Rosacea in Malaysia: Symptoms, Causes & Treatment

Rosacea in Malaysia: Symptoms, Causes & Treatment | aihealz

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How you might notice it

01Recurrent flushing — episodic, transient redness of the face triggered by heat, alcohol, spicy food, sun, exercise, or strong emotion, lasting minutes to hours before fading and progressively contributing to fixed redness over years.

02Persistent central facial erythema — fixed background redness across the cheeks, nose, chin, and central forehead that does not fade between flushing episodes and is the cardinal diagnostic feature.

03Inflammatory papules and small dome-shaped pustules on a red background, distributed centrally on the face, lacking comedones (blackheads or whiteheads) — a key distinction from acne vulgaris.

04Telangiectasias — fine, threadlike, visible blood vessels on the cheeks, nasal alae, and chin, most apparent in fair-skinned patients and easily seen in good lighting.

05Skin sensitivity, stinging, and burning with topical products, sunscreen, soap, or temperature change; many patients have a long history of being unable to tolerate facial cosmetics.

06Phymatous skin changes — thickened, irregular, bumpy skin from sebaceous gland hyperplasia and fibrosis, most often producing a bulbous nose (rhinophyma) and seen predominantly in men.

07Ocular symptoms including burning, foreign-body sensation, dry gritty eyes, redness, photophobia, recurrent styes or chalazia, and crusting at the eyelid margins.

08Edema of the central face, especially the forehead and cheeks, which can be intermittent or persistent in long-standing disease (Morbihan disease in severe cases).

09Symmetric distribution centered on convex facial structures, with the eyelids, periocular skin, and perioral skin typically spared in classic disease.

10Absence of comedones — unlike acne, blackheads and whiteheads are not part of rosacea, and their presence should prompt reconsideration of the diagnosis or concurrent acne.

early warning signs

•Easy facial flushing in response to hot drinks, alcohol, spicy food, or temperature change that lasts longer than blushing should and recurs frequently in the 30s and 40s
•Cheeks and nose that look pink even when calm and indoors, with stinging when sunscreen or cleanser is applied
•A few persistent pink bumps on the cheeks or nose that come and go without forming blackheads
•Visible thread-like vessels on the cheeks or nasal alae in good lighting, especially in fair-skinned individuals over 30
•Eyes that feel gritty, burning, or watery without an obvious infection, with recurrent styes or chalazia

● emergency signs

•Sudden severe eye pain with photophobia and decreased vision in a rosacea patient — possible rosacea keratitis or corneal ulcer, requiring same-day ophthalmology evaluation
•Rapid central facial swelling, fever, and warmth — possible cellulitis or erysipelas superimposed on rosacea, requiring urgent assessment
•New unilateral severe headache with facial flushing, palpitations, and sweating — flushing here is not rosacea but warrants workup for pheochromocytoma or carcinoid
•Acute corneal opacity or visible vessels growing onto the cornea — sight-threatening neovascularization needing prompt ophthalmology referral

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How it’s diagnosed

diagnosis

Rosacea is a clinical diagnosis. The 2017 ROSCO global consensus and the 2018 National Rosacea Society phenotype-based update define the diagnosis by the presence of either of two diagnostic features — persistent central facial erythema or phymatous skin changes — or by two or more major features (papules and pustules, telangiectasias, flushing, ocular manifestations). A focused history identifies typical triggers, family history, prior use of topical corticosteroids, and ocular symptoms that patients often do not connect to their skin disease. Examination is conducted in good natural light and includes the cheeks, nose, chin, central forehead, eyelid margins, and the conjunctiva. Comedones, if present, exclude pure rosacea and indicate acne or an overlap. Skin biopsy is unnecessary in typical disease but useful to rule out lupus erythematosus, sarcoidosis, granulomatous rosacea, or demodicosis when presentation is atypical. Dermoscopy reveals dilated polygonal vessels and demodex tails in characteristic patterns. Ocular rosacea is diagnosed clinically with slit-lamp examination by an ophthalmologist when patients report burning, photophobia, recurrent styes, or visible eyelid margin inflammation; tear breakup time and meibomian gland imaging quantify dysfunction. Differential diagnosis includes acne vulgaris (comedones present), seborrheic dermatitis (greasy yellow scale, nasolabial fold predominance), perioral dermatitis (perioral and periorbital papules sparing the vermilion border), systemic lupus erythematosus (malar rash, photosensitivity, systemic symptoms, positive ANA), and carcinoid or pheochromocytoma in patients with severe flushing accompanied by palpitations, diarrhea, or hypertension. Standard photography under reproducible lighting at diagnosis aids monitoring and treatment response, since erythema and telangiectasia can be hard to track subjectively over months.

Key tests

Clinical examination by a dermatologist using the 2017 ROSCO phenotype frameworkConfirms diagnosis based on diagnostic features (persistent central erythema or phymatous changes) or two or more major features. No imaging or laboratory test is required for typical disease.

Standardized facial photographyProvides an objective baseline to track erythema, papule and pustule counts, and telangiectasia over treatment. Particularly useful for laser and biologic therapy decisions.

Slit-lamp ophthalmologic examinationConfirms ocular rosacea, grades meibomian gland dysfunction, and detects corneal involvement. Recommended at diagnosis when ocular symptoms are present and yearly thereafter in active ocular disease.

Skin biopsy (punch or shave)Reserved for atypical presentations to rule out lupus erythematosus, sarcoidosis, granulomatous rosacea, demodicosis, or cutaneous lymphoma. Histology in classic rosacea shows perivascular and perifollicular lymphohistiocytic infiltrate, dilated vessels, and solar elastosis.

Dermoscopy or videodermoscopyNon-invasive visualization of vascular patterns, demodex tails (white scaly follicular plugs), and follicular features. Useful in atypical or skin-of-color presentations where surface redness is harder to see.

Demodex density assessment (standardized skin surface biopsy)Quantifies follicular Demodex burden when demodicosis or a refractory papulopustular eruption is suspected. Counts above 5 mites per square centimeter are considered pathologically increased.

Targeted workup for flushing differentialsWhen flushing is severe, sustained, accompanied by palpitations, diarrhea, sweating, or hypertension, or refractory to standard rosacea therapy, rule out carcinoid syndrome (24-hour urinary 5-HIAA), pheochromocytoma (plasma free metanephrines), mastocytosis (serum tryptase), and medication-induced flushing.

Outlook

Rosacea is a chronic relapsing disease that cannot be cured permanently, but most patients reach excellent control with phenotype-matched therapy and trigger management. Topical ivermectin and azelaic acid achieve clear or near-clear papulopustular disease in 40-55% by 16 weeks, and oral modified-release doxycycline lifts response rates to 60-70%. Vascular laser and IPL deliver 60-80% reduction in telangiectasia and fixed erythema after 3-4 sessions, with results lasting years under consistent sun protection. Without treatment, the typical course is gradual progression over a decade or more from intermittent flushing to fixed erythema, telangiectasia, and in a subset of patients (predominantly men) phymatous changes. Ocular rosacea, if untreated, can progress to corneal neovascularization, scarring, and vision loss in a small but important minority. The decisive prognostic factor is consistent daily sun protection plus appropriate phenotype-directed therapy maintained over years; with both in place, most patients live with minimal day-to-day impact and avoid the disfiguring complications.

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Causes & risk factors

known causes

Innate immune dysregulation with abnormal cathelicidin processing: Rosacea skin overexpresses toll-like receptor 2, kallikrein-5, and the antimicrobial peptide cathelicidin LL-37. Excess kallikrein-5 cleaves LL-37 into pro-inflammatory peptide fragments that recruit neutrophils, induce vasodilation, and drive the erythema, papules, and pustules. This pathway underlies the rationale for anti-inflammatory therapies such as low-dose doxycycline.
Neurovascular dysregulation: Cutaneous vessels in rosacea respond excessively to neuropeptides (substance P, CGRP, VIP) and to TRPV1/TRPV4 channel activation by heat, capsaicin, and ultraviolet radiation. Repeated vasodilation over years leads to fixed telangiectasias and persistent erythema. This explains why heat, sun, exercise, alcohol, and spicy food are universal triggers.
Increased Demodex folliculorum density: Demodex mite counts in facial follicles are 5-10 times higher in rosacea patients than in healthy controls. Mite proteins and Bacillus oleronius released from dying mites trigger an inflammatory immune response. Anti-parasitic ivermectin reduces mite burden and is one of the most effective topical treatments.
Ultraviolet radiation: UV exposure damages dermal collagen and elastin, weakens vessel-wall support, generates reactive oxygen species, and upregulates matrix metalloproteinases. Daily broad-spectrum SPF 30+ sunscreen reduces flare frequency and slows long-term progression.
Genetic susceptibility: Twin studies estimate heritability near 46%. Genome-wide association studies identify HLA-DRB1*03:01, HLA-DQB1*02:01, and HLA-DQA1*05:01 as risk alleles. A family history of rosacea more than doubles personal risk.
Microbiome and gastrointestinal factors: Small intestinal bacterial overgrowth and Helicobacter pylori carriage are more prevalent in rosacea patients than in controls, and eradication studies show variable improvement in papulopustular disease. The cutaneous microbiome composition also differs from unaffected skin.

risk factors

Fair skin and Northern European ancestrynon-modifiable: Highest prevalence among Fitzpatrick skin types I-II of Northern and Western European descent, reaching 10% in some Scandinavian and Irish cohorts. Less commonly diagnosed in darker skin types, where erythema is harder to detect and the disease is frequently underrecognized.
Age 30-50 at onsetnon-modifiable: Onset before puberty is rare; new-onset rosacea typically develops in the third to fifth decade. Disease tends to stabilize or progress slowly with age.
Female sex (for erythema and papulopustular subtypes)non-modifiable: Women are diagnosed 2-3 times more often than men for the erythematotelangiectatic and papulopustular phenotypes, although men predominate in phymatous disease.
Family history of rosaceagenetic: Heritability estimated at 46% in twin studies. A first-degree relative with rosacea more than doubles personal risk, particularly for early-onset disease.
Cumulative ultraviolet exposureenvironmental: Long-term sun exposure damages vessel-wall support and drives matrix metalloproteinase activation, both implicated in fixed erythema and telangiectasia. Daily SPF 30+ measurably reduces flare frequency.
Frequent flushing triggers (alcohol, spicy food, hot drinks, heat, exercise, stress)modifiable

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Living with it

01Apply broad-spectrum mineral sunscreen SPF 30 or higher every morning regardless of weather — daily UV protection reduces flare frequency and slows progression to telangiectasia and fixed erythema

02Identify and avoid personal flushing triggers using a 2-3 week diary covering hot drinks, alcohol, spicy food, exercise, heat, stress, and topical products

03Use only fragrance-free, soap-free gentle cleansers and avoid abrasive scrubs, alcohol-based toners, and retinoids during active flares

04Switch facial topical corticosteroids to non-steroid anti-inflammatories under specialist guidance — long-term facial steroid use causes steroid-induced rosacea that is harder to treat

05Treat ocular surface disease early with lid hygiene and artificial tears to prevent progression to corneal involvement

06Stop smoking and limit alcohol — both contribute to vessel-wall damage and disease progression over years

recommended foods

•Mediterranean-style eating pattern with vegetables, fruits, whole grains, legumes, olive oil, and fatty fish — observational data link adherence to lower rosacea severity
•Omega-3 fatty acids from oily fish or supplements 1-2 g/day — small randomized data support reduced ocular rosacea symptoms
•Water and room-temperature non-caffeinated drinks to maintain hydration without triggering flushing
•Prebiotic and probiotic foods (yogurt, kefir, fermented vegetables) — emerging data support a gut-skin axis in rosacea
•Foods low on the personal trigger list, as identified through a structured food diary

foods to avoid

•Hot drinks (coffee, tea, soup) — heat is a more reliable trigger than caffeine; cold versions of the same drinks are often well-tolerated
•Alcohol, particularly red wine and spirits — well-documented vasodilator; beer is generally less triggering
•Spicy foods rich in capsaicin (chili peppers, hot sauces) — activate TRPV1 channels and provoke flushing within minutes
•Histamine-rich foods (aged cheese, cured meat, certain fish) in patients who report flushing after these meals
•Sugary and ultra-processed foods, which are associated with systemic inflammation

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When to seek help

why see a dermatology

Refer to a dermatologist when over-the-counter measures and a gentle skincare routine fail to control facial redness, when papules and pustules persist for more than 4-6 weeks, when telangiectasias or phymatous changes appear, when topical corticosteroids have been applied to the face and triggered a flare, and when ocular symptoms suggest ocular rosacea. Early specialist care reduces long-term progression to fixed redness, telangiectasia, and phymatous disease.

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01Rhinophyma and other phymatous changes — irreversible thickening and disfigurement of the nose, chin, ears, or eyelids that requires surgical reduction once established

02Ocular rosacea progressing to corneal neovascularization, scarring, and vision loss — affects about 50% of rosacea patients in milder forms; sight-threatening in roughly 5%

03Persistent telangiectasia and fixed erythema that does not fully fade between flares and only partially responds to topicals — addressed with vascular laser or IPL

04Steroid-induced rosacea and rebound erythema — from inappropriate use of mid- or high-potency facial topical corticosteroids, often presenting with a sudden worsening on withdrawal

05Psychological and quality-of-life impact — rosacea patients show elevated rates of anxiety, depression, and social avoidance, with measurable improvements once erythema and papulopustules are controlled

06Morbihan disease (solid persistent facial edema) — rare but disfiguring chronic lymphedema of the upper face, requiring long-term combined medical and surgical management

choosing the right hospital

01Dermatology service with vascular laser and intense pulsed light capability
02Co-management with ophthalmology for moderate-to-severe ocular rosacea
03Access to isotretinoin prescribing under iPLEDGE (US) or equivalent pregnancy-prevention programs
04Surgical capability for rhinophyma reduction (CO2 laser, electrosurgery, or dermabrasion)
05Standardized photographic documentation for monitoring treatment response over months

Living with Rosacea

Timeline

Topical therapy for papulopustular rosacea (ivermectin, azelaic acid, metronidazole, minocycline foam) typically shows meaningful improvement by week 4 and peak effect by week 12-16. Oral modified-release doxycycline reduces papule and pustule counts within 2-4 weeks and reaches maximum effect by 12 weeks. Brimonidine and oxymetazoline reduce erythema within 30 minutes to 3 hours of application, with the effect lasting 8-12 hours. Vascular laser and IPL produce visible vessel and erythema reduction within 1-2 weeks of each session; full effect builds over 3-4 sessions across 3-6 months. Rhinophyma reduction shows the cosmetic result immediately after re-epithelialization at 2-4 weeks.

Lifestyle

01Wash the face twice daily with a non-foaming, fragrance-free cleanser using lukewarm (not hot) water and pat dry without rubbing
02Apply a moisturizer formulated for sensitive or rosacea-prone skin within 3 minutes of washing to support the skin barrier
03Layer mineral sunscreen (zinc oxide or titanium dioxide) over moisturizer each morning; reapply every 2 hours during prolonged sun exposure
04Choose green-tinted color-correcting primers or foundations to camouflage erythema; avoid heavy long-wear formulations that require harsh removers
05Avoid hot showers, saunas, and prolonged exposure to direct heat sources; cool the face with a damp cloth after exercise
06Sip cold or room-temperature drinks instead of hot beverages during flare-prone periods, and use a straw if possible
07Manage stress with structured techniques (mindfulness, paced breathing, cognitive behavioral therapy) — stress is a documented trigger in 60-80% of patients
08Maintain lid hygiene with warm compresses and gentle eyelid cleansing once or twice daily if you have ocular symptoms

Daily management

01Apply prescribed topical therapy at the same time each day — ivermectin or azelaic acid at bedtime, brimonidine or oxymetazoline in the morning if used
02Use mineral sunscreen SPF 30+ every morning, even on cloudy days and indoors near windows
03Keep a brief trigger diary for the first 8-12 weeks to identify personal flushing patterns
04Carry a small cool-water mister or facial wipe for quick cooling after meals, exercise, or heat exposure
05Schedule yearly dermatology follow-up to reassess phenotype and treatment, and ophthalmology review if ocular features are present

Exercise

Regular moderate-intensity exercise is encouraged for cardiovascular and metabolic health, and rosacea is not a contraindication. Reduce flushing during workouts by exercising in cool environments, using a fan, sipping cold water, and cooling the face with a damp cloth between sets. Brief shorter sessions tolerated better than prolonged sustained heat exposure for many patients. Hot yoga and saunas reliably trigger flares and are best avoided during active disease.

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Frequently asked

What does rosacea look like?

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.

Is rosacea curable?

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.

What triggers a rosacea flare?

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.

What is the difference between rosacea and acne?

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.

Can rosacea affect the eyes?

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.

What is rhinophyma?

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.

Is ivermectin cream effective for rosacea?

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.

Does brimonidine gel help facial redness?

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.

Why is low-dose doxycycline used for rosacea?

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.

Can laser treatment help 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.

Is rosacea hereditary?

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.

Can rosacea occur in skin of color?

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%.

Should I use steroids on rosacea?

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.

What is the best sunscreen for rosacea?

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.

Can rosacea be prevented?

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.

Does diet affect rosacea?

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.

How long does rosacea treatment take to work?

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.

Is rosacea linked to mental health problems?

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.

Can children get rosacea?

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.

Is rosacea related to Helicobacter pylori?

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.

Does makeup make rosacea worse?

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.

Rosacea.Care & specialists in Malaysia

What it is

How you might notice it

How it’s diagnosed

Treatment & cost

Causes & risk factors

Living with it

When to seek help

Related conditions

Easily confused with

Often appears alongside

Types and stages

Living with Rosacea

Complementary approaches

Patient support resources

Frequently asked

Sources & references

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