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Rosacea (acne rosacea) is a chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and in severe cases, rhinophyma. Diagnosis is based on the characteristic appearance and history. Treatment depends on severity and includes topical metronidazole, topical and oral antibiotics, rarely isotretinoin, and, for severe rhinophyma, surgery.

Rosacea most commonly affects patients aged 30 to 50 with fair complexions, most notably those of Irish and Northern European descent, but it affects and is probably under-recognized in darker-skinned patients.

Etiology

The etiology of rosacea is unknown, although associations with abnormal vasomotor control, impaired facial venous drainage, an increase in follicle mites (Demodex folliculorum), and Helicobacter pylori infection have been proposed. People with rosacea may have elevated levels of small antimicrobial peptides that are part of the body's natural defense system. People with rosacea may also have higher than normal levels of cathelicidin as well as another group of enzymes called stratum corneum tryptic enzymes.

Symptoms and Signs

Rosacea is limited to the face and scalp and manifests in 4 phases:

• Pre-rosacea phase
• Vascular phase
• Inflammatory phase
• Late stage

In the pre-rosacea phase, patients describe embarrassing flushing and blushing, often accompanied by uncomfortable stinging. Common reported triggers for these flares include sun exposure, emotional stress, cold or hot weather, alcohol, spicy foods, exercise, wind, cosmetics, and hot baths or hot drinks. These symptoms persist throughout other phases of the disorder.

In the vascular phase, patients develop facial erythema and edema with multiple telangiectasias, possibly as a result of persistent vasomotor instability.

An inflammatory phase often follows, in which sterile papules and pustules (leading to the designation of rosacea as adult acne) develop.

Some patients go on to develop late-stage rosacea, characterized by coarse tissue hyperplasia of the cheeks and nose (rhinophyma) caused by tissue inflammation, collagen deposition, and sebaceous gland hyperplasia.

Rosacea

The phases of rosacea are usually sequential. Some patients go directly into the inflammatory stage bypassing the earlier stages. Treatment may cause a patient to return to an earlier stage. Progression to the late stage is not inevitable.

Ocular rosacea often accompanies facial rosacea and manifests as some combination of blepharoconjunctivitis, iritis, scleritis, and keratitis, causing itching, foreign body sensation, erythema, and edema of the eye.

Diagnosis

• Clinical evaluation

Diagnosis is based on the characteristic appearance; there are no specific diagnostic tests. The age of onset and absence of comedones help distinguish rosacea from acne. Differential diagnosis includes acne vulgaris, SLE, sarcoidosis, photodermatitis, drug eruptions (particularly from iodides and bromides), granulomas of the skin, and perioral dermatitis.

Treatment

• Avoidance of triggers
• Consideration of topical or oral antibiotics
• Consideration of isotretinoin Some Trade Names
  ACCUTANE
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  if antibiotics are unsuccessful
• Consideration of dermabrasion and tissue excision for rhinophyma

Primary initial treatment of rosacea involves avoidance of triggers (including use of sunscreen). Antibiotics may be used for inflammatory disease. The objective of treatment is control of symptoms, not cure.

Metronidazole Some Trade Names
FLAGYL
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cream 1%, lotion (0.75%), or gel (0.75%) and azelaic acid Some Trade Names
AZELEX
FINACEA
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20% cream, applied bid, are equally effective; 2.5% benzoyl peroxide Some Trade Names
BENZAC AC
BENZAGEL
NEUTROGENA ACNE MASK
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, applied once/day or bid, can be added for improved control. Less effective alternatives include sodium sulfacetamide Some Trade Names
BLEPH-10
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10%/sulfur 5% lotion; clindamycin Some Trade Names
CLEOCIN
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1% solution, gel, or lotion; and erythromycin Some Trade Names
ERY-TAB
ERYTHROCIN
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2% solution, all applied bid. Many patients require indefinite treatment for chronic control.

Oral antibiotics are indicated for patients with multiple papules or pustules and those with ocular rosacea; options include tetracycline Some Trade Names
ACHROMYCIN V
TETRACYN
TETREX
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250 to 500 mg bid, doxycycline Some Trade Names
PERIOSTAT
VIBRAMYCIN
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50 to 100 mg bid, minocycline Some Trade Names
MINOCIN
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50 to 100 mg bid, and erythromycin Some Trade Names
ERY-TAB
ERYTHROCIN
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250 to 500 mg bid. Doses should be reduced to the lowest that control symptoms once a beneficial response is achieved. Recalcitrant cases may respond to oral isotretinoin Some Trade Names
ACCUTANE
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. Subantimicrobial doses of doxycycline Some Trade Names
PERIOSTAT
VIBRAMYCIN
Click for Drug Monograph
have also been proven effective for acne and rosacea.

Techniques developed for treatment of rhinophyma include dermabrasion and tissue excision; cosmetic results are good.

Last full review/revision August 2008 by Karen McCoy, MD, MPH

Content last modified August 2008