An acne like inflammatory skin condition, characterised by facial redness, easy flushing,  the appearance of small blood vessels and tiny red pimples on the cheeks and chin and an absence of blackheads and white heads. Much about rosacea is unknown; What is known is that the condition is more common in fair skinned people and adults aged 30-50 years, that it may be aggravated by exposure to sunlight, extreme heat, cold or wind, consumption of hot liquids, spicy foods, caffeinated products, alcohol (especially red wine) and stress. Topical steroids may provide temporary relief but aggravate the condition in the long term.

It is thought that rosacea is a disorder of the microbiome of the skin and in particular excess number of mites (Demodex) or bacteria on the skin causing inflammation and flushing.

The appearance can cause significant psychological and social problems, particularly when facial redness and flushing are mistaken as embarrassment or a sign of excess alcohol consumption.

Eye symptoms are common and include dryness, redness and blepharitis

Differential diagnosis

Seborrhoeic dermatitis (may co-exist); usually associated with dandruff, and dryness and scaling on the eyebrows and sides of the nose

Acne vulgaris; associated with oily skin, blackheads and white heads and not associated with facial redness or flushing

Periorificial dermatitis; typically seen in younger women and associated with redness and tiny pustules around the eyes and mouth

Keratosis pilaris rubra; fixed redness of cheeks since childhood and red bumps on arms and legs

Facial dermatitis: atopic, allergic or airbourne allergens cause itchy red rash

Photodermatitis; dermatitis on light exposed areas and may represent allergy or be associated with underlying conditions such as lupus

Rosacea is divided into 4 sub types and individuals may have features of one or more sub types

Subtype 1: Vascular or flushing rosacea

Symptoms: prolonged flushing, redness and visible blood vessles

Subtype 2: Inflammatory or papulopustular rosacea

Symptoms: redness, papules, pustules and visible blood vessles

Subtype 3: Phymatous rosacea

Symptoms: think, swollen, red skin particularly on nose and chin

Subtype 4: Ocular rosacea

Symptoms: eye dryness, redness, burning, foreign body sensation

General: use a non–irritating cleanser ie. skinceuticals gentle cleanser,  a light emollient SPF  and/ or camouflage skin care (intellishade SPF45) . Avoid trigger factors such as alcohol, spicy foods, hot drinks, smoking or irritating cosmetics or hair sprays.

Treatment options are directed by the predominant type of rosacea.       Flushing and fixed erythema can be helped by topical brimonidine, intensed pulsed light (IPL) or Nd-Yag laser. The more raised inflammatory changes of papules and pustules can be treated with topical agents such as ivermectin, azelaic acid, or metronidazole gels or creams or oral antibiotics. Low dose roaccutane can be highly effective and can be used avoid use long term antibiotics usage or in resistant cases

Treatment Algorithm

Product :                                               Vascular rosacea              Inflammatory     Phymatous         Ocular

Ivermectin 1% gel:                                                                           +++                                        +?

Azelaic acid gel                                                                                  ++                                           +?

Metronidazole0.75% gel                                                               +                                             +?

Brimonidine 0.33%gel                                    +

Eye lubricants                                                                                                                                                    +++

Doxycycline MR 40mg                                                                    +++                                        +

Doxycycline 100mg                                                                          ++                                           +             ++

Oxytetracycline 250/500mg                                                         +                                             +             +

Minocycline 100mg                                                                         ++                                           +             ++

Erythromycin 250/500 mg                                                            +                                                             +

IPL (intensed pulsed light)                            ++                           +                                             +             +

Nd-Yag                                                                 ++                           +                                             +

CO2 Laser                                                                                                                                            +++

Clonidine 25-50                                                 ++

Propranolol 10-40mg                                      +

Patients may initially require a combination of topical and systemic therapy but should be managed on topical treatments on the longer term.