, lubricating drops, and ophthalmology review if the cornea is involved.
Complications
- Rhinophyma and other phymas with disfigurement
- Keratitis, corneal ulceration and vision loss in ocular rosacea
- Psychological distress and social embarrassment
- Steroid-induced rosacea flare after topical corticosteroid use
Prognosis
A chronic relapsing condition without cure, but most people achieve good control with trigger avoidance and treatment. Early treatment reduces fixed redness and phyma formation.
Test yourself
Think of the answer, then tap the question to see it.
Which feature best distinguishes papulopustular rosacea from acne vulgaris?
Rosacea has no comedones; acne has open and closed comedones.
What is rhinophyma?
Thickened, bulbous nasal skin from sebaceous hyperplasia and fibrosis in phymatous rosacea, mostly in men.
Which mite is linked to rosacea?
Demodex folliculorum.
Which oral antibiotic class is used for moderate-severe and ocular rosacea?
Tetracyclines, typically doxycycline.
Why should topical corticosteroids be avoided on the face in rosacea?
They worsen rosacea and can cause steroid-induced rosacea after an initial improvement.
Related conditions
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Rosacea (MedlinePlus, US National Library of Medicine, 2026); Rosacea (National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 2026).
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