Rosacea.

Rosacea presents as persistent redness across the cheeks, nose, chin, and central forehead, often with thread-like visible blood vessels and small red bumps or pus-filled pimples. Many patients also experience episodes of intense flushing triggered by heat, sun, alcohol, or spicy food. Unlike acne, there are no blackheads or whiteheads.

Rosacea is not curable, but it is highly controllable. With phenotype-matched therapy — topical ivermectin or azelaic acid, oral modified-release doxycycline, brimonidine or oxymetazoline for redness, and vascular laser for visible vessels — most patients reach clear or near-clear skin and prevent progression. Treatment is usually lifelong with periodic maintenance.

Common triggers include sun exposure, hot drinks, alcohol (especially red wine), spicy food, hot weather, vigorous exercise, emotional stress, harsh skincare products, and topical corticosteroids applied to the face. Each patient typically has a personal short list identified through a 2-3 week trigger diary. Avoidance reduces flare frequency by 30-50% in most patients.

Acne shows comedones (blackheads and whiteheads) along with papules and pustules and tends to involve the forehead, jawline, chest, and back. Rosacea lacks comedones, centers on the cheeks and nose, includes persistent redness and flushing, and typically starts after age 30. The two can coexist and may need different treatments.

Yes. Ocular rosacea affects about 50% of rosacea patients and can precede skin disease in 20%. Symptoms include burning, gritty foreign-body sensation, watery or dry eyes, redness, photophobia, and recurrent styes or chalazia. Untreated ocular rosacea can progress to corneal damage and vision loss, so prompt ophthalmology evaluation is important.

Rhinophyma is a thickening and disfigurement of the nose caused by long-standing rosacea, marked by enlarged sebaceous glands and fibrosis. It produces a bulbous, irregular, often reddened nose and predominantly affects men. Treatment is surgical — electrosurgery, CO2 laser, dermabrasion, or cold-steel paring — with excellent cosmetic outcomes in experienced hands.

Yes. Ivermectin 1% cream (Soolantra) is now first-line for papulopustular rosacea per the 2020 American Academy of Dermatology guidelines. The pivotal Stein 2014 trials showed clear or almost-clear skin in 38-40% of patients at 12 weeks and superior performance to metronidazole at 16 weeks. It works by reducing Demodex mite burden and skin inflammation.

Brimonidine 0.33% gel is a selective alpha-2 adrenergic agonist that visibly reduces persistent redness within 30 minutes of application and lasts about 12 hours. It does not treat papules or pustules. Rebound erythema affects 10-20% of users; starting with intermittent use and titrating up reduces this risk.

Modified-release doxycycline 40 mg once daily (Oracea) delivers an anti-inflammatory dose too low to select for bacterial resistance. The Del Rosso 2007 pivotal trials showed efficacy comparable to 100 mg doxycycline with far fewer side effects and no antibiotic-resistance pressure. It is the preferred oral therapy for moderate-to-severe papulopustular rosacea.

Yes. Pulsed-dye laser (595 nm) and intense pulsed light reduce telangiectasias and persistent redness by 60-80% after 3-4 sessions spaced 4-6 weeks apart. Results last years with daily sun protection. Laser does not treat active papules or pustules, which need topical or oral therapy. Most plans complement laser with maintenance topical therapy.

Rosacea has a heritability of around 46% from twin studies, with risk genes mapped to HLA-DRB1, HLA-DQB1, and HLA-DQA1 loci. A first-degree relative with rosacea more than doubles personal risk. Lifestyle and environmental triggers determine when and how severely the disease appears.

Yes, although it is frequently underdiagnosed in Black, South Asian, and other darker skin types because redness is harder to detect against more deeply pigmented skin. Dermoscopy, careful examination in good light, and attention to papules, pustules, telangiectasias, and flushing improve recognition. True prevalence is closer to 4-5% in skin of color, not the historically reported under 1%.

Topical corticosteroids should not be used long-term on rosacea. Mid- and high-potency facial steroids cause steroid-induced rosacea with rebound redness and pustules on withdrawal. Short courses under specialist guidance are sometimes used for severe inflammation, but maintenance therapy uses non-steroid agents like ivermectin, azelaic acid, or metronidazole.

Mineral sunscreens containing zinc oxide and titanium dioxide are best tolerated because they sit on the skin surface rather than absorbing UV through chemical reactions. Look for fragrance-free, alcohol-free SPF 30 or higher, ideally tinted to neutralize redness. Daily use measurably reduces flare frequency and slows long-term progression.

Rosacea cannot be prevented from developing in genetically susceptible people, but progression can be slowed. Daily sunscreen, identifying and avoiding personal triggers, gentle skincare, avoiding facial corticosteroids, and early dermatology treatment of mild redness or bumps all reduce flare frequency and limit progression to telangiectasia and phymatous disease.

Diet is not a primary cause, but specific foods reliably trigger flushing in many patients — hot drinks, alcohol (especially red wine), spicy foods rich in capsaicin, and histamine-rich foods. A Mediterranean-style eating pattern and adequate omega-3 intake are associated with milder disease. A short food diary identifies personal triggers.

Topical therapy improves papules and pustules noticeably by week 4 and peaks at 12-16 weeks. Oral modified-release doxycycline reduces lesion counts within 2-4 weeks. Brimonidine and oxymetazoline reduce redness within 30 minutes to 3 hours of application. Vascular laser delivers visible improvement after each session, with full effect across 3-4 treatments.

Yes. Anxiety, depression, and social avoidance are significantly more common in rosacea patients than in the general population, particularly in those with prominent facial redness or phymatous changes. Effective skin treatment measurably improves quality of life and mood; integrated mental-health support is appropriate when symptoms are significant.

Childhood rosacea is rare. New facial flushing, papules, or pustules in children should prompt evaluation for other causes including atopic dermatitis, perioral dermatitis, juvenile dermatomyositis, lupus, and demodicosis. When pediatric rosacea is diagnosed, ocular involvement is often a leading feature and warrants ophthalmology co-management.

There is a modest association between Helicobacter pylori carriage and rosacea, particularly papulopustular disease in patients with dyspepsia. Eradication has produced variable improvement in trials. Testing and treatment are reasonable when gastrointestinal symptoms coexist, but H. pylori is not considered a primary cause.

Most non-irritating mineral-based makeup is well tolerated and can camouflage redness effectively. Green-tinted primers and yellow-toned foundations neutralize background erythema. Avoid heavy long-wear formulations that need harsh removers, alcohol-based products, and fragranced cosmetics. Removing makeup gently with a fragrance-free cleanser at the end of each day reduces irritation.