rosacea
Rosacea is an inflammatory condition that causes facial redness, spots, blotchy skin and in severe cases, rhinophyma (enlargement of the nose). It can be seen affecting the nose, cheeks, forehead, chin, neck and chest. Triggers range in nature from food to the environment to emotional stress.
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In fair-skinned populations, the prevalence of rosacea ranges from 2-22% [1]
A study carried out in Germany and Russia both found that 75% of people affected were women and the mean age was 40 years [2]
A study carried out on the UK found that the incidence rate for diagnosed rosacea was 1.65 per 1000 person-years (measure the number of people in the study and the amount of time spent by each person on the study)
Rosacea was diagnosed in approximately 80% of cases after the age of 30 years [3]
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Inheritance from family
Could potentially be due to bacteria growth which causes the immune system to overreact
H pylori is common in people with rosacea
Abnormal processing of the protein, cathelicidin, that is responsible for protecting your skin from infection [4]
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Medical students
Neurovascular dysregulation
Rosacea is characterised by dilation of lymphatic and blood vessels due to exposure to extreme temperatures, spices, and alcohol.
Nonspecific cation channels on sensory neurons and keratinocytes play a role in erythema and flushing after exposure to triggers.
Activation of the immune system
Over-expression of effector cells and receptors leads to activation of the adaptive and innate immune system in rosacea.
Activation of mast cells via increased protein production is observed due to receptor activation.
Expression of matrix metalloproteinases and vascular endothelial growth factor is increased in rosacea.
Infestation with Demodex mites
The presence of microbes, such as Demodex folliculorum on the skin and helicobacter pylori infection in the gut
This may trigger the immune response in rosacea.
Patients
Sensitive Blood Vessels (Neurovascular Changes)
In rosacea, the immune system becomes more active
Rosacea causes your skin’s blood vessels to widen more easily, leading to redness and flushing.
This can happen after exposure to:
Hot or cold temperatures
Spicy foods
Alcohol
Some natural skin and nerve cells overreact to these triggers, causing the skin to turn red.
Immune System Activation
In rosacea, the immune system becomes more active than usual.
Overproduction of certain proteins and chemicals, which keep the skin red and irritated
Demodex Mites and Gut Bacteria
Demodex mites (tiny organisms that live on most people’s skin) are found in higher numbers in people with rosacea.
These may trigger the immune system and make rosacea worse.
A gut bacteria called Helicobacter pylori may also be linked to rosacea in some people. [5]
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Genetics and immune system damage can cause an abnormal response to inflammation
Increased age
UV exposure
Smoking
Spicy food and hot drinks
Alcohol excess
Stress
Environment change (hot, cold)
Medications such as calcium channel blockers and steroids [6,7]
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Flushing/blushing of the face in early stages
Uncomfortable stinging
Redness and swelling
Hyperpigmentation (dark red/brown) on darker skin
Dilation of blood vessels (capillaries)- telangiectases
Inflammation
Spots
Late stages include increased tissue size (hyperplasia) affecting the cheek and nose
Thickened skins with spots on the nose, known as rhinophyma [8]
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Clinical assessment of appearance of the skin, history of symptoms, family history and possible triggers of rosacea [9]
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Acne vulgaris
Seborrheic dermatitis- also known as dandruff
Contact dermatitis inflammation of the skin caused by contact with substances (irritants and allergens)
Photodermatitis- skin damage caused by sunlight exposure
Peri-oral or peri-ocular dermatitis- inflammation near the eyes, mouth and nose
Drug induced dermatitis (eg. steroids)
Systemic lupus erythematosus- butterfly rash on the face
Erysipelas- bacterial infection of skin that causes a butterfly rash
Keratosis pilaris- spots with follicle inflammation
Mastocytosis- excess of mast cells in the body tissue
Sarcoidosis- yellow-red spots found on the skin caused by a rare condition creating granuloma (white blood cell buildup) [9]
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Medical Students
Initial Management
Avoid known triggers (e.g., heat, alcohol, spicy foods)
Daily sunscreen use is recommended
Treatment aims to control symptoms, not cure
Topical Therapies
Metronidazole (cream, lotion, or gel)
Azelaic acid cream
Benzoyl peroxide can be added for enhanced effect
Topical ivermectin effective for inflammatory lesions
Systemic Therapies
Indicated for multiple papules/pustules or ocular involvement
Oral antibiotics: doxycycline, tetracycline, minocycline, erythromycin, azithromycin
Subantimicrobial doxycycline (e.g., 40 mg daily) effective in inflammatory rosacea
Persistent Erythema/Flushing
Topical brimonidine gel or oxymetazoline hydrochloride cream
Refractory/Severe Disease
Oral isotretinoin for recalcitrant rosacea
Procedural Interventions
Rhinophyma: dermabrasion, laser ablation, tissue excision
Telangiectasia: laser therapy or electrocautery
Patients
First Steps
Avoid triggers like spicy food, alcohol, and heat
Use sunscreen daily
Treatment helps manage symptoms but does not cure rosacea
Skin (Topical) Treatments
Creams or gels with:
Metronidazole
Azelaic acid
Ivermectin (for red bumps and pimples)
Benzoyl peroxide may be added to improve results
Tablets (Oral Antibiotics)
Used if you have many spots or if your eyes are affected
Options include: doxycycline, tetracycline, minocycline, erythromycin, azithromycin
A low-dose doxycycline can be used long-term safely
Redness and Flushing
Can be treated with:
Brimonidine gel
Oxymetazoline cream
If Other Treatments Don't Work
Isotretinoin tablets may be tried in stubborn cases
Procedures for Severe Forms
Rhinophyma (swollen nose): laser, sanding, or cutting away extra tissue
Visible blood vessels: treated with laser or heat-based tools
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Rhinophyma- rosacea affecting the nose
Inflammation of the eyes such as sclera, conjunctiva
Self esteem- self worth complications from appearance
Limitations to activities sue to fear of triggering rosacea (eg. going to sunny places) [10]
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Rosacea presents with the same symptoms on all patients
Rosacea doesn’t flare up, it is constant
There is a cure for rosacea
Rosacea is contagious
Rosacea is the same as acne [11,12]
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What can trigger my rosacea?
What caused my rosacea?
How long does treatment take to be effective?
What lifestyle measures can be taken to manage symptoms of rosacea?
Who do I contact if I suspect the beginning of complications?
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National Rosacea Society
Schweiger Dermatology Group
American Academy of Dermatology
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[2] https://pubmed.ncbi.nlm.nih.gov/26915718/
[3] https://pubmed.ncbi.nlm.nih.gov/22564022/
[4] https://www.aad.org/public/diseases/rosacea/what-is/causes
[6] https://pubmed.ncbi.nlm.nih.gov/2572109/
[9] https://cks.nice.org.uk/topics/rosacea/diagnosis/assessment/
[10] https://dermnetnz.org/topics/rosacea
[11] https://www.rosacea.org/blog/2014/january/debunking-the-top-rosacea-myths
[12] https://www.skinwellnesscenter.net/4-myths-about-rosacea/
Source: DermNetNZ.org
Rosacea
Papular (spots) rosacea found on the cheeks
Source: DermNetNZ.org
Rosacea
Severe rosacea with pustules and papules as well as rhinophyma (nose affected by rosacea)
Source: DermNetNZ.org
Rosacea
Rosacea with papules and pustules on the cheeks
Source: Waikato District Health Board; DermNetNZ
Rosacea
Cluster on the cheek with pustules and redness
Source: Waikato District Health Board; DermNetNZ
Rosacea
Papular (spots) rosacea on the cheeks
Source: DermNetNZ.org
Rosacea
Telangiectatic (blood vessels present) with rosacea on the nose, cheeks and chin
Source: National Rosacea Society
Rosacea
Redness seen distributed on the cheeks