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For further information, see CMDT Part 6-28: Rosacea

Key Features

Essentials of Diagnosis

  • A chronic facial disorder

  • Neurovascular component: erythema and telangiectasis and a tendency to flush easily

  • Acneiform component: papules and pustules may also be present

  • Glandular component: sebaceous hyperplasia and fibrosis of affected areas (eg, rhinophyma)

General Considerations

  • Pathogenesis is not known

  • Topical corticosteroids applied to the face can induce rosacea-like conditions

  • Rosacea is usually a lifelong affliction, so maintenance therapy is required

Clinical Findings

Symptoms and Signs

  • Patients frequently report flushing or exacerbation of the rosacea by heat, hot drinks, spicy food, sunlight, exercise, alcohol, emotions, and menopausal flushing

  • The cheeks, nose, chin, and ears—at times the entire face—may have a rosy hue

  • No comedones

  • In its mildest form, erythema and telangiectasias are seen on the cheeks

  • Inflammatory papules are prominent, and there may be pustules

  • Associated seborrhea may be found

  • It is not uncommon for patients to have associated ophthalmic disease, including blepharitis, keratitis, and chalazion

Differential Diagnosis

  • Acne vulgaris

  • Seborrheic dermatitis

  • Perioral dermatitis

  • Systemic lupus erythematosus

  • Carcinoid

  • Dermatomyositis

  • Topical corticosteroids can change trivial dermatoses of the face into perioral dermatitis and steroid rosacea


  • Clinical



  • See Table 6–2

  • Medications are most effective directed at the inflammatory papules and pustules and the erythema that surrounds them


  • Metronidazole, 0.75% gel applied twice daily or 1% cream once daily, is the topical treatment of choice

  • If metronidazole is not tolerated, topical clindamycin (solution, gel, or lotion) 1% used twice daily is effective; response is noted in 4–8 weeks

  • Sulfur-sodium sulfacetamide-containing topicals are helpful in patients only partially responsive to topical antibiotics

  • Benzoyl peroxide, as in acne vulgaris, may be helpful in reducing the pustular component

  • Topical retinoids can be carefully added for maintenance

  • Topical bromonidine tartrate gel 0.5% can temporarily reduce the flush/redness of rosacea patients


  • Oral tetracyclines should be used when topical therapy is inadequate

  • Minocycline or doxycycline, 50–100 mg once or twice daily orally, may also be effective

  • Metronidazole or amoxicillin, 250–500 mg twice orally daily

    • May be used in refractory cases

    • Side effects are few, although metronidazole may produce a disulfiram-like effect when the patient ingests alcohol and it may cause neuropathy with long-term use

  • Rifaximin, 400 mg orally three times daily (for 10 days), is an alternative for refractory cases

  • Isotretinoin may succeed where other measures fail; a dosage of 0.5–1.0 mg/kg/day orally for 12–28 weeks is recommended

Therapeutic Procedures

  • Educate patients to avoid exacerbating factors (especially alcohol)


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