Dermatology
Rosacea
Library·Dermatology·Rosacea
Don't miss
- Ocular rosacea with corneal involvement - urgent ophthalmology
- Lupus, dermatomyositis, or carcinoid masquerading as rosacea
- SLE rash - butterfly distribution, photosensitive, sparing nasolabial folds
- Steroid-induced rosacea after long topical steroid use
First-line
- Diagnosis
- Centrofacial erythema, papules/pustules WITHOUT comedones
- Erythema
- Trigger avoidance (heat, alcohol, sun, spicy food, hot drinks); brimonidine 0.33% gel for short-term redness
- Papulopustular
- Topical metronidazole 0.75-1% first-line; or azelaic acid 15%; oral doxycycline 40 mg MR for moderate-severe
- Phymatous
- Established rhinophyma needs surgical or laser debulking; isotretinoin (Special Authority) for early
Refer when
- Refractory disease despite optimised therapy
- Phymatous changes for surgical/laser referral
- Ocular rosacea with corneal involvement
- Diagnostic uncertainty (lupus, dermatomyositis)
Tell the patient
- Rosacea is relapsing-remitting - the goal is control, not cure
- Identify your triggers: spicy food, hot drinks, alcohol, heat, sun, stress
- Use gentle skin care; avoid astringents and strong cleansers
- Daily SPF is part of treatment
Rosacea is a chronic inflammatory condition affecting the central face, characterised by episodes of flushing, persistent erythema, telangiectasia, and in papulopustular subtypes, acneiform lesions without comedones. It predominantly affects fair-skinned individuals of northern European ancestry aged 30-60, though it can occur across Fitzpatrick skin types. The aetiology involves neurovascular dysregulation, innate immune activation, and the commensal mite Demodex folliculorum (found in elevated densities on rosacea-affected skin).
❍ Subtypes and treatment
- Erythematotelangiectatic (ETR) - flushing and persistent central facial redness, often with telangiectasia and sensitive skin. Management focuses on trigger avoidance, gentle skincare, and topical brimonidine 0.33% gel (alpha-2 agonist that causes vasoconstriction, reducing redness for 8-12 hours). Laser or intense pulsed light (IPL) therapy is effective for persistent telangiectasia but not funded in New Zealand.
- Papulopustular (PPR) - inflammatory papules and pustules on a background of erythema, no comedones. First-line topical therapy is metronidazole 0.75-1% gel or cream, applied twice daily; azelaic acid 15% gel is an effective alternative with additional anti-pigmentary benefit. For moderate-to-severe PPR, oral doxycycline 40 mg (modified-release, anti-inflammatory dose) is the most evidence-based oral option - it reduces inflammation without substantial antibiotic effect, minimising resistance pressure.1 Standard doxycycline 50-100 mg is used where modified-release is unavailable.
- Phymatous - sebaceous gland hyperplasia causing skin thickening, most notably rhinophyma (bulbous nasal enlargement). More common in men. Phymatous change does not respond well to medical therapy; established rhinophyma requires surgical or laser debulking. Early phymatous change may be slowed with isotretinoin (PHARMAC Special Authority required).
- Ocular rosacea - blepharitis, conjunctival injection, foreign body sensation, and in severe cases, corneal involvement. Often coexists with facial rosacea but may occur in isolation. Management includes lid hygiene (warm compresses, lid scrubs), topical cyclosporine eye drops, and oral doxycycline for moderate-severe cases. Refer to ophthalmology if corneal involvement is suspected.
❍ Trigger avoidance and managing expectations
Common triggers include UV exposure, heat, alcohol (particularly red wine), spicy foods, exercise, temperature extremes, and emotional stress. Skincare products containing alcohol, witch hazel, menthol, or fragrance frequently worsen rosacea. Sun protection with a physical (mineral) sunscreen (zinc oxide or titanium dioxide) is both treatment and prevention; chemical sunscreens are better tolerated in some patients. A symptom diary is useful for identifying individual triggers. Cosmetics with a green tint neutralise facial redness and are a practical option for patients troubled by their appearance.
Rosacea is a relapsing-remitting condition with no cure. The goal is control, not resolution. Topical therapy typically needs to continue long-term (often indefinitely) to maintain remission. Patients who achieve good control with oral doxycycline can usually step down to topical maintenance. Clearly explaining the natural history - that flares will occur, that this reflects the disease not treatment failure, and that consistent topical use is the best prevention - improves adherence and reduces frustration. Emotional impact should not be underestimated; rosacea disproportionately affects social confidence and quality of life, and anxiety about flushing can itself be a trigger.2