View source for Rosacea

{{Short description|Skin condition, usually on the face}}
{{other uses}}
{{distinguish|Pityriasis rosea|Roseola|Rosaceae}}

{{cs1 config|name-list-style=vanc}}
{{Use dmy dates|date=December 2017}}
{{Use American English|date=December 2017}}

{{Infobox medical condition (new)
| name            = Rosacea
| image           = Rosacea.jpg
| caption         = Rosacea over the cheeks and nose<ref>{{cite journal |last1=Sand |first1=M |last2=Sand |first2=D |last3=Thrandorf |first3=C |last4=Paech |first4=V |last5=Altmeyer |first5=P |last6=Bechara |first6=FG |title=Cutaneous lesions of the nose. |journal=Head & Face Medicine |date=4 June 2010 |volume=6 |article-number=7 |doi=10.1186/1746-160X-6-7 |pmid=20525327|pmc=2903548 |doi-access=free }}</ref>
| synonyms        = Acne rosacea
| field           = [[Dermatology]]
| pronounce       = {{IPAc-en|r|oʊ|ˈ|z|eɪ|ʃ|(|i|)|ə}}
| symptoms        = Facial [[erythema|redness]], [[edema|swelling]], and [[telangiectasia|small and superficial dilated blood vessels]]<ref name=Tuzun2014 /><ref name=NIH2016 />
| complications   = [[Rhinophyma]]<ref name=NIH2016 />
| onset           = 30{{ndash}}50 years old<ref name=Tuzun2014 />
| duration        = Long term<ref name=Tuzun2014 />
| types           = Erythematotelangiectatic, papulopustular, phymatous, [[ocular rosacea|ocular]]<ref name=Tuzun2014 />
| causes          = Unknown<ref name=Tuzun2014 />
| risks           = Family history<ref name=NIH2016 />
| diagnosis       = Based on symptoms<ref name=Tuzun2014 />
| differential    = [[Acne]], [[perioral dermatitis]], [[seborrhoeic dermatitis]], [[dermatomyositis]], [[lupus]]<ref name=Tuzun2014 />
| prevention      =
| treatment       =
| medication      = [[Antibiotics]] either by mouth or applied to the skin<ref name=NIH2016 />
| prognosis       =
| frequency       = ~5%<ref name=Tuzun2014 />
| deaths          = 
}}
<!-- Definition and symptoms -->

'''Rosacea''' is a [[Chronic (medicine)|long-term]] [[cutaneous condition|skin condition]] that typically affects the face.<ref name=Tuzun2014 /><ref name=NIH2016>{{cite web |title = Questions and Answers about Rosacea |url = https://www.niams.nih.gov/health-topics/rosacea |website = www.niams.nih.gov |access-date = 5 June 2017 |language = en |date = April 2016 |url-status = live |archive-url=https://web.archive.org/web/20170513064456/https://www.niams.nih.gov/Health_Info/Rosacea/default.asp |archive-date = 13 May 2017 }}</ref> It results in [[erythema|redness]], [[pimple]]s, [[edema|swelling]], and [[telangiectasia|small and superficial dilated blood vessels]].<ref name=Tuzun2014>{{cite journal |vauthors = Tüzün Y, Wolf R, Kutlubay Z, Karakuş O, Engin B |title = Rosacea and rhinophyma |journal = Clinics in Dermatology |date = February 2014 |volume = 32 |issue = 1 |pages = 35–46 |pmid = 24314376 |doi = 10.1016/j.clindermatol.2013.05.024 }}</ref> Often, the nose, cheeks, forehead, and chin are most involved.<ref name=NIH2016 /> A red, enlarged nose may occur in severe disease, a condition known as [[rhinophyma]].<ref name=NIH2016 />

<!-- Cause and diagnosis -->
The cause of rosacea is unknown.<ref name=Tuzun2014 /> Risk factors are believed to include a family history of the condition.<ref name=NIH2016 /> Factors that may potentially worsen the condition include heat, exercise, sunlight, cold, spicy food, alcohol, [[menopause]], [[psychological stress]], or [[corticosteroid|steroid cream]] on the face.<ref name="Stein S" /> Diagnosis is based on symptoms.<ref name=Tuzun2014 />

<!-- Treatment -->
While not curable, treatment usually improves symptoms.<ref name=NIH2016 /> Treatment is typically with [[metronidazole]], [[doxycycline]], [[minocycline]], or [[tetracycline]].<ref name=BJD2015>{{cite journal |last1 = van Zuuren |first1 = EJ |last2 = Fedorowicz |first2 = Z |title = Interventions for rosacea: abridged updated Cochrane systematic review including GRADE assessments. |journal = The British Journal of Dermatology |date = September 2015 |volume = 173 |issue = 3 |pages = 651–62 |pmid = 26099423 |doi = 10.1111/bjd.13956 |s2cid = 41303286 }}</ref> When the eyes are affected, [[azithromycin]] eye drops may help.<ref>{{cite journal |title = Rosacea First choice treatments |journal = Prescrire International |date = May 2017 |volume = 182 |pages = 126–128 |url = http://english.prescrire.org/en/SummaryDetail.aspx?Issueid=182 |url-status = live |archive-url = https://web.archive.org/web/20170910171617/http://english.prescrire.org/en/SummaryDetail.aspx?Issueid=182 |archive-date = 10 September 2017 }}</ref> Other treatments with tentative benefit include [[brimonidine]] cream, [[ivermectin]] cream, and [[isotretinoin]].<ref name=BJD2015 /> [[Dermabrasion]] or [[laser surgery]] may also be used.<ref name=NIH2016 /> The use of [[sunscreen]] is typically recommended.<ref name=NIH2016 />

<!-- Epidemiology and history -->
Rosacea affects between 1% and 10% of people.<ref name=Tuzun2014 /> Those affected are most often 30 to 50 years old and female.<ref name=Tuzun2014 /> Fair-skinned people seem to be more commonly affected.<ref name="Rainer">{{cite journal |vauthors=Rainer BM, Kang S, Chien AL |title=Rosacea: Epidemiology, pathogenesis, and treatment |journal=Dermatoendocrinol |volume=9 |issue=1 |article-number=e1361574 |date=2017 |pmid=29484096 |pmc=5821167 |doi=10.1080/19381980.2017.1361574 |url=}}</ref>  The condition was described in ''[[The Canterbury Tales]]'' in the 1300s, and possibly as early as the 200s BC by [[Theocritus]].<ref>{{cite book |last1 = Zouboulis |first1 = Christos C. |last2 = Katsambas |first2 = Andreas D. |last3 = Kligman |first3 = Albert M. |title = Pathogenesis and Treatment of Acne and Rosacea |date = 2014 |publisher = Springer |isbn = 978-3-540-69375-8 |page = XXV |url = https://books.google.com/books?id=vnQqBAAAQBAJ&pg=PR25 |language = en |url-status = live |archive-url = https://web.archive.org/web/20170910171616/https://books.google.ca/books?id=vnQqBAAAQBAJ&pg=PR25 |archive-date = 10 September 2017 }}</ref><ref>{{cite book |last1 = Schachner |first1 = Lawrence A. |last2 = Hansen |first2 = Ronald C. |title = Pediatric Dermatology E-Book |date = 2011 |publisher = Elsevier Health Sciences |isbn = 978-0-7234-3665-2 |page = 827 |url = https://books.google.com/books?id=tAlGLYplkacC&pg=PA827 |language = en |url-status = live |archive-url = https://web.archive.org/web/20170910171616/https://books.google.ca/books?id=tAlGLYplkacC&pg=PA827 |archive-date = 10 September 2017 }}</ref>

== Signs and symptoms ==
[[File:Rasacee couperose zones.svg|thumb|Commonly affected zones<ref>name="JAmAcadDermatol2004-Wilkin">{{cite journal |vauthors = Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell F |title = Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea |journal = J Am Acad Dermatol |year = 2004 |pages = 907–12 |volume = 50 |issue = 6 |pmid = 15153893 |url = http://www.rosacea.org/grading/gradingsystem.pdf |format = PDF reprint |doi = 10.1016/j.jaad.2004.01.048 |archive-url = https://web.archive.org/web/20070227075925/http://www.rosacea.org/grading/gradingsystem.pdf |archive-date = 27 February 2007 }}</ref>]]

Rosacea typically begins with [[erythema|reddening (flushing)]] of the skin in symmetrical patches near the center of the face.<ref name=Buddenkotte2018/> Common signs can depend on age and sex: [[flushing (physiology)|flushing]] and [[erythema|red swollen patches]] are common in the young, [[Telangiectasia|small and visible dilated blood vessels]] in older individuals, and [[rhinophyma|swelling of the nose]] is common in men.<ref name=Buddenkotte2018/> Other signs include lumps on the skin ([[papule]]s or [[pustule]]s) and [[edema|swelling]] of the face.<ref name=Buddenkotte2018/> Many people experience stinging or burning pain, and rarely itching.<ref name=Buddenkotte2018/>

Rosacea is often triggered or worsened by specific stimuli. The exact risk factors vary from person to person, and some people with rosacea may not be able to identify any consistent factors. Common triggers are [[ultraviolet]] light, temperature of weather and/or food, spicy foods, exercise, and emotional stress.<ref name=Buddenkotte2018/><ref name="Stein S">Stein S (2020). Rosacea. Stern S.C., & Cifu A.S., & Altkorn D(Eds.), ''Symptom to Diagnosis: An Evidence-Based Guide, 4e''. McGraw-Hill Education.{{Better source needed|date=July 2025}}</ref>

=== Erythematotelangiectatic rosacea ===

Erythematotelangiectatic rosacea<ref name="Bolognia">{{cite book |author1 = Rapini, Ronald P. |author2 = Bolognia, Jean L. |author3 = Jorizzo, Joseph L. |title = Dermatology: 2-Volume Set |publisher = Mosby |location = St. Louis |year = 2007 |isbn = 978-1-4160-2999-1 }}</ref> (also known as "vascular rosacea"<ref name="Bolognia" />) is characterized by prominent history of prolonged (over 10 minutes) [[Flushing (physiology)|flushing]] reaction to various [[Stimulus (physiology)|stimuli]], such as [[emotional stress]], hot drinks, alcohol, spicy foods, [[exercise]], cold or hot weather, or hot [[Bathing|baths]] and [[showers]].<ref name="Andrews">James, William; Berger, Timothy; Elston, Dirk (2005). ''Andrews' Diseases of the Skin: Clinical Dermatology''. (10th ed.). Saunders. Page 245. {{ISBN|0-7216-2921-0}}.</ref>

=== Glandular rosacea ===

In glandular rosacea, men with thick sebaceous skin predominate, a disease in which the papules are [[edema]]tous, and the [[Pustule|pustules]] are often 0.5 to 1.0&nbsp;cm in size, with nodulocystic lesions often present.<ref name="Andrews" />

== Cause ==

[[File:Steroid Rosacea.jpg|thumb|Topical steroid-induced rosacea ''(left)''; after steroid withdrawal and photobiomodulation therapy ''(right)'']]

The exact cause of rosacea is unknown.<ref name="Tuzun2014" /> Triggers that cause episodes of flushing and blushing play a part in its development. Exposure to temperature extremes, strenuous exercise, heat from sunlight, severe [[sunburn]], stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one, such as heated shops and offices during the winter, can each cause the face to become flushed.<ref name="Tuzun2014" /> Certain foods and drinks can also trigger flushing, such as alcohol, foods, and beverages containing [[caffeine]] (especially hot tea and coffee), foods high in [[histamine]]s, and [[spicy food]]s.<ref name=DelRosso2014 />

Medications and topical irritants have also been known to trigger rosacea flares. Some [[Acne vulgaris|acne]] and wrinkle treatments reported to cause rosacea include [[microdermabrasion]] and [[chemical peels]], as well as high dosages of [[isotretinoin]], [[benzoyl peroxide]], and [[tretinoin]].

[[steroid rosacea|Steroid-induced rosacea]] is caused by topical use of [[steroid]]s,<ref name="urlDermNetNZ">{{cite web |url = http://www.dermnetnz.org/acne/rosacea.html |title = Rosacea |publisher = DermNet, [[New Zealand Dermatological Society]] |access-date = 3 February 2011 |url-status = live |archive-url = https://web.archive.org/web/20101207111722/http://dermnetnz.org/acne/rosacea.html |archive-date = 7 December 2010 }}</ref> which are often prescribed for [[seborrheic dermatitis]]. Dosage should be slowly decreased and not stopped abruptly to avoid a flare-up.

=== Cathelicidins ===

In 2007, [[Richard Gallo]] and colleagues noticed that patients with rosacea had high levels of [[cathelicidin]], an [[antimicrobial peptide]],<ref name="pmid17676051">{{cite journal |author1 = Kenshi Yamasaki |author2 = Anna Di Nardo |author3 = Antonella Bardan |author4 = Masamoto Murakami |author5 = Takaaki Ohtake |author6 = Alvin Coda |author7 = Robert A Dorschner |author8 = Chrystelle Bonnart |author9 = Pascal Descargues |author10 = Alain Hovnanian |author11 = Vera B Morhenn |author12 = Richard L Gallo |title = Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea |journal = [[Nature Medicine]] |volume = 13 |issue = 8 |pages = 975–80 |date = August 2007 |pmid = 17676051 |doi = 10.1038/nm1616 |s2cid = 23470611 }}</ref> and elevated levels of [[stratum corneum]] tryptic [[enzyme]]s ([[KLK5|SCTEs]]). [[Antibiotic]]s have been used in the past to treat rosacea, but they may only work because they inhibit some SCTEs.<ref name="pmid17676051" />

=== Demodex folliculitis and ''Demodex'' mites ===

Studies of rosacea and ''[[Demodex]]'' mites have revealed that some people with rosacea have increased numbers of the mite,<ref name=DelRosso2014 /> especially those with steroid-induced rosacea. [[Demodex folliculitis]] (demodicidosis, also known as "mange" in animals) is a condition that may have a "rosacea-like" appearance.<ref name="Baima2002">{{cite journal |vauthors = Baima B, Sticherling M |title = Demodicidosis revisited |journal = Acta Dermato-Venereologica |volume = 82 |issue = 1 |pages = 3–6 |year = 2002 |pmid = 12013194 |doi = 10.1080/000155502753600795 |doi-access = free }}</ref>

A 2007, [[National Rosacea Society]]-funded study demonstrated that ''[[Demodex folliculorum]]'' mites may be a cause or exacerbating factor in rosacea.<ref name=lacey>{{cite journal |vauthors = Lacey N, Delaney S, Kavanagh K, Powell FC |title = Mite-related bacterial antigens stimulate inflammatory cells in rosacea |journal = [[British Journal of Dermatology]] |volume =  157|issue = 3 |pages = 474–481 |year = 2007 |pmid =  17596156|doi = 10.1111/j.1365-2133.2007.08028.x|s2cid = 8057780 |url = http://eprints.maynoothuniversity.ie/607/1/clinical.pdf }}</ref> The researchers identified ''[[Bacillus oleronius]]'' as a distinct bacterium associated with ''Demodex'' mites. When analyzing blood samples using a peripheral blood mononuclear cell proliferation assay, they discovered that ''B. oleronius'' stimulated an immune system response in 79 percent of 22 patients with subtype 2 (papulopustular) rosacea, compared with only 29% of 17 subjects without the disorder. They concluded, "The immune response results in inflammation, as evident in the papules (bumps) and [[Cutaneous condition#Pustule|pustules]] (pimples) of subtype 2 rosacea. This suggests that the ''B. oleronius'' bacteria found in the mites could be responsible for the inflammation associated with the condition."<ref name=lacey />

=== Intestinal bacteria ===

[[Small intestinal bacterial overgrowth]] (SIBO) was demonstrated to have a greater prevalence in rosacea patients, and treating it with locally acting antibiotics led to rosacea lesion improvement in two studies. Conversely, in rosacea patients who were SIBO-negative, antibiotic therapy had no effect.<ref>{{cite journal |author1 = Elizabeth Lazaridou |author2 = Christina Giannopoulou |author3 = Christina Fotiadou |author4 = Eustratios Vakirlis |author5 = Anastasia Trigoni |author6 = Demetris Ioannides |title = The potential role of microorganisms in the development of rosacea |journal = JDDG: Journal der Deutschen Dermatologischen Gesellschaft |date = November 2010 |pages = 21–25 |volume = 9 |issue = 1 |pmid = 21059171 |doi = 10.1111/j.1610-0387.2010.07513.x |s2cid = 23494211 |doi-access = free }}</ref> The effectiveness of treating SIBO in rosacea patients may suggest that gut bacteria play a role in the pathogenesis of rosacea lesions.

== Diagnosis ==

Most people with rosacea have only mild redness and are never formally diagnosed or treated.  No test for rosacea is known. In many cases, a simple visual inspection by a trained healthcare professional is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis. The disorder can be confused with or co-exist with [[acne vulgaris]] or [[seborrheic dermatitis]]. The presence of a rash on the scalp or ears suggests a different or co-existing diagnosis because rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.

=== Classification ===
[[File:Acne rosacea.jpg|thumbnail|Rosacea on the face]]

[[File:Micrograph of rosacea.jpg|thumb|[[Micrograph]] showing rosacea as enlarged, dilated capillaries and venules located in the upper dermis, angulated telangiectasias, perivascular and perifollicular lymphocytic infiltration, and superficial dermal edema<ref>{{cite journal|last1=Celiker|first1=Hande|last2=Toker|first2=Ebru|last3=Ergun|first3=Tulin|last4=Cinel|first4=Leyla|title=An unusual presentation of ocular rosacea|journal=Arquivos Brasileiros de Oftalmologia|volume=80|issue=6|pages=396–398|year=2017|issn=0004-2749|doi=10.5935/0004-2749.20170097|pmid=29267579|doi-access=free|hdl=11424/241569|hdl-access=free}}</ref>]]
Four rosacea subtypes exist,<ref name="JAmAcadDermatol2004-Wilkin">{{cite journal |vauthors = Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell F |title = Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea |journal = J Am Acad Dermatol |year = 2004 |pages = 907–12 |volume = 50 |issue = 6 |pmid = 15153893 |url = http://www.rosacea.org/grading/gradingsystem.pdf |format = PDF reprint |doi = 10.1016/j.jaad.2004.01.048 |archive-url = https://web.archive.org/web/20070227075925/http://www.rosacea.org/grading/gradingsystem.pdf |archive-date = 27 February 2007 }}</ref> and a patient may have more than one subtype:<ref name="Lookingbill">Marks, James G; Miller, Jeffery (2006). ''Lookingbill and Marks' Principles of Dermatology'' (4th ed.). Elsevier Inc. {{ISBN|1-4160-3185-5}}.</ref>{{rp|176}}

# '''Erythematotelangiectatic rosacea''' exhibits permanent redness (erythema) with a tendency to flush and [[Blushing|blush]] easily.<ref name=DelRosso2014 /> Also small, widened blood vessels visible near the surface of the skin ([[telangiectasias]]) and possibly intense burning, stinging, and itching are common.<ref name=DelRosso2014>{{cite journal |author = Del Rosso JQ |title = Management of cutaneous rosacea: emphasis on new medical therapies |journal = Expert Opin Pharmacother |volume = 15 |issue = 14 |pages = 2029–38 |date = October 2014 |pmid = 25186025 |doi = 10.1517/14656566.2014.945423 |url = https://touroscholar.touro.edu/tuncom_pubs/42 |url-access = subscription }}</ref> People with this type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp.<ref name="RosaceaNet">{{cite web |url = http://www.skincarephysicians.com/rosaceanet/signs_symptoms.html |title = What Rosacea Looks Like |access-date = 30 January 2013 |archive-url = https://web.archive.org/web/20130204224955/http://www.skincarephysicians.com/rosaceanet/signs_symptoms.html |archive-date = 4 February 2013 }}</ref>
# '''Papulopustular rosacea''' presents with some permanent redness with red bumps (papules); some pus-filled pustules can last 1–4 days or longer. This subtype is often confused with acne.
# '''Phymatous rosacea''' is most commonly associated with [[rhinophyma]], an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).<ref>{{cite journal |vauthors = Jansen T, Plewig G |title = Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities |journal = Facial Plast Surg |volume = 14 |issue = 4 |pages = 241–53 |year = 1998 |pmid = 11816064 |doi = 10.1055/s-2008-1064456 |s2cid = 962065 }}</ref> Telangiectasias may be present.
# In '''[[ocular rosacea]]''', affected eyes and eyelids may appear red due to [[telangiectasias]] and inflammation, and may feel dry, irritated, or gritty. Other symptoms include foreign-body sensations, itching,  burning, stinging, and [[Photophobia|sensitivity to light]].<ref name=Vieira2013>{{cite journal |vauthors = Vieira AC, Mannis MJ |title = Ocular rosacea: common and commonly missed |journal = J Am Acad Dermatol |volume = 69 |issue = 6 (Suppl 1) |pages = S36–41 |date = December 2013 |pmid = 24229635 |doi = 10.1016/j.jaad.2013.04.042 }}</ref> Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. [[Keratitis]] is a rare complication that is characterized by blurry vision and vision loss as the [[cornea]] is affected.<ref name=Vieira2013 /><ref name="van Zuuren 2017" />

=== Variants ===

Variants of rosacea include:<ref name="Fitz2">Freedberg, et al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McGraw-Hill. {{ISBN|0-07-138076-0}}.</ref>{{rp|689}}
* '''Pyoderma faciale''', also known as '''rosacea fulminans''',<ref name="Fitz2" /> is a conglobate, nodular disease that arises abruptly on the face.<ref name="Bolognia" /><ref name="Fitz2" />
* '''Rosacea conglobata''' is a severe rosacea that can mimic [[acne conglobata]], with hemorrhagic nodular abscesses and indurated plaques.<ref name="Fitz2" />
* '''Phymatous rosacea''' is a [[cutaneous condition]] characterized by overgrowth of [[sebaceous glands]].<ref name="Bolognia" />  ''Phyma'' is [[Greek language|Greek]] for swelling, mass, or bulb, and these can occur on the face and ears.<ref name="Fitz2" />{{rp|693}}

== Treatment ==
The type of rosacea that a person has will indicate the choice of treatment.<ref name=Van2019>{{cite journal |last1=van Zuuren |first1=EJ |last2=Fedorowicz |first2=Z |last3=Tan |first3=J |last4=van der Linden |first4=MMD |last5=Arents |first5=BWM |last6=Carter |first6=B |last7=Charland |first7=L |title=Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. |journal=The British Journal of Dermatology |date=July 2019 |volume=181 |issue=1 |pages= 65–79 |doi=10.1111/bjd.17590 |pmid=30585305|pmc=6850438 }}</ref> Mild cases are often not treated at all, or are simply covered up with [[Foundation (cosmetics)|normal cosmetics]].

Therapy for the treatment of rosacea is not curative and is best measured in terms of a reduction in the amount of facial redness and inflammatory lesions, a decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents.<ref name="Scheinfeld&Berk">{{cite journal |author1 = Noah Scheinfeld |author2 = Thomas Berk |title = A Review of the Diagnosis and Treatment of Rosacea |journal = Postgraduate Medicine |date = January 2010 |pages = 139–43 |volume = 122 |issue = 1 |url = http://www.postgradmed.com/index.php?article=2107 |doi = 10.3810/pgm.2010.01.2107 |pmid = 20107297 |s2cid = 22914205 |url-status = live |archive-url = https://web.archive.org/web/20110105060409/http://www.postgradmed.com/index.php?article=2107 |archive-date = 5 January 2011 |url-access = subscription }}</ref> Laser therapy has also been classified as a form of treatment.<ref name="Scheinfeld&Berk" /> While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended.  Long-term treatment, usually 1–2 years, may result in permanent control of the condition for some patients.<ref name="Scheinfeld&Berk" /><ref name="Culp&Scheinfeld">{{cite journal |vauthors = Culp B, Scheinfeld N |title = Rosacea: a review. |journal = P&T |date = Jan 2009 |pages = 38–45 |volume = 34 |issue = 1 |pmid = 19562004 |pmc = 2700634 }}</ref> Lifelong treatment is often necessary, although some cases resolve after a while and go into permanent remission.<ref name="Culp&Scheinfeld" />  Other cases, if left untreated, worsen over time.<ref>{{Cite journal|last=Huynh|first=Tu T.|title=Burden of Disease: The Psychosocial Impact of Rosacea on a Patient's Quality of Life|journal=American Health & Drug Benefits|year=2013 |volume=6|issue=6|pages=348–354|issn=1942-2962|pmc=4031723|pmid=24991368}}</ref> Some people have also reported better results after changing diet. This is not confirmed by medical studies, even though some studies relate the histamine production to outbreak of rosacea.<ref>{{Cite journal |last1=Searle |first1=Tamara |last2=Ali |first2=Faisal R. |last3=Carolides |first3=Sarah |last4=Al-Niaimi |first4=Firas |date=2021 |title=Rosacea and Diet: What is New in 2021? |journal=The Journal of Clinical and Aesthetic Dermatology |volume=14 |issue=12 |pages=49–54 |issn=1941-2789 |pmc=8794493 |pmid=35096255}}</ref>

=== Behavior ===
Certain behavioral changes may improve the symptoms of rosacea or prevent exacerbations. Keeping a symptoms diary to document potential symptom triggers and avoiding those triggers is recommended.<ref name="van Zuuren 2017">{{cite journal |last1=van Zuuren |first1=Esther J. |title=Rosacea |journal=New England Journal of Medicine |date=2 November 2017 |volume=377 |issue=18 |pages=1754–1764 |doi=10.1056/NEJMcp1506630|pmid=29091565 }}</ref> Common exacerbating triggers include ultraviolet light and irritant cosmetics, therefore it is recommended that those with rosacea wear [[sunscreen]] (with a sun factor protection (SPF) of 30 or greater) and avoid cosmetics.<ref name="van Zuuren 2017" /> If using cosmetics or makeup is desired, then oil-free foundation and concealer should be used.<ref name="van Zuuren 2017" /> Skin astringents, products that can dry the skin and impair the skin barrier, including products with alcohol, menthol, peppermint, camphor, or eucalyptus oil, should generally be avoided. People should avoid using exfoliating skin scrubs, cosmetics, or soaps containing [[sodium laureth sulfate]], or waterproof makeup on the affected area, as these products can compromise the skin barrier protection and be difficult to remove.<ref name="van Zuuren 2017" /> Using soap-free cleansers and non-oily moisturizers is preferred if used on the affected area. Many skin care products have been specifically formulated for those with sensitive skin or those with conditions such as rosacea.<ref name="van Zuuren 2017" /> Ocular rosacea may be treated with daily gentle eyelid washing using warm water, and artificial tears to lubricate the eye.<ref name="van Zuuren 2017" />

Managing pre-trigger events, such as prolonged exposure to cool environments, can directly influence warm-room flushing.<ref>{{cite book |author = Dahl, Colin |title = A Practical Understanding of Rosacea – part one. |url = http://www.ausci.com/rosacea.htm |year = 2008 |publisher = Australian Sciences |archive-url = https://web.archive.org/web/20080321024745/http://www.ausci.com/rosacea.htm |archive-date = 21 March 2008 |access-date = 27 August 2008 }}</ref>

=== Medications ===
{{Very long section|date=July 2025|nosplit=y}}
Medications with good evidence include topical [[metronidazole]],<ref name="pmid38418773">{{cite journal |vauthors=Desai SR, Baldwin H, Del Rosso JQ, Gallo RL, Bhatia N, Harper JC, York JP, Gold LS |title=Microencapsulated Benzoyl Peroxide for Rosacea in Context: A Review of the Current Treatment Landscape |journal=Drugs |volume= 84|issue= 3|pages= 275–284|date=February 2024 |pmid=38418773 |doi=10.1007/s40265-024-02003-w |url=|doi-access=free |pmc=10982091 }}</ref><ref name="Stein S" /> [[ivermectin]],<ref name="Stein S" /> [[brimonidine]],<ref name="Stein S" /> and [[azelaic acid]].<ref name=Fed2015/> Good evidence medications taken by mouth include brimonidine, [[doxycycline]], and [[isotretinoin]],<ref name=Fed2015>{{cite journal |last1 = van Zuuren |first1 = EJ |last2 = Fedorowicz |first2 = Z |last3 = Carter |first3 = B |last4 = van der Linden |first4 = MM |last5 = Charland |first5 = L |title = Interventions for rosacea |journal = The Cochrane Database of Systematic Reviews |date = 28 April 2015 |volume = 4 |issue = 4 |article-number = CD003262 |pmid = 25919144 |pmc = 6481562 |doi = 10.1002/14651858.CD003262.pub5 }}</ref> with [[Tetracycline antibiotics|tetracyclines]] such as doxycycline representing the oral medications preferred by most clinicians.<ref name="Stein S" /> Lesser evidence supports [[tetracycline]] by mouth.<ref name=Fed2015 /> Isotretinoin and tetracycline antibiotics, which may be used in more severe cases of inflammatory rosacea, are absolutely [[Contraindication|contraindicated]] in women who are pregnant, may become pregnant, or are lactating as they are highly [[teratogenic]] (associated with birth defects). Contraception is required for women of childbearing age who are using these medications.<ref name="van Zuuren 2017" />

Metronidazole is thought to act through anti-inflammatory mechanisms, while azelaic acid is thought to decrease [[Cathelicidin antimicrobial peptide|cathelicidin]] production. Oral antibiotics of the [[tetracycline]] class, such as doxycycline, minocycline, and [[oxytetracycline]], are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.<ref name=DelRosso2014 />

Topical minocycline applied as foam is a newer treatment option for rosacea that the FDA has approved. Minocycline shows a targeted approach for managing inflammatory lesions of rosacea while minimizing systemic side effects commonly associated with oral antibiotic use. It is available in foam formulation and is applied to the affected areas once daily. Minocycline belongs to the tetracycline family of antibiotics and exhibits antimicrobial properties and anti-inflammatory activity, similar to other members of this class, such as doxycycline. Topical minocycline reduces inflammatory lesions associated with rosacea; however, rare adverse events such as folliculitis have been reported.<ref name="pmid38418773"/>

Topical metronidazole is a commonly used treatment for rosacea; it is available in various formulations such as creams, gels, or lotions and applied to clean, dry skin once or twice daily. Topical metronidazole has been shown to effectively reduce inflammatory lesions and perilesional erythema associated with rosacea by inhibiting both microbial growth and pro-inflammatory mediators generated by neutrophils. Benefits of topical metronidazole include its effectiveness in reducing symptoms, extensive clinical experience supporting its use, and generally good tolerability with minimal systemic side effects; still, some patients may experience mild local irritation upon initial use, and it may have limited impact on persistent facial redness (erythema).<ref name="pmid38418773"/>

Topical azelaic acid is available in gel or cream formulations; it exerts its effects by reducing inflammation through its activity on the cathelicidin pathway, which is upregulated in rosacea-affected skin; it also reduces inflammatory lesions and improves overall symptoms of rosacea; it has been well-studied and shown to be effective in clinical trials; still, some patients may experience mild local irritation during the first few weeks of use.<ref name="pmid38418773"/>

Oral [[Beta-blockers]] are often used for those with flushing due to rosacea. These include [[nadolol]], [[propranolol]] or [[carvedilol]]. The possible adverse reactions of the oral beta-blockers include [[hypotension|low blood pressure]], [[bradycardia|low heart rate]], or dizziness.<ref name="van Zuuren 2017" /> The oral [[alpha-2 adrenergic receptor|α-2 adrenergic receptor agonist]] [[clonidine]] can also be used for flushing symptoms.<ref name="van Zuuren 2017" /> The flushing and blushing that typically accompany rosacea may also be treated with the topical application of [[alpha-adrenergic agonist|alpha agonists]] such as brimonidine which has vasoconstrictor activity and achieves maximal symptom improvement 3–6 hours after application, other topicals used for flushing or erythema include [[oxymetazoline]] or [[xylometazoline]].<ref name=DelRosso2014 />

Topical ivermectin is a treatment option for rosacea that targets Demodex mites, which are associated with inflammation in the skin of patients with rosacea; the cream is applied once daily to clean, dry skin. Topical ivermectin has been shown to reduce Demodex mite density and improve cutaneous inflammatory markers in clinical studies; overall, it decreases Demodex mite density and improves the symptoms of inflammation associated with rosacea; however, some patients may experience transient burning or itching upon application. Topical ivermectin offers a targeted approach for managing rosacea by addressing the role of Demodex mites in the disease process.<ref name="pmid38418773"/> A review found that ivermectin was more effective than alternatives for the treatment of papulopustular acne rosacea.<ref>{{cite journal |vauthors=Husein-ElAhmed H, Steinhoff M |title=Efficacy of topical ivermectin and impact on quality of life in patients with papulopustular rosacea: A systematic review and meta-analysis |journal=Dermatol Ther |volume=33 |issue=1 |article-number=e13203 |date=January 2020 |pmid=31863543 |doi=10.1111/dth.13203 |s2cid=209433363 |doi-access=free }}</ref><ref>{{cite journal |vauthors=Siddiqui K, Stein Gold L, Gill J |title=The efficacy, safety, and tolerability of ivermectin compared with current topical treatments for the inflammatory lesions of rosacea: a network meta-analysis |journal=SpringerPlus |volume=5 |issue=1 |article-number=1151 |date=2016 |pmid=27504249 |pmc=4956638 |doi=10.1186/s40064-016-2819-8 |doi-access=free }}</ref> An ivermectin cream has been approved by the [[FDA]], as well as in Europe, for the treatment of inflammatory [[lesion]]s of rosacea. The treatment is based upon the hypothesis that parasitic mites of the genus ''[[Demodex]]'' play a role in rosacea.<ref>{{cite journal |vauthors=Moran EM, Foley R, Powell FC |title=Demodex and rosacea revisited |journal=Clin. Dermatol. |volume=35 |issue=2 |pages=195–200 |date=2017 |pmid=28274359 |doi=10.1016/j.clindermatol.2016.10.014 }}</ref> In a clinical study, ivermectin reduced lesions by 83% over 4 months, as compared to 74% under a [[metronidazole]] standard therapy.<ref>{{cite web | url = https://www.drugs.com/newdrugs/galderma-receives-fda-approval-soolantra-ivermectin-cream-rosacea-4135.html | title = Galderma Receives FDA Approval of Soolantra (Ivermectin) Cream for Rosacea | archive-url = https://web.archive.org/web/20150122021246/http://www.drugs.com/newdrugs/galderma-receives-fda-approval-soolantra-ivermectin-cream-rosacea-4135.html | archive-date=January 22, 2015 | work = drugs.com }}"</ref>  Quassia amara extract at 4% demonstrated to have clinical efficacy for rosacea.<ref>{{cite journal |last1=Ferrari |first1=Alicia |last2=Diehl |first2=Christian |title=Evaluation of the Efficacy and Tolerance of a Topical Gel With 4% Quassia Extract in the Treatment of Rosacea |journal=The Journal of Clinical Pharmacology |date=January 2012 |volume=52 |issue=1 |pages=84–88 |doi=10.1177/0091270010391533|pmid=21343346 |s2cid=29876609 }}</ref>
 
[[Cyclosporin]] eye drops have been shown to reduce symptoms in those with ocular rosacea. Cyclosporin should not be used in those with an active ocular infection.<ref name="van Zuuren 2017" /> Other options include topical metronidazole cream or topical [[fusidic acid]] applied to the eyelids, or oral doxycycline in more severe cases of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.<ref name="IntJDermatol1986-Hoting">{{cite journal |vauthors = Hoting E, Paul E, Plewig G |title = Treatment of rosacea with isotretinoin |journal = Int J Dermatol |date = December 1986 |pages = 660–3 |volume = 25 |issue = 10 |pmid = 2948928 |doi = 10.1111/j.1365-4362.1986.tb04533.x |s2cid = 22421145 }}</ref>

Systemic doxycycline modified-release capsules are commonly used for the treatment of rosacea. The capsules are taken orally once daily, usually in a low dose, to achieve anti-inflammatory effects.<ref name="pmid38418773"/> Doxycycline acts by inhibiting inflammation, reducing the production of reactive oxygen species, [[Matrix metalloproteinase|matrix metalloproteases]] and [[Kallikrein-5|kallikrein 5]].<ref name="pmid38649625">{{cite journal |vauthors=Lee JJ, Chien AL |title=Rosacea in Older Adults and Pharmacologic Treatments |journal=Drugs Aging |volume=41 |issue=5 |pages=407–421 |date=May 2024 |pmid=38649625 |doi=10.1007/s40266-024-01115-y }}</ref> The benefits of systemic doxycycline include its effectiveness in reducing inflammatory lesions, improving erythema, and controlling symptoms related to ocular involvement in rosacea patients; it is also well-tolerated at lower doses compared to traditional higher-dose regimens used for other indications. However, potential cons include gastrointestinal side effects such as nausea or abdominal pain, photosensitivity reactions that require sun protection measures during treatment, and rare instances of antibiotic-associated diarrhea or bacterial resistance development with long-term use.<ref name="pmid38418773"/>

Encapsulated benzoyl peroxide (E-BPO) cream, a newly FDA-approved topical agent for inflammatory lesions of rosacea, utilizes porous silica microcapsule technology to slow the absorption of benzoyl peroxide and diminish potential irritation.<ref name="pmid38418773"/>

=== Phototherapy ===

[[Nd:YAG laser|Nd:YAG lasers]], [[intense pulsed light]], and [[Pulsed dye laser|pulsed dye lasers]] are techniques for [[phototherapy]] of rosacea. Typically, they are used to reduce the appearance of [[Telangiectasia|telangiectasias]], which are abnormal surface-level blood vessels. These therapies cause selective [[photothermolysis]] of [[hemoglobin]] in the local vessels, resulting in their destruction without causing vessel ruptures and bruising.<ref>Gao Y, & Farah R (2022). Acne, rosacea, and related disorders. Soutor C, & Hordinsky M.K.(Eds.), ''Clinical Dermatology: Diagnosis and Management of Common Disorders, 2e''. McGraw-Hill Education.</ref><ref>{{Cite journal |last1=Cassuto |first1=Daniel A |last2=Ancona |first2=Deborah M |last3=Emanuelli |first3=Guglielmo |date=January 2000 |title=Treatment of facial telangiectasias with a diode-pumped Nd:YAG laser at 532nm |journal=Journal of Cutaneous Laser Therapy |volume=2 |issue=3 |pages=141–146 |doi=10.1080/14628830050516399 |pmid=11360331 |issn=1462-883X}}</ref>

== Outcomes ==
The highly visible nature of rosacea symptoms is often psychologically challenging for those affected. People with rosacea can experience issues with self-esteem, socializing, and changes to their thoughts, feelings, and coping mechanisms.<ref name=Buddenkotte2018/>

== Epidemiology ==

Rosacea affects around 5% of people worldwide.<ref name=Buddenkotte2018>{{cite journal |vauthors=Buddenkotte J, Steinhoff M |title=Recent advances in understanding and managing rosacea |journal=F1000Res |volume=7 |issue= |date=2018 |page=1885 |pmid=30631431 |pmc=6281021 |doi=10.12688/f1000research.16537.1 |doi-access=free }}</ref> Incidence varies by ethnicity, and is particularly prevalent in those of [[Celts (modern)|Celtic]] heritage.<ref name=Buddenkotte2018/> Men and women are equally likely to develop rosacea.<ref name=Buddenkotte2018/>

== See also ==

{{Portal|Medicine}}

* [[Seborrheic dermatitis]]
* [[Keratosis pilaris]]
{{clear}}

== References ==
{{Reflist}}

== External links ==

{{Medical resources
|  DiseasesDB     = 96
|  ICD10          = {{ICD10|L|71||l|60}}
|  ICD9           = {{ICD9|695.3}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    = 000879
|  eMedicineSubj  = derm
|  eMedicineTopic = 377
|  MeshID         = D012393
}}
{{Wikibooks|Rosacea}}
{{Commons category|Rosacea (disease)}}
* [http://www.dermnet.com/rosacea Rosacea photo library at Dermnet] {{Webarchive|url=https://web.archive.org/web/20111026031614/http://www.dermnet.com/rosacea |date=26 October 2011 }}
* [https://www.niams.nih.gov/health-topics/rosacea Questions and Answers about Rosacea], from the US National Institute of Arthritis and Musculoskeletal and Skin Diseases

{{Diseases of the skin and appendages by morphology}}
{{Disorders of skin appendages}}
{{authority control}}

[[Category:Acneiform eruptions]]
[[Category:Erythemas]]
[[Category:Cutaneous conditions]]