Subtypes of Rosacea and Their Treatment

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

  • 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: Characterized by papules and pustules often on a blush of erythema primarily affecting the nose, cheeks, and forehead. Predilection of lesions on the central aspect of the face, sometimes with central facial edema. Associated with flushing.

  • 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: 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.

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 (see table).

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.

  • 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.

Differential diagnosis

Acne vulgaris: Open (blackheads) and closed (whiteheads) 1-2mm 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).

This subtype is also treated with topical or systemic antibiotics (tetracyclines), as well as topical 5% sulfur/10% sulfacetamide wash or lotion.


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