Key Points

  • Rosacea has four different clinical presentations: erythemato-telangiectatic, papulo-pustular, phymatous, and ocular. It is essential to correctly identify the subtype of rosacea in order to select the appropriate medical or surgical therapy.
  • Rosacea treatment should be tailored to the clinical subtype and disease severity to optimize therapy.
  • Facial erythema is the primary feature of rosacea and presents ubiquitously in all subtypes. Persistent facial erythema has significant impact on quality of life.
  • Erythemato-telangiectatic rosacea must be differentiated from chronic sun damage.
  • Papulo-pustular rosacea must be distinguished from acne vulgaris, seborrheic dermatitis, perioral dermatitis, and Demodex folliculitis/demodicidosis. Rosacea can be distinguished from acne vulgaris by the lack of comedones, identification of triggers for flushing, absence of scarring, the presence of phymatous changes, and the predilection to affect older adults rather than teenage adults.
  • Rosacea patients often have sensitive skin and suffer from intolerance to skin products and cosmetics.
  • Patients with rosacea flush, have facial erythema, telangectasia, papules and pustules, sebaceous hyperplasia of the nose (rhinophyma), and/or ocular symptoms. Triggers for flushing include alcohol, sun exposure, hot weather, exercise, ingestion of hot or spicy foods/ drink or a medication, and emotional stress. Eliminating the triggers of flushing can alleviate rosacea symptoms.
  • Newer topical treatments provide effective options for treating rosacea subtypes. The alpha adrenergic agonist brimonidine (Mirvaso) effectively reduces erythema in erythemato-telangiectactic rosacea, as well as in other subtypes. Ivermectin cream (Soolantra) is highly effective in reducing inflammatory lesions of papulo-pustular rosacea.
  • Ocular rosacea requires systemic antibiotics.
  • Phymatous rosacea may require laser treatment or other surgical intervention.

Initial Evaluation

Erythemato-telangiectatic (E-T) subtype: Characterized by diffuse erythema and telangiectasias on the cheeks, forehead, dorsal nose, or entire face.

Papulo-pustular subtype: Characterized by papules and pustules often on a blush of erythema primarily affecting the nose, cheeks, and forehead. Predilection of lesions is on the central aspect of the face, sometimes with central facial edema; associated with flushing.

Phymatous subtype: Marked by thickening of the skin, irregular skin texture, edema, hypertrophy and hyperplasia of sebaceous glands, connective tissue, and vascular bed of the nose (rhinophyma). These changes can also be seen on the chin (gnathophyma), ears (otophyma), forehead (metophyma), and eyelids (blepharophyma); almost exclusively in males.

Ocular subtype: Can be seen in the presence or absence of skin manifestations of rosacea. Characterized by conjunctival erythema and injection, sometimes accompanied by eyelid edema (blepharitis), foreign body sensation, and/or glandular inflammation (chalazion) along the eyelid margin. Patients report subjective symptoms: foreign body sensations, dry eyes, itching and burning, photosensitivity. The vision is rarely affected. Because severe long-term consequences may result from untreated ocular rosacea, ongoing ophthalmologic evaluation is strongly recommended.

Differential diagnosis

Acne vulgaris: Open (blackheads) and closed (whiteheads) 1-2 mm follicular-based papules. Some of the lesions are excoriated. Comedones are not a feature of rosacea.

Nodular acne: Nodules are present on the upper right forehead and bilateral medial cheeks, in addition to inflammatory papules, pustules, and scars. Nodules and scars are not typical features of rosacea.

Seborrheic dermatitis: Scaly, flaky, itchy, red skin on the scalp, face (nasolabial folds), and trunk.

Peri-orificial dermatitis (i.e., peri-oral dermatitis): Papules and pustules are small in size, monomorphous, and occur around the mouth (rarely around eyes).

Systemic lupus erythematosus: Malar erythema in a clearly photodistributed pattern on the face.

Subtypes of rosacea and their treatments

Erythemato-telangiectatic (E-T) subtype

  • Patients often complain of intolerance or sensitivity to topical products and cosmetics.
  • This subtype is best treated with avoidance of flushing, photoprotection, and surgical or laser therapies (see table, Subtype Directed Therapy).
  • Though considered the mildest form of rosacea, the E-T subtype is marked by significant impact on quality of life stemming from persistent facial erythema.
  • A significant advancement in treatment of rosacea erythema is now commercially available; once-daily application of brimonidine gel 0.33% (Mirvaso) has been approved as an effective topical treatment for facial redness in rosacea.

Papulo-pustular subtype

  • This subtype is best treated with topical or systemic antibiotics and/or topical 5% sulfur/ 10% sulfacetamide wash or lotion (such as Plexion, Rosac, Rosanil, Rosula, or Sulfacet-R).
  • Start with topical metronidazole gel, lotion, or cream 0.75% – 1% (such as MetroCream, MetroGel, MetroLotion, or Noritate) b.i.d. The only drug validated for the maintenance treatment of papulo-pustular rosacea by randomized controlled trial is topical metronidazole.
  • Another effective topical option is azelaic acid (15 or 20% cream), such as Azelex or Finacea, applied b.i.d.
  • If papules/pustules persist or do not respond to topicals, consider low-dose doxycycline 40 mg once daily (Oracea) or oral tetracycline 250-500 mg daily to b.i.d., minocycline (such as Minocin or Solodyn) 40-100 mg or doxycycline (such as Adoxa, Doryx) 100 mg daily to b.i.d. After initial clearance, the dosing may be reduced or stopped.
  • Systemic tetracycline antibiotics should not be used in children under the age of 8 because of potential permanent discoloration of teeth. Macrolide antibiotics are an alternative treatment for children under the age of 8.
  • Severe cases may require isotretinoin (such as Accutane, Amnesteem, Claravis, or Sotret). It is important to note that isotretinoin will not necessarily eradicate all of the features of rosacea, with the notable exception being facial erythema.

Phymatous subtype

This severe form of rosacea requires maximizing medical therapy with systemic antibiotics, and sometimes use of isotretinoin. Once the medical regimen has been maximized, the patient is a candidate for surgical/laser resurfacing of the affected area by a dermatologist.

  • Electrosurgical sculpturing of the rhinophymatous nose gives excellent results, is fast, and is almost bloodless. It is equivalent to laser therapy, although it may be more likely to scar.
  • A CO2 laser or erbium-YAG laser may also be used for the treatment of rhinophyma, although it is more costly and time-consuming than electrosurgical treatment.
  • Cold-steel surgery and dermabrasion are also effective, but they are more difficult owing to the vascularity of the nose.

Ocular subtype

  • Ocular rosacea requires systemic antibiotics, and oral tetracycline 250-500 mg b.i.d. is an excellent first-line therapy for this form of rosacea. Minocycline 40-100 mg or doxycycline 100 mg daily to b.i.d may also be used.
  • Topical corticosteroid eyedrops may be beneficial.

Management of the patient with rosacea

  1. Establish the clinical diagnosis of rosacea (subtype, severity, ocular involvement).
  2. Prescribe treatment (topical, systemic, physical).
  3. Refer patient to an ophthalmologist when needed.
  4. Advise patient to avoid trigger factors, use photoprotection (broad spectrum, both UVA and UVB), select gentle daily skin care. Skin care becomes an important part of their therapy (see handout Skin care for rosacea patients).
  5. Avoid drugs that worsen rosacea. Stop or taper all topical corticosteroids stronger than hydrocortisone 1%. Anticipate a flare when they are discontinued.
  6. Use maintenance therapy.

Subtype Directed Therapy




Sun protection, specific skin care


Erythemato-telangiectatic Brimonidine 0.33% gel

Pulse-dye laser/KTP laser/ Nd :YAG/ intense pulsed light therapy


Avoidance of triggers
Papulo-pustular Ivermectin 1% cream
Azelaic acid
Sulfacetamide/ sulfur
Low-dose doxycycline
Pulse-dye laser/KTP laser/ Nd:YAG/ intense pulsed light therapy


Avoidance of triggers

Systemic antibiotics
Surgery (conventional, laser)


Avoidance of triggers
Ocular Corticosteroid eyedrops Tetracyclines Eyelid warm compress


Lid hygiene
Artificial tears

Note that only the following agents are FDA-approved for use in rosacea:


  • Ivermectin 1% cream (for papulo-pustular rosacea).
  • Brimonidine 0.33% gel (for ET rosacea).
  • Metronidazole 0.75 and 1% (gel, cream, lotion).
  • Azelaic acid 15 and 20% (cream).
  • Sulfacetamide 10%-sulfur 5% (gel, cream, topical suspension, wash).


  • Doxycycline 40 mg capsule once daily.
  • Efficacy beyond 16 weeks and safety beyond 9 months has not been established.

Additional principles of rosacea therapy

  • If flushing is a significant factor, consider addition of clonidine (such as Catapres 0.05-0.1 mg daily) or a beta-adrenergic antagonist such as propranolol (such as Inderal) 20-80 mg daily, nadolol (such as Corgard) 10-40 mg daily or atenolol (such as Tenormin) 12.5-25 mg daily. Brimonidine gel 0.33% is a recently approved topical therapeutic that has demonstrated excellent efficacy for facial erythema; it is the only medication indicated for treating facial erythema in rosacea. It is essential to reduce triggers for flushing such as sun exposure, alcohol, exercise, hot weather, hot or spicy foods/ drinks, medications (niacin), and emotional triggers when possible.
  • Green-tinted moisturizers and make-up neutralize the erythematous quality of skin affected by rosacea.


  • Isotretinoin is contraindicated in pregnancy, and tetracycline-class antibiotics are contraindicated after week 14 gestation. Adequately documented contraception, a negative pregnancy test, and extensive counseling are required.
  • Topical corticosteroids can induce rosacea (steroid-induced rosacea).
  • Patients with rosacea have sensitive skin and tolerate topical irritants poorly. Topical retinoids (i.e., tretinoin cream) or high concentrations of benzoyl peroxide are not always recommended (see handout Skin care for rosacea patients).
  • It is recommended that patients are referred to an experienced dermatologist to supervise systemic isotretinoin treatment.
  • Rosacea fulminans (sudden onset of coalescent papules, pustules, nodules) may occur during pregnancy, thyroid diseases, depression, emotional stress, or be induced by medications. This exacerbation may require use of systemic corticosteroids (prednisone 0.5 to 1 mg/kg/day) and/or isotretinoin.

When to refer to a dermatologist (and ophthalmologist)

  • As the differential diagnosis and treatment of rosacea is challenging, it is always beneficial to refer the patient to a dermatologist.
  • Severe rosacea cases that require systemic isotretinoin.
  • If a diagnosis of cutaneous rosacea is suspected, an ophthalmologic examination is always beneficial to detect ocular involvement and to prevent complications such as keratitis and corneal ulcers.

Clinical Cases

Case 1

Erythemato-telangiectatic rosacea

  • 55-year-old woman
  • Chronic flushing, erythema and telangiectasias on cheeks, nose
  • Not responding to topical antibiotics


  • Discontinue topical antibiotics
  • Topical brimonidine 0.33% gel (Mirvaso)
  • Photoprotection, sunscreen use advised, appropriate skin care (gentle facial cleanser and moisturizer)
  • Identify and avoid triggers of flushing
  • Consider referral to laser treatment for vascular features

Case 2

Papulo-pustular rosacea

  • 40-year-old woman
  • Long-standing erythematous papules, plaques on the cheeks, nose, chin, forehead
  • Skin lesions are exacerbated by sun exposure and alcohol consumption
  • No response to topical antibiotics alone


  • Topical ivermectin 1% cream (such as Soolantra) applied once daily
  • Photoprotection, sunscreens advised. Appropriate skin care (gentle facial cleanser and moisturizer)
  • Avoid alcohol consumption, sun exposure

Follow-up visit at 6 weeks

  • Lesions improved
  • Continue topical ivermectin cream
  • Continue photoprotection and skin care
  • Continue to avoid alcohol consumption and other triggers

Case 3

Rosacea with ocular symptoms

  • 25-year-old woman
  • Recurrent erythematous papules on cheeks, nose, forehead with associated blepharitis, conjunctival erythema and edema, foreign body sensation
  • Topical antibiotic lotion alleviates skin but not ocular symptoms
  • No clear triggers for symptoms


  • Tetracycline 500 mg p.o. b.i.d. (oral tetracyclines are first-line treatment for ocular rosacea)
  • Metronidazole 1% cream or gel applied b.i.d. to skin lesions
  • Photoprotection, sunscreens advised; appropriate skin care with gentle facial cleanser and moisturizer
  • Refer to an opthalmologist if needed

Follow-up visit at 6 weeks

  • Lesions improved, no ocular signs present
  • Continue metronidazole 1% cream or gel applied b.i.d. to skin lesions
  • Continue photoprotection, skin care

Suggested Reading

Del Rosso JQ et al (2014). Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 5: a guide on the management of rosacea, Cutis, 93(3):134-138.

Del Rosso JQ et al (2014). Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies, Cutis, 93(1):18-28.

Del Rosso JQ et al (2013). Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 2: a status report on topical agents, Cutis, 92(6):277-284.

Del Rosso JQ et al (2013). Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 1: a status report on the disease state, general measures, and adjunctive skin care, Cutis, 92(5):234-240.

Elewski BE et al (2011). Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group, JEADV, 25(2):188-200.

Fowler J et al (2013). Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized double-blind, vehicle-controlled pivotal studies, JDD, 12(6):650-656.

Fowler J et al (2012). Once-daily topical brimonidine tartrate gel 0.5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicenter, randomized and vehicle-controlled studies, BJD, 166:633-641.

Gold LS et al (2014). Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies, J Drugs Derm, 13(3): 316-323.

Taieb A et al (2014). Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial, BJD, Epub ahead of print.

Tanghetti E et al (2014). Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 4: a status report on physical modalities and devices, Cutis, 93(2):71-76.

Weinstock LB, Steinhoff M (2013). Rosacea and small intestinal bacterial overgrowth: prevalence and response to rifaximin, JAAD, 68:875-876.