Rosacea

Overview

Rosacea is a chronic inflammatory condition of the centrofacial skin, following a relapsing-remitting course, managed via a phenotype-based framework focusing on individual features present.

Presentation

•Persistent erythema - fixed central facial redness; hallmark diagnostic feature; does not resolve with rest

•Flushing - episodic, transient; triggered by heat, alcohol, spicy food, emotion; often earliest symptom

•Telangiectasia - dilated superficial vessels on cheeks/nose; does not blanch on pressure

•Papules and pustules - inflammatory lesions on central face; NO comedones (key differentiator from acne vulgaris)

•Phymatous changes - tissue hypertrophy/sebaceous hyperplasia; rhinophyma most common; more common in men

•Ocular rosacea - up to 50% of patients; blepharitis, conjunctival injection, meibomian gland dysfunction, photophobia; can precede skin changes

🎯

Rosacea does NOT cause comedones. If blackheads or whiteheads are present, reconsider - acne vulgaris is far more likely. Rosacea also spares periorbital and perioral skin.

Investigations

•Clinical diagnosis - history and examination; no investigations required in typical cases

•ANA / anti-dsDNA - if lupus suspected (malar rash with systemic features: arthralgia, fatigue, photosensitivity)

•Skin biopsy - rarely needed; consider if diagnosis uncertain (e.g. granulomatous rosacea or cutaneous lupus)

•Ophthalmology referral - if ocular rosacea not improving, to assess for corneal involvement

Management

Treatment is phenotype-guided. All patients receive general measures first, then pharmacological treatment based on dominant features.

•General measures (all patients): daily SPF 30-50 broad-spectrum sunscreen; trigger avoidance (alcohol, hot drinks, spicy food, heat, stress, exercise); gentle fragrance-free moisturiser; psychosocial support

•First-line - persistent erythema: brimonidine 0.33% topical gel - alpha-2 agonist; vasoconstriction; onset ~30 min, duration ~8-12 h; does not treat papules/pustules or telangiectasia

•First-line - papules/pustules: ivermectin 1% topical cream - once daily; anti-inflammatory and anti-parasitic (reduces Demodex burden); superior to topical metronidazole

•Second-line - papules/pustules: metronidazole 0.75% topical gel/cream (if ivermectin not tolerated); azelaic acid 15% topical gel (useful in pregnancy)

•Second-line - moderate-to-severe papules/pustules: doxycycline oral 40 mg modified-release once daily - sub-antimicrobial dose; anti-inflammatory mechanism; minimises antibiotic resistance

•Third-line - severe refractory disease: oral isotretinoin - dermatology initiation; pregnancy prevention programme required

•Telangiectasia: laser (pulsed dye) or intense pulsed light (IPL) - secondary care only; does not respond to topical/oral treatment

•Rhinophyma: surgical reshaping - secondary care only

•Ocular rosacea: eyelid hygiene, warm compresses, lubricating drops; topical cyclosporine eye drops or oral doxycycline for severe cases; ophthalmology if corneal involvement

⚠️

Avoid topical corticosteroids in rosacea - they cause short-term improvement but lead to rebound worsening on withdrawal (steroid-induced rosacea) and accelerate telangiectasia and skin atrophy. This is a common prescribing pitfall.

Complications

•Rhinophyma - progressive fibrosis and sebaceous hyperplasia; predominantly men; significant disfigurement

•Ocular complications - keratitis and corneal scarring in severe untreated ocular rosacea can threaten vision

•Psychosocial impact - anxiety, depression, social withdrawal; often disproportionate to disease severity; actively assess

Follow-up and Referral

•Review at 8-12 weeks after initiating topical treatment to assess response and tolerability

•Refer to dermatology if: no response to optimal primary care treatment; telangiectasia requiring laser/IPL; diagnostic uncertainty; phymatous changes needing surgery; severe or corneal ocular rosacea