AKT · Dermatology/Inflammatory & papulosquamous

Rosacea

Chronic facial neurovascular + inflammatory dysregulation

Overview

A chronic, relapsing inflammatory facial dermatosis with vascular hyperreactivity. Subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular. Central-face distribution with papulopustules but NO comedones is the discriminator from acne.

Recognise

Central-face (cheeks, nose, chin, forehead) flushing → persistent erythema with telangiectasia
Inflammatory papules and pustules WITHOUT comedones (the key difference from acne)
Phymatous change (rhinophyma — sebaceous overgrowth of the nose, mainly men); ocular rosacea (gritty, dry, blepharitis); triggers: sun, heat, alcohol, spicy food, stress

Red flags

Ocular rosacea with eye pain or visual disturbance (keratitis) → ophthalmology; disfiguring rhinophyma

Differentials & how to tell them apart

Acne vulgariscomedones are present and the patient is usually younger

Seborrhoeic dermatitisgreasy scale in nasolabial folds and scalp

Systemic lupus (malar rash)spares the nasolabial folds, photosensitive, systemic features and positive serology

Perioral dermatitispapulopustules around the mouth sparing the vermilion border

Clinical image

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Rosacea — clinical imagesDermNet

Investigations

Clinical diagnosis. The absence of comedones distinguishes it from acne.

Management

Trigger avoidance + sun protection, with topical metronidazole/azelaic acid/ivermectin for papulopustular disease (or brimonidine for erythema)

1Identify and avoid triggers + daily sun protection. Predominant flushing/erythema → topical brimonidine; papules/pustules → topical metronidazole, azelaic acid or ivermectin.Gate: Rosacea has NO comedones — if comedones are present it is acne; and topical corticosteroids must be avoided as they cause/worsen a steroid rosacea
2Moderate-to-severe papulopustular disease → oral doxycycline (or lymecycline).
3Refractory or phymatous disease → dermatology (isotretinoin, laser for telangiectasia/rhinophyma); ocular rosacea with eye symptoms → ophthalmology.

Topical brimonidine — alpha-agonist vasoconstrictor for transient flushing/persistent erythema

Topical metronidazole / azelaic acid / ivermectin — for papulopustular rosacea

Oral doxycycline (or lymecycline) — moderate-to-severe papulopustular disease

Lid hygiene — ocular rosacea

Isotretinoin; laser — refractory disease; laser for telangiectasia/rhinophyma (specialist)

Key points

Ocular rosacea is common and under-recognised. Topical steroids are a trap — they transiently help then trigger steroid-induced rosacea.

Monitor & prognosis

Response and ocular involvement.

Chronic and controllable; rhinophyma may need surgical/laser reduction.

Source: NICE CKS Rosacea