What Is Acne Rosacea? Symptoms, Causes, And Treatment

Acne rosacea is a chronic, persistent skin disorder that causes flushing, redness, pimples or pustules, noticeably enlarged blood vessels, and skin thickening over the central area of the face. Around 16 million Americans¹ suffer from it, and both men and women are affected equally. 

Because acne and acne rosacea are both relatively common and can present with similar symptoms, it can be difficult to tell which one you have. Here’s how to differentiate between acne and acne rosacea and what treatment is available if you have the latter. 

What is acne rosacea?

Acne rosacea is a skin disorder characterized by reddening of the skin, pimple, or pustule formation, enlargement of the small blood vessels on the skin’s surface (telangiectasia), and thickening of the skin on the nose (rhinophyma).

It’s normally present in the central area of your face and can involve your forehead, eyes (also called ocular rosacea), nose, cheeks, and chin area.

Acne rosacea can be classified according to the four phases² that acne rosacea may go through:

Phase 1

Phase 1 is called the pre-rosacea phase. At this stage, the skin over the cheeks and nose becomes flushed. You may also feel that your skin in the reddened area stings or burns.

Phase 2

Phase 2 is called the vascular phase. Your skin looks red and swollen and small blood vessels may become visible just below the skin’s surface.

Phase 3

This is called the inflammatory phase. You may develop small pimples or pustules on the affected skin.

Phase 4

Phase 4 is also called the late phase. The skin of your nose becomes thickened and your nose begins to look bulbous. Not everyone who has acne rosacea may go on to develop the signs and symptoms of this phase of acne rosacea. 

Classification of acne rosacea according to signs and symptoms

This classification system divides acne rosacea into four subtypes¹ based on the predominant signs and symptoms. 

Erythematotelangiectatic rosacea (ETR) 

ETR is characterized by redness of the skin over your nose, cheeks, forehead, and/or chin; flushing; and visible blood vessels just beneath your skin’s surface. Your skin may also feel thickened, dry, or flaky.

Papulopustular rosacea 

This type of acne rosacea is associated with the formation of pimples and pustules over the affected skin. You may be more likely to get this type if you are a middle-aged woman. 

Rhinophyma

This acne rosacea is characterized by thickening of the skin on your nose. Pores may appear enlarged and broken blood vessels may be visible over the thickened skin. 

This type is more likely to affect men and it may develop in combination with other types of acne rosacea.

Ocular rosacea

Ocular rosacea affects your eyelids. It often accompanies another subtype of acne rosacea. You may get inflammation, redness, and swelling of the eyelids as well as redness and irritability of the white of your eye. 

It may feel as though you have grit or dirt in your eyes and your eyes may be more sensitive to light. Cysts may form on your eyelids.

How is acne rosacea different from acne?

It can be difficult to tell whether you have acne or acne rosacea because some of the signs and symptoms are similar. It is important to differentiate between the two conditions because treatment is different. 

The following table³ describes some of the major differences between acne and acne rosacea.

What causes acne rosacea?

While the exact cause of acne rosacea is still unknown, many factors contribute to the condition. The following may play a role in its development.

Genetics

A genetic risk¹ factor for the development of acne rosacea exists. If you have a strong family history of acne rosacea, you are more likely to develop it yourself. 

Acne rosacea is also more common in people of Irish and Scandinavian descent².

Dysregulated immunity

Some research suggest that part of the pathophysiology of acne rosacea may be related to a dysregulation of the immune system¹. More research needs to be done to define the exact role of the immune system in causing this skin condition. 

Dysregulated inflammatory processes

Research has indicated that some symptoms of acne rosacea may be caused by a dysregulated inflammatory process¹. Products of microbes on the skin can be recognized by the body’s immune system and can activate cells to release proinflammatory cytokines, chemokines, proteases, and pro-angiogenic factors. 

These mediators are associated with increased skin redness, inflammation, and blood vessel formation. 

What can worsen acne rosacea?

Although the exact mechanisms that cause acne rosacea still need to be determined, some triggers exacerbate this condition.

The following are some of the common and recognized triggers that can worsen your acne rosacea:

• Sun exposure

• Wind exposure

• Cold exposure

• Alcohol consumption

• Certain skin products (especially those containing formaldehyde)

• Emotional stress

• Exercise

• Hot or spicy foods

• Hot baths, steam rooms, or saunas

• Hot drinks

• Medications such as amiodarone, cortisone, and excessive vitamin B6 and B12

How can you treat acne rosacea?

No cure has been developed for acne rosacea, so treatment is aimed at controlling and managing the symptoms.

Here are some guidelines you can follow. 

General skin care

A good skincare routine can go a long way to ameliorating the symptoms of acne rosacea.

It’s paramount that you learn to identify and avoid triggers that worsen your condition. This includes learning stress management techniques; using sunscreen with a sun protection factor above 30, suitable for sensitive skin, when outdoors; and choosing gentle, non-irritating skin cleansers and moisturizers.

Flushing and redness

If your predominant symptoms are flushing and redness, your doctor may prescribe brimonidine gel or oxymetazoline cream to use on the affected areas.

Visible blood vessels

If you’re struggling with broken and visible blood vessels due to your acne rosacea, your doctor may suggest that you undergo laser therapy or electrocautery of the blood vessels to shrink them. 

Your doctor may also suggest injecting aethoxysklerol directly into the blood vessels to reduce them.

Pimples and pustules

Various topical treatments are available for reducing the pimples and pustules associated with acne rosacea. Your doctor may prescribe an antibiotic (usually metronidazole, clindamycin, or erythromycin) cream or gel that you can apply to the affected area. 

Sometimes ivermectin 1% cream or azelaic acid may be prescribed to reduce pimples and pustules. 

In severe cases or in cases of ocular rosacea, you may have to take an oral antibiotic to clear pustules. Commonly prescribed oral antibiotics for acne rosacea include doxycycline, tetracycline, minocycline, or erythromycin.

On occasion, topical or systemic isotretinoin may be prescribed; however, because of the side effects, this is rare and usually saved for cases where all other treatments have been ineffective.

Rhinophyma

Rhinophyma is difficult to treat and is unlikely to clear completely with medication alone. Laser treatment or dermatosurgery may be necessary to remove excess tissue. 

Your doctor may also try to treat you with oral isotretinoin as it has been shown to reduce inflammation and sebaceous gland proliferation. 

Ocular rosacea

If you have extensive involvement of your eyes, you will need to involve an ophthalmologist in your management. You may be prescribed artificial tear drops or ointments to reduce stinging and burning. 

If your eye symptoms are severe, you may require cyclosporine eye drops or oral therapy with tetracycline antibiotics. 

When to see a doctor for your acne rosacea

If your acne rosacea is not controlled by simple avoidance of triggers and a good skincare routine, you should see your doctor or dermatologist so they can appropriately treat your symptoms. 

As it is a complex disorder with various causes and manifestations, it is best to allow your doctor to prescribe a personalized treatment plan for you that best targets your specific condition.

Another reason it’s important to see your doctor is because acne rosacea can have a significant negative psychological impact¹ if left untreated. People with acne rosacea may have impaired self-esteem, problems socializing, and changes in the way they think, feel, and cope. 

If you think you have acne rosacea, it’s better to get it treated before it negatively affects your mental health.

The lowdown

Acne rosacea is a chronic skin disorder characterized by redness of the face, pimples, or pustules, the presence of visible blood vessels, and thickening of the skin. It’s usually classified according to the predominant symptoms. There may be eye involvement with redness and swelling of the eyelids as well as stinging and redness of the eye itself.  

Acne rosacea is a complex condition and the causes are not fully understood. It’s likely caused by a combination of genetics and dysregulation of the immune and inflammatory processes. 

Several well-recognized triggers exacerbate acne rosacea. These include heat, cold, sun, wind, alcohol, spicy foods, emotional stress, and certain cosmetics. 

Management of acne rosacea is focused on avoiding triggers and managing symptoms. If simple avoidance of triggers doesn’t control your acne rosacea, it’s best to see a dermatologist. Your doctor will identify your predominant symptoms and personalize a treatment plan for you that targets your specific situation.