Chronic condition with recurrent facial flushing, erythema (small blood vessel dilation), papules, pustules, and telangiectasia (increased capillary reactivity) in a symmetric, central facial distribution.
May be associated with ocular symptoms (ocular rosacea).
Four subtypes:
Erythematotelangiectatic rosacea (ETR)
Papulopustular rosacea (PPR)
Phymatous rosacea
Ocular rosacea
Affects skin and exocrine systems.
Synonym: rosacea.
Geriatric Considerations
Chronic inflammatory dermatosis with onset typically in middle age.
Aging may increase side effects of oral isotretinoin; limited data for patients β₯65 years.
EPIDEMIOLOGY
Predominant age of onset: 30 to 50 years.
Female > male; however, males at greater risk for progression.
More common in Fitzpatrick skin types I and II.
ETIOLOGY AND PATHOPHYSIOLOGY
No proven cause; suspected factors:
Thyroid and sex hormone disturbances.
Alcohol, coffee, tea, spicy foods (unproven).
Demodex follicular mite (suspected).
Exposure to cold, heat, emotional stress.
GI dysfunction (possible Helicobacter pylori association).
Genetics: Northern European/Celtic descent, associated with HLA-DRB1, HLA-DQB1, HLA-DQA1 alleles (MHC class II).
RISK FACTORS
Exposure to spicy foods, hot drinks.
Environmental factors: sun, wind, cold, heat.
GENERAL PREVENTION
No known preventive measures.
COMMONLY ASSOCIATED CONDITIONS
Seborrheic dermatitis (scalp, eyelids).
Keratitis with photophobia, lacrimation, visual disturbance.
Blepharitis.
Uveitis.
DIAGNOSIS
History
Episodic flushing with skin warmth triggered by hot liquids, spicy foods, alcohol, sun exposure.
Rosacea typically arises de novo, without prior acne or seborrhea.
Predominant complaints: excessive facial warmth and redness.
Itching usually absent.
Physical Exam
Four rosacea subtypes:
Rosacea diathesis: episodic erythema ("flushing and blushing").
Recent classification favors phenotype-based approach for tailored treatment.
Histology:
Inflammation around hypertrophied sebaceous glands producing papules, pustules, cysts.
Absence of comedones and blocked ducts.
Vascular dilatation and dermal lymphocytic infiltrate.
Granulomatous inflammation.
TREATMENT
General Measures
Proper skin care and photoprotection (mild, nondrying soaps; avoid irritants).
Avoid known triggers.
Reassure patients that rosacea is unrelated to hygiene.
Manage psychological stress.
Avoid topical steroids (may worsen rosacea).
Avoid oil-based cosmetics; others may help symptom tolerance.
Consider electrodesiccation or chemical sclerosis for dilated vessels.
Laser therapy emerging.
Encourage physical fitness.
Medication
First Line
Topical metronidazole (1% once daily or 0.75% twice daily) for 7β12 weeks effective vs placebo.
Rosacea treatment systems combining cleanser, metronidazole 0.75% gel, hydrating corrector, sunscreen SPF 30 may improve outcomes.
Azelaic acid topical effective for initial and maintenance therapy.
Topical ivermectin 1% cream superior to metronidazole for PPR.
Topical brimonidine tartrate 0.5% gel reduces erythema in ETR (Ξ±2-adrenergic agonist, vasoconstrictor).
Oxymetazoline 1% cream (Ξ±1A-adrenergic agonist) approved for persistent erythema.
Doxycycline 40 mg daily as effective as 100 mg with fewer side effects.
Photosensitivity common; sunscreen recommended.
Avoid co-administration with antacids, dairy, iron.
Broad-spectrum antibiotics may reduce OCP effectiveness; only confirmed with rifampin; consider barrier contraception.
Second Line
Topical erythromycin.
Topical timolol maleate 0.5%.
Topical clindamycin (lotion preferred), can combine with benzoyl peroxide.
Calcineurin inhibitors: tacrolimus 0.1%, pimecrolimus 1% (effective in mild-moderate cases).
Permethrin 5% cream (similar efficacy to metronidazole in severe cases).
Oral isotretinoin 0.3 mg/kg minimum 3 months.
Pediatric Considerations
Avoid tetracyclines <8 years.
Pregnancy Considerations
Avoid tetracyclines.
Isotretinoin teratogenic; contraindicated unless strict contraception and registration with iPLEDGE program.
Additional Therapies
Cyclosporine 0.05% ophthalmic emulsion may improve ocular rosacea more than artificial tears.
Surgery/Procedures
Laser treatment for progressive telangiectasias or rhinophyma.
Pulsed dye laser (585/595 nm) effective for telangiectasia and erythema.
COβ fractional ablative laser for rhinophyma.
ONGOING CARE
Follow-Up
Outpatient treatment with occasional monitoring.
Close follow-up and labs for isotretinoin patients per prescribing and iPLEDGE.
Ophthalmology evaluation if ocular symptoms present.
Diet
Avoid alcohol and hot beverages.
PROGNOSIS
Slowly progressive.
May spontaneously subside.
COMPLICATIONS
Rhinophyma (bulbous nasal thickening, more in men).
Conjunctivitis.
Blepharitis.
Keratitis.
Visual deterioration.
REFERENCES
Schaller M, Almeida LMC, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471.
van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;2015(4):CD003262.
van Zuuren EJ, Fedorowicz Z, Tan J, et al. Interventions for rosacea based on the phenotype approach: updated systematic review including GRADE. Br J Dermatol. 2019;181(1):65-79.
Fowler J Jr, Jackson M, Moore A, et al. Safety and efficacy of topical brimonidine tartrate gel 0.5% in rosacea. J Drugs Dermatol. 2013;12(6):650-656.
Oxymetazoline cream (Rhofade) for rosacea. Med Lett Drugs Ther. 2017;59(1521):84-86.
Del Rosso JQ, Webster GF, Jackson M, et al. Phase III trials evaluating anti-inflammatory dose doxycycline (40 mg) for rosacea. J Am Acad Dermatol. 2007;56(5):791-802.
Additional Reading
Al Mokadem SM, Ibrahim ASM, El Sayed AM. Efficacy of topical timolol 0.5% in acne and rosacea: multicenter study. J Clin Aesthet Dermatol. 2020;13(3):22-27.
Liu RH, Smith MK, Basta SA, et al. Azelaic acid in papulopustular rosacea: systematic review. Arch Dermatol. 2006;142(8):1047-1052.