In South Africa, rosacea is managed by dermatologists. Rosacea is a chronic inflammatory facial skin disease characterized by recurrent flushing, persistent central-face erythema, telangiectasias, and inflammatory papules and pustules, driven by an overactive innate immune response and dysregulation of the cutaneous vasculature. It affects roughly 5% of adults worldwide and about 16 million adults in the United States, with peak onset between ages 30 and 50 and a strong predilection for fair-skinned individuals of Northern European descent.
Rosacea (ICD-10: L71; L71.0 perioral dermatitis, L71.1 rhinophyma, L71.8 other rosacea, L71.9 rosacea unspecified) is a chronic, relapsing inflammatory disease of the central face driven by an exaggerated innate immune response, neurovascular dysregulation, and disordered cutaneous antimicrobial peptide processing. Cathelicidin LL-37 is overexpressed and abnormally cleaved by elevated kallikrein-5 in rosacea skin, producing the pro-inflammatory peptides that recruit neutrophils and drive vasodilation. The disease is now classified by phenotype rather than the older four-subtype system: the 2017 ROSCO global consensus and 2018 NRS update recommend identifying the diagnostic features (persistent central facial erythema and phymatous changes) and the major features (papules and pustules, telangiectasias, flushing, ocular manifestations) present in each individual patient. Severity ranges from mild transient flushing to disfiguring phymatous thickening of the nose (rhinophyma) and sight-threatening ocular rosacea with keratitis.
The key symptoms of Rosacea are: Recurrent 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., Persistent 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., Inflammatory 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., Telangiectasias — fine, threadlike, visible blood vessels on the cheeks, nasal alae, and chin, most apparent in fair-skinned patients and easily seen in good lighting., Skin 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., Phymatous skin changes — thickened, irregular, bumpy skin from sebaceous gland hyperplasia and fibrosis, most often producing a bulbous nose (rhinophyma) and seen predominantly in men., Ocular symptoms including burning, foreign-body sensation, dry gritty eyes, redness, photophobia, recurrent styes or chalazia, and crusting at the eyelid margins..
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.
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.
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.
Find specialists →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.
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.
Choose a board-certified dermatologist with experience in vascular laser and intense pulsed light therapy, as these modalities meaningfully improve outcomes for telangiectasia and persistent erythema. For ocular involvement, a dermatologist who co-manages with an ophthalmologist (or a dedicated cornea specialist) is ideal. For phymatous disease, look for a clinician experienced in CO2 laser, dermabrasion, or electrosurgical contouring — these are technique-dependent procedures, and operator experience drives the cosmetic result.
Medically reviewed by AIHealz Medical Editorial Board · May 12, 2026
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