Rosacea is a chronic inflammatory skin disease of the central face, affecting 5% of the population. The exact etiology is unknown. A diagnosis is made based on the updated 2017 National Rosacea Society Expert Committee guidelines, including fixed erythema, phymatous changes of skin thickening due to sebaceous gland hyperplasia and fibrosis, papules, pustules, telangiectasia, and flushing. Delays in an accurate diagnosis and treatment may occur in skin of color due to difficulty visualizing erythema and telangiectasia. The daily use of sunscreen, moisturizers, and mild skin cleansers and avoidance of triggers are essential aspects of maintenance treatment. Effective topical treatment options include alpha-adrenergic receptor agonists for flushing and ivermectin, metronidazole, and azelaic acid for papules and pustules. Systemic treatments include nonselective beta blockers for flushing, low-dose doxycycline, and isotretinoin for papules and pustules. Rosacea can significantly affect a patient's emotional health and quality of life. A referral for care is recommended for fixed phymatous changes and ocular rosacea. (Am Fam Physician. 2024;109(6):533-542. Copyright © 2024 American Academy of Family Physicians.)
Rosacea is a chronic, relapsing, remitting cutaneous disease primarily affecting the cheeks, nose, chin, and central forehead, typically sparing the skinfolds.1,2 Rosacea is a common condition affecting 1 in 20 adults worldwide.3 Although the etiology is unclear, rosacea pathogenesis involves exaggerated inflammatory, immune, and vascular responses to identifiable triggers and environmental exposures.2 Table 1 lists common rosacea triggers.4
WHAT'S NEW ON THIS TOPIC
| The classification of rosacea was updated in 2017 to better represent rosacea as a disease with a spectrum of several phenotypes. The updated classification emphasizes the diagnostic certainty associated with phymatous changes while downgrading the importance of papules, pustules, telangiectasia, and flushing. |
| A cohort study of 82,737 women found a positive correlation between alcohol intake and the risk of rosacea compared with never-drinkers, with white wine and liquor consumption having the strongest association with an increased rosacea risk. A systematic review and meta-analysis found alcohol consumption increased the risk of phymatous changes fourfold. |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
TABLE 1. Common Rosacea Triggers
| Trigger | Patients reporting |
|---|---|
| Sun exposure | 81% |
| Emotional stress | 79% |
| Hot weather | 75% |
| Wind | 57% |
| Heavy exercise | 56% |
| Alcohol consumption | 52% |
| Hot baths | 51% |
| Cold weather | 46% |
| Spicy food | 42% |
Adapted with permission from the National Rosacea Society. Rosacea triggers survey. Accessed June 13, 2023. https://www.rosacea.org/patients/rosacea-triggers/rosacea-triggers-survey.
The Demodex mite may play an inflammatory role in rosacea by disrupting the skin microbiome and triggering an immune response; however, the extent of the mite's contribution to pathogenesis is unclear.2,5 Rosacea is most common in Fitzpatrick skin types I to III, which are the least pigmented types of a subjective determination of skin color based on the propensity to sunburn, but rosacea can be present in all skin types.1,6,7 The lower incidence of rosacea in Fitzpatrick skin types IV to VI may be due to misdiagnosis and underdiagnosis.1,8 Rosacea typically presents in adults older than 30 years and is more common in females.1,9
How Is Rosacea Diagnosed?
Rosacea is diagnosed clinically without the need for specific diagnostic testing. The 2017 National Rosacea Society Expert Committee updated the guidelines with diagnostic, major, and secondary phenotypes.1 The diagnosis of rosacea requires one diagnostic or two major phenotypes. Secondary phenotypes are not required for diagnosis but aid in assessing rosacea severity. A rosacea diagnosis may be considered with fixed central facial erythema in a characteristic pattern that may intermittently intensify phymatous changes, including facial fibrosis with sebaceous gland hyperplasia.1 These phymatous changes may be further classified as active (if inflamed) or fixed (if not inflamed).10,11 Table 2 provides diagnostic criteria for rosacea using dermatologic and ocular manifestations.1,12
TABLE 2. Rosacea Classification: Dermatologic and Ocular Phenotypes
| Diagnostic | Major | Secondary* | |
|---|---|---|---|
| One or more of these phenotypes are diagnostic of rosacea | Two or more of these phenotypes suggest rosacea | ||
| Dermatologic | Fixed erythema May intermittently intensify Presents in a characteristic centrofacial distribution Phymatous changes | Flushing Papules and pustules Telangiectasia | Burning Dryness Stinging Swelling |
| Ocular | Sclerokeratitis/scleritis/keratitis/conjunctivitis/anterior uveitis Spade-shaped corneal infiltrates Telangiectasia of the lid margin | Dry eye (evaporative) Nonuniform lid margins Waxy, collarette build-up at lash bases (i.e., honey crust) | |
*—Secondary features are subjective signs and symptoms that often appear with one or more major features that help assess the severity of rosacea.
Adapted with permission from Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):152, with additional information from reference 12.
EVIDENCE SUMMARY
The classification of rosacea was updated to better represent rosacea as a disease with a spectrum of several phenotypes.1 The updated classification emphasized the diagnostic certainty associated with phymatous changes while downgrading the importance of papules, pustules, telangiectasia, and flushing.13,14 Diagnostic and major criteria clarify the rosacea diagnosis, whereas secondary features, including burning, stinging, dryness, and edema, aid in grading severity when their duration, frequency, intensity, and impact are assessed.1,14 Despite this diagnostic criteria, the differential diagnosis for rosacea is broad (Table 3).15,16 Acne vulgaris can present with central facial pustules and papules, typically without telangiectasia. The malar rash seen in patients with lupus does not affect the nasolabial folds, unlike the facial erythema of rosacea. Although seborrheic dermatitis often presents with facial erythema, including the nasolabial folds, scalp, and hairlines, rosacea typically does not affect the hairline or scalp.
TABLE 3. Differential Diagnosis of Rosacea
| Diagnosis | Distinguishing features from rosacea |
|---|---|
| Acne vulgaris | Presence of comedonal lesions and hyperpigmented macules; lack of telangiectasia or ocular symptoms |
| Atopic dermatitis | Presence of dryness and scaling; commonly affects other areas of the body; history of eczema triggers |
| Carcinoid | Systemic symptoms experienced during flushing |
| Dermatomyositis | Involvement of periorbital region and periocular edema; involvement of other nonfacial areas; presence of violaceous hue |
| Gram-negative folliculitis | History of prolonged oral antibiotics for acne or rosacea; sudden flare-up despite no changes in treatment or triggers |
| Keratosis pilaris rubra | Asymptomatic, lacks other rosacea features such as triggers; may involve cheeks rather than a full centrofacial distribution |
| Lupus erythematosus | Malar rash in lupus typically spares nasolabial folds; possible presence of systemic symptoms in systemic lupus erythematosus; may have edema; less likely to have papules and pustules; may have sharp demarcations |
| Perioral dermatitis | Inflammatory eruption around the mouth, nasolabial folds, and chin with sparing of a clear area between the eruption and the vermilion border |
| Pheochromocytoma | Presence of systemic symptoms; flush without other rosacea features |
| Photodamage | Presence of rough skin and wrinkles; may involve the lateral face more and other sun-exposed areas |
| Sarcoidosis | Presence of other rashes such as erythema nodosum and plaques; may involve scaling; lack of additional rosacea features other than inflammatory rash |
| Seborrheic dermatitis | Presence of erythematous patches and plaques involving the scalp, anterior and posterior hairlines, preauricular and postauricular areas, and medial eyebrows; presence of scaling |
| Steroid dermatitis | Covers entire facial area rather than centrofacial distribution; history of prolonged topical steroid use or rebound after discontinuation of topical steroids |
| Tinea barbae | Pustular eruption usually presents on the chin and jawline |
| Tinea faciei | Rash has sharp demarcations; presence of scaling |
What Are Diagnostic and Treatment Considerations for Skin of Color?
The diagnosis of rosacea in skin of color is often delayed or misdiagnosed due to difficulty visualizing erythema and telangiectasia6,17 (Figure 1). Treatment for rosacea is similar across skin types, although many treatments have an additional risk of altering local pigmentation.
FIGURE 1.
Rosacea in skin of color with papules and pustules present.
EVIDENCE SUMMARY
Rosacea in skin of color is likely underestimated due to misdiagnosis.16,17 A history focusing on symptoms of facial stinging, burning, dryness, and subjective flushing and more subtle examination findings than erythema and telangiectasia, such as postinflammatory hyperpigmentation, are especially important to assess skin of color. Diascopy, a clinical test for skin blanching performed by applying pressure with a glass slide to the skin, can help discern telangiectasia on examination. Dermatoscopy can also help demonstrate telangiectasia by differentiating small blood vessels.16 Taking patient photographs against a blue background may also help visualize the erythema.16 Granulomatous rosacea, a histologic subtype characterized by facial papules and nodules with granulomatous changes seen on microscopy, is more common in skin of color, possibly due to a delayed diagnosis.18–20 The treatment approach for skin of color is similar to treatment in lighter skin types, although treatment data for skin of color are limited.15 Certain therapies carry a risk of hypo- and hyperpigmentation.
What Lifestyle Interventions Are Important for Rosacea?
Patient education on trigger identification and avoidance is important for rosacea management.4,21,22 Optimal rosacea treatment includes photoprotection, cleansing, and moisturization.23 Sunscreen use is recommended because ultraviolet (UV) radiation can worsen rosacea in all skin types.24,25
EVIDENCE SUMMARY
More than 90% of patients identify triggers that worsen their rosacea.21 Advising patients to journal their symptoms and dietary, emotional, and environmental exposures can help identify triggers.22 A survey of 400 patients with rosacea showed that 78% changed their diet to control rosacea symptoms, with reduced rosacea flare-ups in 95% of the patients who changed their diet.26 In the same survey, at least monthly, 69% of patients experienced a flare-up related to emotional stress.26
Alcohol use appears to increase the risk of rosacea and severity of presentation, whereas tobacco use does not. A cohort study involving 82,737 women found a positive correlation between alcohol intake and the risk of rosacea compared with never-drinkers, with white wine and liquor consumption having the strongest association with an increased risk.27 A systematic review and meta-analysis of 152,381 patients found that alcohol consumption increased the risk of phymatous changes fourfold.28 Two systematic reviews and meta-analyses found that tobacco use did not increase rosacea risk.29,30
Proper skin care can decrease symptoms of rosacea. Acute UV radiation causes skin inflammation, neoangiogenesis, and telangiectasia; chronic UVA radiation causes fibrosis. Using a water-based broad-spectrum sun-screen with zinc oxide or titanium dioxide and a sun protection factor of 30 or more reduces symptoms in rosacea.25 The application of fragrance-free cream moisturizers to improve skin hydration and barrier function, and twice-daily gentle cleansing using a soap-free cleanser reduce rosacea symptoms.23,25,31–33
There is limited evidence on the effectiveness of dietary supplements in rosacea. Zinc and vitamin D supplementation do not appear to improve symptoms.34 Two systematic reviews of small, low-quality studies suggest that polyphenols (i.e., plant-derived supplements with antioxidant and anti-inflammatory properties) may reduce erythema, papules, and pustules.35,36 More studies are needed to examine the role of oral and topical pre- and probiotics.34
Which Topical Options Are Effective for Rosacea?
Topical therapies are first-line treatments for mild to moderate rosacea with persistent erythema, papules, and pustules (Table 4).10,11,37 Alpha-adrenergic receptor agonists are first-line treatments for persistent erythema. Ivermectin, metronidazole (Metrogel), and azelaic acid can be used to treat the papules and pustules phenotype, with ivermectin showing the highest effectiveness.10,31,38–41 For moderate to severe rosacea or persistent symptoms despite topical treatment, systemic therapies can be added to topical treatments and be discontinued when symptoms are controlled.10,11
EVIDENCE SUMMARY
Topical alpha-adrenergic receptor agonists, brimonidine and oxymetazoline, temporarily reduce persistent erythema with rapid onset (30 minutes or less) and peak effectiveness of 3 to 6 hours with an eventual return to baseline.10 Two studies showed that topical brimonidine improved persistent erythema with a number needed to treat (NNT) of 5 for a two-grade improvement compared with placebo, whereas oxymetazoline had an NNT of 11 for the same benefit.42–44 Although brimonidine and oxymetazoline are well tolerated, few patients treated with oxymetazoline experience rebound erythema, with no rebound erythema seen in patients treated with brimonidine.10 In a randomized controlled trial, using brimonidine 0.33% gel for 8 days increased the likelihood of satisfaction with facial erythema, with an NNT of 7 compared with placebo.45
For papules and pustules, metronidazole and ivermectin are effective, and metronidazole gel is considered the standard of care due to its well-proven effectiveness and tolerability.10 Topical metronidazole 0.75% gel and 1% cream were twice as effective in improving papules and pustules compared with placebo based on a systematic review of 152 studies.10 Ivermectin cream used daily for 12 weeks had an NNT of 3 for good-to-excellent improvement of papules and pustules compared with placebo.39 In another study, ivermectin 1% gel was more likely to clear papules and pustules than 0.75% metronidazole, with an NNT of 10 with fewer adverse effects in the ivermectin group.38 Azelaic acid is an alternative treatment for papules and pustules that appears slightly less tolerable compared with metronidazole.10 Twice-daily azelaic acid at 15% to 20% improved papules and pustules markedly or excellently based on patient assessment, with an NNT of 6 compared with placebo.10 Patients with skin of color should be counseled on the risk of altering skin pigmentation with azelaic acid.46 Minocycline 1.5% foam applied once daily for 12 weeks also improved papules and pustules compared with placebo.47
Which Systemic Therapy Options Are Effective for Rosacea?
Systemic treatment should be considered for severe rosacea, or when milder forms do not respond adequately to topical options (Table 4).10,11,37 Nonselective beta blockers can improve flushing and erythema.31,48 Subantimicrobial-dose doxycycline administered for an average of 3 months is the first-line systemic therapy for the papules and pustules rosacea phenotype.10,31,49 Isotretinoin, which requires safety registration with the iPLEDGE program, is effective for severe and persistent papules and pustules and may be superior to doxycycline with a similar frequency of adverse effects.31 Isotretinoin may also be superior to doxycycline for the treatment of active phymatous changes.11 Doxycycline is first-line treatment over isotretinoin because of the potential for serious adverse effects, the monitoring needs of isotretinoin, and lack of strength of evidence proving benefit over doxycycline.11
TABLE 4. Topical and Systemic Medications for Rosacea
| Phenotype | Medication class | Medication | Dosage and formulation | Common adverse effects | Cost* |
|---|---|---|---|---|---|
| Topical | |||||
| Fixed erythema | Alpha-1A adrenergic receptor agonist | Oxymetazoline (Rhofade) | 1% cream once daily | Application-site dermatitis, pain, worsening erythema | 30-g tube: — ($150) |
| Fixed erythema | Alpha-2 adrenergic receptor agonist | Brimonidine | 0.33% gel once daily | Dryness, erythema (including rebound), flushing, irritation, pruritus, stinging | 30-g gel pump: $150 |
| Papules and pustules | Antiparasitic agent | Ivermectin | 1% cream once daily | Burning, dryness, peeling, pruritus | 45-g tube: $140 |
| Papules and pustules | Antibiotic | Metronidazole (Metrogel) | 0.75% gel, cream, or lotion twice daily 1% gel once daily | Burning, dryness, peeling, pruritus | Gel, 45-g tube: $35 Cream, 45-g tube: $30 Lotion, 59-mL bottle: $70 1% gel, 60-g tube: $60 |
| Papules and pustules | Antibiotic | Minocycline | 1.5% foam once daily | Burning, dryness, itching, stinging | 30-g can: $370 |
| Papules and pustules | Antibiotic | Sulfacetamide/sulfur | 10% lotion, 10% suspension, 10% cream twice daily | Erythema, irritation, local edema | Lotion, 60-g bottle: $120 Suspension, 1-oz bottle: $70 Cream, 57-g tube: $80 |
| Papules and pustules | Dicarboxylic acid | Azelaic acid | 15% gel or foam twice daily | Burning, change in skin pigmentation (especially in skin of color), dryness, peeling, pruritus | 50-g tube: $50 |
| Papules and pustules Telangiectasia | Vitamin A derivative | Retinoids | Cream: 0.02%, 0.025%, 0.05%, 0.1% Gel: 0.01%, 0.025%, 0.04%, 0.05%, 0.08%, 0.1% Lotion (isotretinoin [Altreno]): 0.05% once daily at bedtime | Change in skin pigmentation, irritation (burning, dryness, peeling, pruritus), photosensitivity | 0.025% cream, 20-g tube: $15 0.025% gel, 45-g tube: $45 0.05% lotion, 45-g tube: — ($125) |
| Systemic | |||||
| Fixed erythema Papules and pustules | Antibiotic | Doxycycline (subantimicrobial) | 40-mg delayed-release capsule once daily or 20-mg immediate-release tablets twice daily | Abdominal pain and distention, diarrhea, esophagitis, nausea/vomiting, photosensitivity, tooth discoloration, vulvovaginal candidiasis | 40-mg delayed-release capsules: $270 for 30 20-mg immediate-release tablets: $15 for 60 |
| Fixed erythema Ocular rosacea Papules and pustules | Antibiotic | Doxycycline (antimicrobial) | 50- to 100-mg immediate-release capsule or tablet twice daily | Abdominal pain and distention, diarrhea, esophagitis, nausea/vomiting, photosensitivity, tooth discoloration, vulvovaginal candidiasis | 50-mg immediate-release capsules: $15 for 60 50-mg immediate-release tablets: $50 for 60 |
| Fixed erythema Papules and pustules Phymatous changes | Vitamin A derivative | Isotretinoin | Lidose: 0.5 mg per kg per day rounded to nearest capsule dosage in two divided doses for 1 month, then increase to 1 mg per kg per day in two divided doses as tolerated Micronized: 0.4 to 0.8 mg per kg per day in two divided doses with dosage adjustments based on treatment response | Arthralgias, cheilitis, conjunctivitis, elevated liver enzymes, elevated triglycerides, erythema, myalgias, photosensitivity, scaling, seborrhea, xeroderma, xerophthalmia Contraindications: pregnancy | 30-mg lidose capsules: $180 for 60 30-mg micronized capsules: $200 for 60 |
| Flushing | Nonselective beta-adrenergic antagonist | Carvedilol (Coreg) | Several regimens available, including: One 31.25-mg immediate-release tablet or one 6.25-mg immediate-release tablet two to three times daily, titrated as tolerated up to 31.25 mg daily One 6.25-mg immediate-release tablet once or twice daily, titrated up to 12.5 mg twice daily | Hypotension including orthostatic, diarrhea, weight gain | 6.25-mg tablets: $4 ($450) for 60 |
| Flushing | Nonselective beta-adrenergic antagonist | Propranolol | One 10-mg immediate-release tablet three times daily; this can be increased as tolerated until symptoms improve One study suggested 20 to 40 mg two to three times daily | Bradyarrhythmias, bronchospasm, fatigue, hypoglycemia | 10-mg tablets: $5 for 60 |
*—Estimated lowest GoodRx price. Actual cost will vary with insurance and by region. Generic price listed first; brand name price listed in parentheses. Information obtained at https://www.goodrx.com (accessed March 7, 2024; zip code: 66211).
EVIDENCE SUMMARY
A cross-sectional survey reported persistent facial erythema (69%) and flushing (61%) as the most bothersome symptoms.50 Oral beta blockers are effective for erythema and flushing. A systematic review of nine studies showed that nonselective beta blockers, specifically carvedilol (Coreg; 6.25 to 25 mg per day) and propranolol (30 to 40 mg per day), could improve persistent facial erythema and flushing.48 In a 2023 randomized controlled trial on refractory erythema in rosacea, a 12-week course of daily paroxetine improved erythema scores (43% vs. 21%) and flushing (45% vs. 25%) compared with placebo.37
Systemic antibiotic treatment is effective against papules and pustules, but the effect on erythema and telangiectasia is limited. Modified-release doxycycline, 40 mg once daily, administered via 30-mg immediate-release and 10-mg delayed-release capsules, is the only U.S. Food and Drug Administration–approved oral treatment for rosacea with papules and pustules.51 A Cochrane review demonstrated that doxycycline was more effective for moderate to severe rosacea than placebo.41 Doxycycline had similar effectiveness at 100 mg daily and 40 mg daily, with fewer adverse effects at the lower dosage.41 Combining doxycycline, 40-mg modified-release capsules, and daily ivermectin 1% cream improved the response rate and speed while increasing patient satisfaction compared with 1% ivermectin alone in severe rosacea.52
Low-dose oral isotretinoin at 0.25 to 0.30 mg per kg per day for 16 weeks in studies was effective for patients with severe papules and pustules not responding to oral antibiotics or recurring after completing oral antibiotics.53,54 In a single study, patients were more likely to report rosacea improvement on low-dose isotretinoin at 0.3 per mg per kg per day compared with doxycycline at 100 mg daily for 14 days followed by 50 mg daily, with an NNT of 7.55 Physicians assessed more improvement with isotretinoin than doxycycline, with an NNT of 9.41
When Should Patients With Rosacea Be Referred for Care?
Providing a referral to dermatology is appropriate when the initial treatment is not effective or for consideration of intervention therapies. If phymatous changes are fixed, a dermatology or plastic surgery referral is indicated. Patients with ocular symptoms should be urgently referred to ophthalmology.
EVIDENCE SUMMARY
Laser and light-based therapies can treat severe rosacea associated with persistent centrofacial erythema, telangiectasia, and phymatous changes.1,11 Although artificial tears and lid hygiene can mitigate mild ocular symptoms with a twice-daily warm water compress to reduce meibomian gland dysfunction and oral doxycycline, patients with moderate to severe ocular manifestations, including diminished visual acuity, should be referred for urgent ophthalmologic evaluation.11,56
What Other Medical Conditions Are Common in Patients With Rosacea?
Rosacea is associated with an increased risk of systemic diseases, including gastroesophageal reflux disease, hypertension, hyperlipidemia, depression, and anxiety.57,58
EVIDENCE SUMMARY
Patients with rosacea are more likely to have gastrointestinal disorders, including gastroesophageal reflux disease, independent of doxycycline use (odds ratio = 4.2).58 A systematic review and meta-analysis of 42 articles showed a weak association between rosacea and Helicobacter pylori infection.59
Rosacea negatively effects psychosocial factors such as self-esteem, confidence, and the ability to socialize.60–62 A systematic review demonstrated a high prevalence of depression and anxiety in patients with rosacea.63 Another demonstrated that patients with rosacea are more likely to develop depression and anxiety than those without rosacea.64 Clinicians can consider screening patients with rosacea for depression, anxiety, and cardiovascular risk.
This article updates previous articles on this topic by Oge’, et al.12; Goldgar, et al.65; and Blount, et al.66
Data Sources: A PubMed search was completed in Clinical Queries using the key terms rosacea, acne rosacea, phymatous changes, telangiectasia, and papulopustular. The search included meta-analyses, randomized controlled trials, clinical trials, and systematic reviews. We also searched the Cochrane database, DynaMed, and Essential Evidence Plus. We critically reviewed studies that used patient categories such as race and/or gender but did not define how these categories were assigned, stating their limitations in the text. Search dates: April to December 2023 and April 11, 2024.
