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Dermatology

Rosacea

A chronic inflammatory facial dermatosis with flushing, persistent erythema, telangiectasia, papules or pustules, phymatous change and/or ocular disease; identify the dominant feature because treatment is feature-directed.

In a nutshell

Rosacea is a chronic inflammatory central-facial dermatosis causing flushing, persistent erythema, telangiectasia and papules or pustules, usually without comedones. Ask about the eyes and nasal thickening; manage the dominant phenotype with gentle skin care and sun protection, topical anti-inflammatory treatment for papulopustular disease, feature-directed treatment for erythema, and urgent eye assessment when keratitis is possible.

Classic presentation

An adult with recurrent flushing and persistent central facial erythema, burning or stinging, telangiectasia and papules or pustules without blackheads or whiteheads.

Key points

  • No comedones is the classic discriminator from acne vulgaris.
  • Rosacea may include flushing, fixed erythema, telangiectasia, papulopustular lesions, rhinophyma and ocular disease.
  • Papulopustular disease: use topical ivermectin, metronidazole or azelaic acid according to local guidance; oral tetracycline is reserved for more extensive or resistant inflammatory disease.
  • Fixed erythema may respond to topical brimonidine; telangiectasia and rhinophyma need specialist procedural treatment.
  • Painful red eye, photophobia, blurred vision or significant gritty symptoms need urgent assessment because keratitis can threaten sight.
  • Topical corticosteroids may worsen rosacea and oral antibiotics are anti-inflammatory treatments that require review.

First-line investigation

Clinical diagnosis with deliberate assessment of the dominant phenotype, comedones, ocular symptoms, triggers, medication history and psychological impact; no routine tests in typical disease.

Management

Check the eyes and urgent mimics

  • Arrange urgent assessment for painful red eye, photophobia, blurred vision or marked gritty symptoms; reconsider the diagnosis if the eruption is atypical or systemic features suggest lupus or another dermatosis.2,1,5

Start skin care and trigger management

  • Use gentle non-perfumed skin care, emollient moisturiser and daily SPF30+ protection, and identify individual triggers without implying that poor hygiene caused the condition.2,1

Treat inflammatory lesions

  • Use topical ivermectin, metronidazole or azelaic acid according to local formulary and BNF; consider oral tetracycline under prescriber guidance for moderate, severe or resistant inflammatory disease.3,5,4,6

Treat the dominant residual phenotype

  • Use brimonidine for selected persistent erythema, specialist laser or IPL for telangiectasia, and dermatology or surgical treatment for rhinophyma; manage mild ocular symptoms with lid hygiene and lubricants.3,5,1

Refer refractory or high-impact disease

  • Refer severe, treatment-resistant, diagnostically uncertain, phymatous, ocular or psychologically distressing disease, and check pregnancy, breastfeeding, contraindications and interactions before systemic treatment.2,1,6

Review response and antibiotic need

  • Review after an appropriate initial interval, often around 8 to 12 weeks, step down unnecessary systemic treatment when controlled and safety-net for ocular symptoms, rapid change, severe pain or visual disturbance.5,1,4,2

Exam traps

  • Rosacea has papules and pustules but usually no comedones; blackheads point towards acne.
  • Do not miss ocular rosacea: painful red eye, photophobia or visual disturbance is an urgent warning sign.
  • Antibiotics help inflammatory rosacea through anti-inflammatory effects; this is not evidence of a primary bacterial infection.
  • Topical corticosteroids can aggravate rosacea and should not be used routinely on the face.
  • Brimonidine treats persistent erythema, not inflammatory papules or telangiectasia, and rebound flushing can occur.
  • Rhinophyma is a phymatous complication and may need specialist procedural treatment.

Illustrations

Central facial rosacea with erythema and papulesA clinical photograph showing persistent central facial erythema and telangiectasia over the nose and cheeks with scattered inflammatory papules.Michael Sand, Daniel Sand, Christina Thrandorf, Volker Paech, Peter Al, Wikimedia Commons · CC-BY-2.5
RhinophymaA photograph of rhinophyma showing a thickened, bulbous, enlarged nose from phymatous rosacea.M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara, Wikimedia Commons · CC-BY-2.0

Key sources

  1. British Association of Dermatologists: Rosacea patient information leaflet (BAD consensus patient information on rosacea features, ocular risk, topical and oral treatment, procedural options, skin care and steroid avoidance; updated May 2022 and accessed 4 August 2026.)Updated 1 May 2022
  2. NHS: Rosacea (Current NHS information on symptoms, triggers, urgent ocular warning signs, treatment and self-care; media updated 10 August 2024 and accessed 4 August 2026.)Updated 10 Aug 2024
  3. NICE Evidence Summary ESNM68: Inflammatory lesions of papulopustular rosacea: ivermectin 10 mg/g cream (NICE evidence summary on topical ivermectin and alternative topical treatments for papulopustular rosacea; published 4 February 2016 and accessed 4 August 2026.)Updated 4 Feb 2016
  4. NICE NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (NICE antimicrobial-stewardship recommendations for documenting indication, considering harms and reviewing continued antimicrobial need; published 18 August 2015 and accessed 4 August 2026.)Updated 18 Aug 2015
  5. Primary Care Dermatology Society: Rosacea clinical guidance (UK primary-care dermatology guidance on rosacea diagnosis, phenotypes, topical and systemic options, ocular symptoms, rhinophyma and referral; last updated 26 August 2024 and accessed 4 August 2026.)Updated 26 Aug 2024
  6. British National Formulary (BNF) (BNF online prescribing information for ivermectin, metronidazole, azelaic acid, brimonidine, tetracyclines, ocular preparations and specialist treatments; current product-specific details, contraindications, interactions and monitoring must be checked at the point of care; accessed 4 August 2026.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.