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by Jacob Mathew, Jr. DO, FACOI, FACP, CHSE, FAWM
A 41-year-old fair-skinned woman visits your clinic for the first time. Other than coming for a yearly check-up, she is concerned because when she goes out with her friends to the bars or a restaurant, they mention that her face always seems to be flushed. She has noticed some redness but has not thought much of it. She uses copious amounts of sunscreen but nevertheless attributes it to sun exposure. On exam, you notice that along with a flushed appearance to the central face, she does have scattered pustules and some telangiectasias. Her nose is of normal appearance. She denies any ocular symptoms.
Bottom line, up front
Rosacea is a condition that is often diagnosed clinically (erythema primarily involving the face, flushing, telangiectasias, inflammatory papules as seen in Figures 1-3.1,2 Laboratory analysis is recommended only if the diagnosis is uncertain or if a rheumatologic condition is being considered.1 Treatment is centered around avoiding triggers, if known. If avoidance is not enough, or if disease is more than mild in nature, pharmacologic options include topical metronidazole or oral tetracyclines; however, their use is based on the clinical symptoms and severity.1,3
Figure 1: Distribution of clinical findings
Figure 2: Diffuse erythema and fine telangiectasias on the cheeks and nose
Figure 3: Early rhinophyma manifesting as erythema, fullness, and an irregular contour of the nose
So, what is it?
Rosacea is a chronic skin condition characterized by erythema and flushing of the face.1 While it is seen in all populations, those that are fair-skinned appear to be more at risk.3-5 Women are affected more than men, and the condition typically affects individuals between the ages of 30 and 50.3,4
How am I going to diagnose it?
While primarily a clinical diagnosis, the presence of primary features of transient erythema (flushing) in the central face with or without papules, pustules, or telangiectasias in the appropriate demographic (female, 30-50 years old, fair skin) is suggestive of the condition. A skin biopsy is not required. If you are considering autoimmune disorders in your differential, ANA, CBC, and C-RP laboratory tests may be beneficial.
Is the patient doing something to cause this?6
While many cases may be considered idiopathic, there are notable stimuli that have been identified. They include exercise, sun exposure, extremes in weather, and stress among others. Weaker, but still documented, risk factors include spicy foods and alcohol ingestion.
How does it present?
In more extreme situations, roughened skin and rhinophyma can occur, which may be not only more noticeable to the patient, but more concerning.7
Where do we often see it?
While rosacea has been reported all over the face and upper body, it often will be found on the cheeks, nose, and central forehead.
What symptoms should point me toward another condition?8,9
If patients with flushing and erythema complain of palpitations, light-headedness, syncope, or periods of sweating, you should broaden your differential to include conditions such as pheochromocytoma, carcinoid syndrome, or those of autoimmune origin.
Not a one-and-done condition10
Unfortunately, rosacea can be difficult to treat, with marked periods of remission and recurrence. It is important to correctly identify the subtype (see Table 1), as this will determine your treatment plan.11 Furthermore, if the condition goes untreated, it may progress from milder symptoms of transient erythema to papules and telangiectasias.
Okay, I'm ready for treatment options!
There are multiple treatment options available, and none is considered to be superior to another.12,13 As with other dermatologic conditions, a trial-and-error approach is often employed until the patient reaches a clinical state that they are happy with.12,13 Table 1 lists treatment options based on clinical presentation. Stresses and changes in environment may cause a once-controlled condition to flare, and these factors should be considered to ensure a patient is not mislabeled as failing treatment.7,12-14
|1 - Erythematotelangiectatic||Flushing, facial erythema, some scaling. May be associated with a burning sensation.|
Azelaic acid + sulfacetamide
|2 - Papulopustular||May be confused with acne. Erythema, telangiectasias, papules, pustules mostly around the face|
Benzoyl peroxide, isotretinoin, topical tretinoin, spironolactone*
Oral tetracycline (eg., doxycycline)
|3 - Phymatous||Thick skin, which may result in rhinophyma. Watch out for involvement in the ears and eyelids!|
More invasive treatment options such as surgical paring, CO laser, cryotherapy15
|4 - Ocular||Watery eyes, bloodshot eyes, ocular dryness, patients may have a foreign body sensation. These symptoms may precede or follow facial symptoms as seen in subtypes 1 and 2.|
Oral antibiotics (if concurrent subtypes 1 + 2)
*May be considered for augmentation therapy with antibiotics.
1. Lehmann P. [Rosacea. Clinical features, pathogenesis and therapy]. Hautarzt. 2005 Sep; 56(9):871-885; quiz 886-887.
2. Strazzula L, Burgin S. Rosacea. In: Goldsmith LA, ed. VisualDx Visual Clinical Decision Support Tool [online]. Rochester, NY: Logical Images; 2019. https://www.visualdx.com/visualdx/diagnosis/rosacea?diagnosisId=51025&moduleId=101. Last updated March 21, 2019. Accessed May 10, 2019.
3. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018 Jan;78(1):148-155.
4. Mikkelsen CS, Holmgren HR, Kjellman P, et al. Rosacea: a clinical review. Dermatol Reports. 2016 Jun;8(1):6387.
5. Rainer BM, Kang S, Chien AL. Rosacea: epidemiology, pathogenesis, and treatment. Dermatoendocrinol. 2017:9(1):e136157.
6. Vemuri RC, Gundamaraju R, Sekaran SD, Manikam R. Major pathophysiological correlations of rosacea: a complete clinical appraisal. Int J Med Sci. 2015 May 5;12(5):387-396.
7. Heisig M, Reich A. Psychosocial aspects of rosacea with a focus on anxiety and depression. Clin Cosmet Investig Dermatol. 2018 Mar 6;11:103-107.
8. Hannah-Shmouni F, Stratakis CA, Koch CA. Flushing in (neuro)endocrinology. Rev Endocr Metab Disord. 2016 Sep; 17(3):373-380.
9. Ikizoglu, G. Red face revisited: flushing. Clin Dermatol. 2014 Nov-Dec;32(6):800-808.
10. Nielsen PG. The relapse rate for rosacea after treatment with either oral tetracycline or metronidazole cream. Br J Dermatol. 1983 Jul;109(1):122.
11. Bikowski JB, Goldman MP. Rosacea: where are we now? J Drugs Dermatol. 2004 Jun;3(3):251-261.
12. Pelle MT, Crawford GH, James WD. Rosacea: II. Therapy. J Am Acad Dermatol. 2004 Oct;51(4):499-512.
13. Scheinfeld N, Berk T. A review of the diagnosis and treatment of rosacea. Postgrad Med. 2010 Jan;122(1):139-143.
14. Kennedy Carney C, Cantrell W, Elewski BE. Rosacea: a review of current topical, systemic and light-based therapies. G Ital Dermatol Venereol. 2009 Dec;144(6):673-688.
15. Yoo JJ, Thaller SR. Treatment of rhinophyma with surgical excision and amniotic membrane. J Craniofac Surg. 2019 Apr 10. [Epub ahead of print]
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