Acne Rosacea

Aka: Acne Rosacea, Rosacea, Rhinophyma

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II. Epidemiology

  1. Typical onset ages 30 to 50 years old
  2. Northern european descent and fair skinned persons (esp. Fitzpatrick Skin Types 1 to 3)
  3. More common in women by factor of 2-3
  4. Prevalence
    1. United States: 1.3-2.1% (14 Million cases)
    2. Worldwide: Up to 5%

III. Risk Factors: Predisposing triggers and exacerbating factors

  1. Nose Hair Follicle mites (Demodex folliculorum)
    1. May predispose to inflammation and alter the skin microbiome
  2. Triggers
    1. Sun Exposure, hot weather, and hot baths
    2. Emotional stressors
    3. Alcohol use (esp. white wine, liquor; RR 4 for phymatous changes)
    4. Hot drinks and spicy food
    5. Exercise
    6. May also be triggered by wind and Cold Weather

IV. Pathophysiology

  1. Acneiform eruption
  2. Exaggerated inflammatory, immune and vascular response to triggers
  3. Nose Hair Follicle mites (Demodex folliculorum) appear to be involved in pathogenesis

V. Types

  1. Subtype 1: Erythematotelangiectatic (most difficult to treat)
    1. Persistent central face Macular erythema with Telangiectasias and Flushing
    2. Possible ocular involvement
  2. Subtype 2: Papulopustular (easiest to treat)
    1. Persistent central face erythema with small Papules and tiny Pustules (acne-like)
    2. Periocular sparing
  3. Subtype 3: Phymatous (more common in men)
    1. Skin thickening and nodular irregularities (due to Sebaceous Gland hyperplasia)
    2. Distribution: Nose (Rhinophyma), chin, ears, forehead or Eyelid
  4. Subtype 4: Ocular
    1. Watery, Bloodshot Eyes may become dry with foreign body Sensation and photophobia
    2. Distribution: Blepharitis, Conjunctivitis, and Eyelid Inflammation
  5. Variant: Granulomatous
    1. Brown, yellow or red firm, indurated non-inflammatory Papules or Nodules

VI. Symptoms

  1. Stinging or burning pain may accompany facial Flushing
  2. Flushing and swelling may be present
  3. Eyes and skin may feel dry

VII. Signs: Skin

  1. Course is variable
    1. Stages listed below are for organization only
  2. Distribution for all lesions
    1. Affects middle third of face (forehead to chin)
  3. Findings in Skin of Color
    1. Facial stinging, burning, dryness
    2. Subjective facial Flushing
    3. Postinflammatory Hyperpigmentation
  4. Stage 1: Initial presentation
    1. Intermittent facial Flushing lasting 5 minutes or less
    2. May involve neck and chest
    3. Sensation of warmth may be present
  5. Stage 2: Early vascular changes
    1. Facial erythema
      1. More evident in patient photographs when against a blue background
    2. Telangiectasis
      1. Telangiectasias are more evident under Diascopy (blanched skin under a glass slide) or Dermatoscopy
    3. Eye changes (see ocular signs below)
  6. Stage 3: Inflammatory changes
    1. Papules
    2. Sterile Pustules
    3. Comedones are typically absent
  7. Stage 4: Rhinophyma (Red bulbous nose)
    1. More common in men
    2. Thickening of facial skin (especially nose)
      1. Connective tissue hypertrophy
      2. Sebaceous Gland hypertrophy
    3. Previously thought to be a sign Alcohol Abuse
      1. Example: W. C. Fields
  8. Variant: Granulomatous Rosacea
    1. Facial Papules and Nodules with Granulomatous change
    2. May appear similar to facial sarcoid

VIII. Signs: Ocular involvement (50% of Rosacea cases)

  1. Eyelid Inflammation (may be presenting sign)
    1. Acne involving Eyelids
    2. Eyelid redness and swelling
    3. Eyelid margin Telangiectasia
  2. Inflammatory Conjunctivitis
    1. Blepharitis may accompany Conjunctivitis (waxy, honey crust at lash bases)
    2. Eyes that itch or burn
    3. Dry Eyes with sandpaper or foreign body Sensation
  3. Other less common changes
    1. Corneal neovascularization
    2. Keratitis
    3. Anterior Uveitis
    4. Corneal scarring (spade shaped Corneal infiltrates)

IX. Differential Diagnosis: Skin

  1. Late-onset Acne Vulgaris
    1. Comedones present
    2. No Telangiectasis
    3. No eye symptoms or signs
  2. Steroid-induced Acne
    1. Results from Corticosteroid use on face (esp. perioral changes)
    2. Systemic Corticosteroids may involve the entire face (unlike Rosacea which involves central face)
  3. Perioral Dermatitis
    1. Some dermatologists consider Perioral Dermatitis a variant of Rosacea
  4. Systemic Lupus Erythematosus (SLE)
    1. Malar Rash of SLE does not affect the nasolabial folds (unlike Rosacea)
  5. Seborrheic Dermatitis
    1. Seborrhea affects the hairline and scalp (unlike Rosacea)
  6. Sarcoidosis
    1. Facial sarcoid may appear similar to Granulomatous Rosacea
  7. Polymorphous Light Eruption or other Photodermatitis
  8. Contact Dermatitis
  9. Atopic Dermatitis
    1. Eczema or atopic history with skin dryness and Scaling
  10. Dermatomyositis or Polymyositis
    1. Periorbital violaceous (purple) dermatitis
  11. Facial Infections
    1. Gram NegativeFolliculitis (complication of prolonged antibiotic use in acne or Rosacea)
    2. Tinea Barbae (beard area)
    3. Tinea Faciei (sharply demarcated facial dermatitis)
  12. Systemic conditions of Flushing
    1. See Flushing
    2. Carcinoid Syndrome (severe facial Flushing)
    3. Mastocytosis
    4. Pheochromocytoma

X. Differential Diagnosis: Ocular Rosacea

  1. Blepharokeratoconjunctivitis (staphylococcal or seborrheic)
  2. Sebaceous Gland carcinoma
  3. Allergic Conjunctivitis

XI. Diagnosis

  1. See Types and signs as above
  2. Central face dermatitis with at least one of the following findings
    1. Transient erythema (Flushing)
    2. Nontransient erythema
    3. Papules and Pustules
    4. Telangiectasia

XII. Associated Conditions

  1. Gastroesophageal Reflux Disease
    1. Rainer (2015) J Am Acad Dermatol 73(4): 604-8 [PubMed]
  2. Helicobacter Pylori Infection
    1. Jorgensen (2017) J Eur Acad Dermatol Venereol 31(12): 2010-5 [PubMed]

XIII. Management: General Measures

  1. General
    1. Patients can identify their specific triggers in >90% of cases (log exposures and reactions)
    2. Dietary changes alone can reduce Rosacea flares
  2. Avoid triggers
    1. Avoid Alcohol
    2. Avoid prolonged heat exposure
    3. Avoid hot liquids (coffee, tea)
    4. Avoid heavy cosmetics
  3. Use sun screen (minimum SPF 30) regularly (better tolerated agents are listed)
    1. Avoid chemical Sunscreens which may be irritating
    2. Use a mineral or physical Sunscreen
      1. Base: Simethicone, dimethicone or cyclomethicone
      2. Active ingredient: Titanium Dioxide or Zinc Oxide
  4. Choose gentle skin care products
    1. Clear and free (dye and perfume free) products
    2. Mild cleansers with near neutral pH (e.g. cetaphil, dove sensitive skin) used twice daily
    3. Skin Moisturizers (Emollients) applied to moist skin
    4. Avoid abrasive skin products
    5. Green or yellow tinted consmetics may hide facial erythema
  5. Avoid provocative medications
    1. Benzoyl Peroxide (avoid in erythematotelangiectatic Rosacea - subtype 1)
    2. Topical Corticosteroids
  6. No definitive evidence for dietary supplements
    1. No significant benefit with Zinc or Vitamin D supplementation
      1. Weiss (2017) Dermatol Pract Concept 7(4): 31-7 [PubMed]
    2. Polyphenols may decrease Rosacea lesions
      1. Saric (2017) J Altern Complement Med 23(12): 920-9 +PMID: 28650692 [PubMed]

XIV. Management: Papular and Pustular Rosacea

  1. Step 1
    1. Apply across entire central face
    2. First Line agents (most effective agents)
      1. Metronidazole topical
        1. Once daily (1% gel) or twice daily (0.75% gel, cream or lotion)
        2. Effective in 80% of cases
        3. Similar efficacy between 0.75% and 1%, as well as between once and twice daily dosing
      2. Azelaic Acid (Azelex) 15% gel
        1. Slight benefit over Metrogel, but less tolerated (consider in those not responding to Metronidazole)
        2. Gel is generic, while cream and foam are trade name only at twice the price
        3. Irritation may be reduced with gentle skin cleansers (e.g. cetaphil) and Skin Lubricants (e.g. vanicream)
        4. Avoid in Skin of Color (may alter pigmentation)
        5. Elewski (2003) Arch Dermatol 139:1444-50 [PubMed]
      3. Ivermectin (Scolantra) 1% cream (see below)
        1. Applied once daily
        2. May be more effective than Metronidazole, but is far more expensive
        3. Stein (2014) J Drugs Dermatol 13(3): 316-23 [PubMed]
    3. Alternative agents that have been used historically in Rosacea
      1. Clindamycin (Cleocin-T)
      2. Sulfacetamide/Sulfur (10%/5%) cream, foam or lotion
      3. Permethrin 5% cream
        1. Effective for erythema and Papules (but not as effective with Pustules)
        2. Kocak (2002) Dermatology 205:265-70 [PubMed]
      4. Permethrin 2.5% with tea tree oil gel
        1. Reduces inflammation and decreases Demodex mite population
        2. Ebneyamin (2020) J Cosmet Dermatol 19(6):1426-31 +PMID: 31613050 [PubMed]
  2. Step 2: May use the following oral agents in combination with topicals listed above
    1. Doxycyline (preferred)
      1. Moderate Rosacea
        1. Doxycyline 40 mg daily or 20 mg twice daily (sub-antimicrobial dose)
        2. Lower dose has similar efficacy to the 100 mg dose
      2. Severe Rosacea or refractory to 8-12 weeks at lower dose Doxycycline
        1. Doxycycline 100 mg twice daily (then taper to once daily after the first month)
    2. Alternative systemic antibiotics (tapering to once daily after the first month)
      1. Tetracycline 250 mg twice daily or
      2. Erythromycin 250 mg twice daily
      3. Amoxicillin 250 mg twice daily
    3. Efficacy
      1. Useful in treating Blepharitis, Keratitis
      2. Most effective treatment
  3. Step 3: Additional topical agents to consider
    1. Erythema (without Papules or Pustules)
      1. Brimonidine gel 0.33% (Mirvaso) - see below
      2. Oxymetazoline 1% (Rhofade) - see below
    2. Inflammatory papular and pustular Rosacea
      1. Precaution: Avoid in erythematotelangiectatic Rosacea (Flushing) - subtype 1 (may worsen)
      2. Topical Benzoyl Peroxide with Clindamycin (e.g. Benzaclin)
        1. Avoid Benzyl Peroxide with Erythromycin (no benefit to the Erythromycin)
      3. Ivermectin (Scolantra) 1% cream applied once daily
        1. Very expensive (nearly $500 for 45 grams)
        2. (2015) Presc Lett 22(3): 16
      4. Minocycline 1.5% Foam (Zilxi)
        1. Very expensive (nearly $500 for 30 grams)
        2. No evidence of benefit over other Rosacea topicals
        3. (2021) Presc Lett 28(6): 36
        4. Stein Gold (2020) J Am Acad Dermatol 82(5): 1166-73 [PubMed]
  4. Step 4: Refractory Cases
    1. Topical Tretinoin (Retin A)
      1. May exacerbate erythema and Telangiectasis
    2. Isotretinoin (Accutane)
      1. Requires IPledge registration (related to Teratogenicity risk)
      2. Administer 0.25 to 0.3 mg/kg/day (up to 0.5 mg/kg/day) for 20 weeks
      3. Variably effective in severe, refractory Rosacea; however more effective than Doxycycline
    3. Consider mite or tinea management
      1. Examine sample with Potassium Hydroxide
      2. Crotamiton (Eurax)

XV. Management: Facial Flushing and Erythema

  1. First-line: See general measures above
  2. Topical vasconstrictors (Alpha Adrenergic ReceptorAgonists
    1. Activity
      1. Onset of action 30 minutes
      2. Peak effect in 3 to 6 hours
      3. Duration up to 12 hours
    2. Brimonidine gel 0.33% (Mirvaso)
      1. Topical Vasoconstrictor released in 2013 in U.S.
      2. Can reduce facial redness (NNT 6 for significant benefit)
      3. May be more effective than Oxymetazoline
      4. Very expensive ($400 for 30 grams)
        1. Consider using generic Brimonidine 0.2% eye drops topically on face (10% of cost)
      5. References
        1. (2013) Presc Lett 20(11): 65
        2. Fowler (2013) J Drugs Dermatol 12(6): 650-6 [PubMed]
    3. Oxymetazoline 1% (Rhofade)
      1. Topical Vasoconstrictor released in 2017 in U.S. (same ingredient as Afrin 0.05%, but 1%)
      2. Very expensive ($475 for 30 grams)
      3. References
        1. (2017) Presc Lett 24(5):30
        2. Baumann (2018) J Drugs Dermatol 17(3): 290-8 [PubMed]
  3. Second-line
    1. See Vasomotor Symptoms of Menopause
    2. Propranolol (Inderal)
      1. Start with 10 mg immediate release orally three times daily
      2. May titrate as tolerated to 20 to 40 mg orally twice to three times daily
        1. Alternatively may use Propranolol LA 80 mg orally daily
    3. Carvedilol (Coreg)
      1. Start with 3.125 mg immediate release tablet orally twice to three times daily
      2. May titrate as tolerated to 6.25 mg orally twice daily
      3. Maximum: 12.5 mg orally twice daily
    4. Other agents that have been used for Flushing
      1. Clonidine 0.05 mg orally twice daily

XVI. Management: Ocular changes

  1. Precautions
    1. Risk of complications such as Chalazion, Scleritis, Corneal Ulcer
    2. Consider ophthalmology Consultation
  2. First-line therapy
    1. Oral Doxycycline (or other oral antibiotics listed above)
    2. Artificial tears for eye dryness
    3. Lid and lashes cleansing with baby Shampoo
    4. Topical metrogel to Eyelid if involved
    5. Omega-3 Fatty Acid Supplementation (inadequate evidence)
  3. Second-line therapy for refractory cases
    1. Ocular steroids (by ophthalmology)
    2. Cyclosporine Ophthalmic Emulsion (Restasis) - by ophthalmology
    3. Isotretinoin (Accutane)
  4. References
    1. Oltz (2011) Optometry 82(2): 92-103 [PubMed]
    2. Vieira (2013) J Am Acad Dermatol 69 (suppl 1): S36-41 [PubMed]

XVII. Management: Other Rosacea Manifestations

  1. Telangiectasis
    1. Green-tinted cosmetics
    2. Pulsed dye laser
  2. Rhinophyma
    1. Mild to moderate
      1. Antibiotics such as Doxycycline (as listed above)
      2. Oral Isotretinoin (Accutane)
    2. Advanced cases (Surgery)
      1. Dermabrasion
      2. Hypertrophic tissue excision

XVIII. References

  1. (2021) Presc Lett 28(6): 36
  2. Habif (1996) Clinical Dermatology, p. 182-4
  3. Blount (2002) Am Fam Physician 66(3):435-40 [PubMed]
  4. Frazier (2024) Am Fam Physician 109(6): 533-42 [PubMed]
  5. Goldgar (2009) Am Fam Physician 80(5): 461-8 [PubMed]
  6. Oge (2015) Am Fam Physician 92(3): 187-96 [PubMed]
  7. Powell (2005) N Engl J Med 352(8):793-803 [PubMed]
  8. Van Zuuren (2015) Cochrane Database Syst Rev (4): CD003262 [PubMed]
  9. Van Zuuren (2019) Br J Dermatol 181(1): 65-79 [PubMed]
  10. Zuber (2000) Prim Care 27(2):309-18 [PubMed]

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