Rosacea. Is It the Same as Acne?

Rosacea: redness and dilated capillaries of the central face

Rosacea, also known as Acne Rosacea or “adult acne,” is a skin disease that appears very similar to common teenage acne but is actually  a separate disease entity with a different cause.  For example, it usually affects adults of middle age, around 40’s and 50’s.  In contrast to common acne, blackheads and white heads are usually not seen.  There is a genetic tendency for Rosacea, so that you are more likely to acquire it if one or both of your parents had it.  There is also a tendency for certain ethnic groups to develop Rosacea, notably Celtic-English-Welsh and Northern European populations and Americans with this ancestry .

Rosacea, as one might expect from the name, begins as a flushing or blushing tendency which usually affects the face, neck, and upper chest associated with emotion or stressful situations.  This is considered to be the first and mildest stage of Rosacea and suggests that the disease is based on a sensitivity of the blood vessels to either emotional or thermal stimuli.

After the flushing stage, which may result in permanent dilation of small blood vessels on the face called capillaries, the next stages of Rosacea include the development of red papules and pustules, usually localized to the central face including the nose and cheeks. Sometimes there is also swelling of the face including the eyelids associated with flares of Rosacea.  There are also forms of Rosacea where the pimples and pustules predominate either on the skin around the mouth or the skin around the eyes which would be called perioral or periocular dermatitis, respectively.  The fourth and most serious stage of Rosacea is usually seen only in men and involves the nose with an enlargement of the oil (sebaceous) glands in the skin.  This condition is known as Rhinophyma and describes an enlarged, lumpy-bumpy, and misshapen nose. The patient may also have the inflammatory papules and pustules and dilated capillaries called telangiectasias on the nose or on the facial skin around the nose.  The Rhinophyma has been associated with alcoholism because of the alleged behavior of the famous comedian WC Fields, but


certainly not all patients who have Rosacea or Rhinophyma are alcoholics.  Another celebrity who has Rosacea is former President Bill Clinton.

We know that there are many triggers for the development or cause of Rosacea.  The most common ones are sun exposure, hot environment, and vigorous exercise which all have the same effect of increasing the dilation of the blood vessels on the skin leading to redness but also the development of inflammatory papules and pustules.  Other less common but important aggravating factors for Rosacea include emotional stress, drinking alcohol, especially red wine, and eating spicy foods.  Drinking extremely hot or cold liquids completes the list of triggers of Rosacea. Contrary to popular belief, caffeinated drinks are not the problem but rather the temperature of the drink itself. Therefore, more tepid or lukewarm water would help prevent the Rosacea flare up for people who like to drink tea and coffee.

Skin affected by Rosacea tends to be very sensitive, and certain skin care products may not react well with it.  This might include any of your everyday cosmetics and cleansers. For this reason, the treatment of Rosacea  differs from the treatment for common acne in some respects:  the treatments which cause drying and exfoliation used in acne patients, who generally have oily skin, often cannot be tolerated by the already reddened and sensitive skin of

Ocular Rosacea

Rosacea patients. A small subset of patients with Rosacea of the skin will also develop a form of Rosacea that affects the eyes called Ocular Rosacea, especially the membranes inside the eyelid and the outside white membrane of the eye globe.  The most severe form of Rosacea may even affect the cornea. If a patient with Rosacea of the skin complains of dry eyes or a gritty sensation in their eyes, he or she should consult an eye doctor as well as the dermatologist.

In most cases, the diagnosis of Rosacea can be made by the dermatologist after taking a history of aggravating factors and an examination of the skin.  Occasionally, because of sun sensitivity, other diagnoses may have to be entertained such as Lupus or Sarcoidosis of the skin.  Therefore,  additional blood testing or skin biopsies may be performed in such cases.


The treatment of Rosacea should always include informing the patient about all of the aggravating factors that may be relevant to their lifestyle and asking them to reduce or eliminate those triggers.  In addition, the two most effective medications for Rosacea are oral Tetracycline (including Minocycline and Doxycycline) and topical Metronidazole cream or gel.  The former can be used in low doses or for a short period of time followed by the use of the latter for chronic maintenance.  The patient should be informed that Rosacea is a chronic disease, and if they discontinue the medications which are helping them, then the condition is likely to recur.  An alternative to Metronidazole cream is Azelaic acid gel. A cleanser containing 5 percent precipitated Sulfur and 10 percent Sulfacetamide is also very helpful for Rosacea patients when used 1-2 times daily.  Unfortunately, these medications do not really help an established Rhinophyma , and those patients may require some form of surgical or laser treatment of the nose to reduce the enlargement and smooth out the irregularities.  The dilated capillary spots called telangiectasias can be removed by certain types of lasers that are specific for blood vessels.

It has long been suspected that a mite called Demodex which normally lives in hair follicles

Demodex mites in a skin scraping

and feeds on sebum is associated with Rosacea.  Demodex mites are found in greater numbers in patients with Rosacea and other skin diseases resembling Rosacea.  It was recently suggested by scientists that bacteria in the gut of the mites are released when the mites die, aggravating the inflammatory response.  In some cases, reducing the mite population with sulfur-containing creams or the miticide permethrin yields temporary improvement.