Rosacea: Types, Causes, Symptoms and Treatments

By: Tiffany Cochran, MD • Posted on April 08, 2021

Rosacea: Types, Causes, Symptoms and Treatments

What is Rosacea?

Rosacea is a chronic inflammatory skin condition commonly affecting the face, mainly the forehead, nose and cheeks. This condition causes redness of the face with visible blood vessels (telangiectasia) and some may see tiny, red, pus-filled bumps (pustules and papules).

A person can have a flare-up for weeks to months followed by no symptoms for a length of time. Rosacea is often confused with facial acne, so many do not seek medical treatment.

Who is Commonly Affected by Rosacea?

  • Rosacea mostly affects midlife women (ages 30-50) and fair-skinned people.
  • It can also affect younger age individuals and men (often developing the more severe form of the condition).
  • Individuals with darker skin tones can be affected, but usually are underdiagnosed and underestimated. The darker tone of skin makes it difficult to identify rosacea hallmark features, including prolonged flushing of the face.

What Causes Rosacea?

Increasing evidence suggests that demodex mites may play a role in the pathogenesis of rosacea. Several factors suggested to play a role are genetics, changes to immune systems function, defective skin barrier, increase bacteria on the face's surface, and environmental factors (i.e., ultraviolet light exposure and alcohol).

Avoiding oil based cleansers may help along with exfoliating the skin 1-2 times per week to remove dead skin cells.

What are common rosacea triggers?

  • Extreme temperature fluctuations and hot flashes
  • Spicy foods
  • Alcohol
  • Emotional or physical stress
  • Exercise
  • Sunlight, ultraviolet rays, strong winds
  • Caffeine

Certain medications that cause dilation of blood vessels, such as topical corticosteroids and niacin (vitamin B3) can exacerbate rosacea and flushing. Discuss with your physician if you should stop these drugs early to prevent worsening symptoms of rosacea.

Lupus can present with facial rash, although rarely has pimples and bumps.

What are the Symptoms of Rosacea?

The National Rosacea Society Expert Committee put together a system to help standardize the diagnosis of rosacea. In 2004, this committee established a classification system based on primary and secondary features of rosacea. A person having more than one primary symptom could be diagnosed with rosacea.

Primary features of rosacea

  1. Flushing of face
  2. Redness of face
  3. Visible blood vessels on face (telangiectasia)
  4. Papules (small red bumps) and pustules (when the small red bumps filled with pus)

Secondary features of rosacea

  1. Symptoms located outside the face
  2. Eye symptoms - red eyes, gritty sensation to eyes
  3. Dry appearance to the skin
  4. Phymatous skin changes (skin thickening or irregular skin surface nodularities on face)
  5. Skin plaques (elevated skin lesion greater than 1 cm in diameter)
  6. Swelling of the face or other affected skin
  7. Burning or stinging of face

Rhinophyma happens when skin thickens on the nose, appearing bulbous (or bumpy). Often a complication of rosacea, rhinophyma occurs more often in men compared to women.

Are there Different Subtypes of Rosacea?

There are 4 sub-types of rosacea:

1. Erythematotelangiectatic

  • Permanent facial redness
  • Visible blood vessels (telangiectasia)
  • Increased skin sensitivity (burning and stinging facial sensation)
  • More often have flushing of the face

2. Papulopustular

  • Facial redness with papules and pustules
  • Affected skin have a scaly and rough feel
  • Less often have flushing of the face

3. Phymatous

  • Thickened skin of the face with enlarged sebaceous (oil) glands
  • Usually affecting nose (rhinophyma)

4. Ocular

  • Affects 50% of people with rosacea
  • Dry, gritty eye sensation
  • Swelling of eyelid
  • Recurring styes
  • Visible blood vessels are seen on conjunctivae

How is Rosacea Diagnosed?

This condition is diagnosed based on the history of symptoms and examination of the skin. No blood test exists to confirm the diagnosis of rosacea. Still, you may have blood tests ordered to exclude other similar medical conditions such as lupus, psoriasis or eczema.

How is Rosacea Treated?

Non-pharmacologic treatment

  • Gentle facial cleanser: Use twice daily to help to maintain a healthy and clean skin surface
  • Facial moisturizer: Choose a moisturizer with a mixture of occlusive (oily substances that help retain hydration) and humectant (substances that attract water to the skin surface of the face)
  • Sunscreen: Choose a sunscreen with 30+ SPF to protect against ultraviolet radiation. Also, an inorganic sunscreen with zinc oxide and titanium oxide is preferred since it is less sticky and will not increase skin warmth, which can worsen symptoms
  • Avoid the common rosacea triggers mentioned above

Pharmacologic treatment

1. Topical treatment

  • FDA approved: Azelaic acid, metronidazole, sodium sulfacetamide, and brimonidine (𝛼-adrenergic agonist)
  • Off-label topical options: Benzoyl peroxide, clindamycin, ivermectin tretinoin and tacrolimus

2. Systemic treatment

  • FDA approved: Tetracyclines (antibiotics)
  • Off-label options: Metronidazole, amoxicillin, propranolol, carvedilol, isotretinoin and oral ivermectin

3. Other Treatment options

  • Light-based treatment: Lasers or Intense pulsed light rays
  • Surgical treatment: excision, dermabrasion (removal of superficial skin layer) or electrosurgery (high-frequency electric current is used to heat and cut targeted skin)

Rosacea is a common skin condition. If you are experiencing any of the above symptoms, please schedule an appointment with your physician to discuss the disease and treatment options. Your primary physician and/or nurse practitioner can determine if you need to see a dermatologist for managing the skin condition. It is better to start treatment sooner rather than later and figure out what your triggers are.

Be Strong, Be Healthy, Be in Charge!

-Tiffany Cochran MD

Tiffany Cochran, MD is a Women's Health Fellow in Cleveland Clinic's Specialized Women's Health Fellowship program. Dr. Cochran received her Bachelor of Science from Valdosta State University and her Doctorate of Medicine from Morehouse School of Medicine. She also has an MA in Healthcare Administration.


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