Rosacea: Symptoms, Causes & Treatment Options

What Is Rosacea and What Causes It?

Rosacea is a chronic inflammatory skin condition causing facial redness, visible blood vessels, bumps, and pustules primarily on the nose and cheeks. The exact cause is unknown but involves inflammation, vascular dysfunction, and immune system dysregulation. Genetics, Demodex mites, and environmental triggers play contributing roles.

Rosacea is one of the most common skin conditions affecting adults, estimated to impact approximately 5% of the global population. The condition predominantly affects the central face – particularly the nose, cheeks, chin, and forehead – creating persistent redness that can significantly impact a person's quality of life and self-esteem. Unlike temporary flushing that everyone experiences occasionally, rosacea involves chronic inflammation that requires ongoing management.

The precise cause of rosacea remains incompletely understood, but research has identified several contributing factors that work together to produce the characteristic symptoms. At its core, rosacea involves dysfunction in the skin's immune system and blood vessels, leading to excessive inflammation and dilation of facial blood vessels. This creates the persistent redness and visible blood vessels (telangiectasia) that characterize the condition.

Scientific studies have shown that people with rosacea have elevated levels of certain antimicrobial peptides, particularly cathelicidin, in their skin. These peptides trigger inflammatory responses and cause blood vessel dilation. Additionally, the skin's innate immune system appears to be hyperactive, responding to stimuli that would not typically cause inflammation in unaffected individuals.

Genetic and Environmental Factors

There is a clear genetic component to rosacea, with the condition frequently running in families. Studies of twins have confirmed this hereditary link, and research has identified several genetic variations associated with increased rosacea risk. People of Northern European and Celtic ancestry have particularly high rates of rosacea, though the condition occurs in all ethnicities and skin types.

Environmental factors work alongside genetic predisposition to trigger and worsen rosacea. These include ultraviolet radiation from sun exposure, temperature extremes, certain foods and beverages, and emotional stress. The interplay between genetic susceptibility and environmental triggers explains why rosacea symptoms fluctuate over time, with periods of remission followed by flare-ups.

The Role of Demodex Mites

Demodex folliculorum mites are microscopic organisms that naturally inhabit human hair follicles and sebaceous glands. Research has consistently found that people with rosacea have significantly higher numbers of these mites compared to unaffected individuals. While Demodex mites are not the sole cause of rosacea, their overpopulation appears to contribute to the inflammatory response characteristic of the condition.

The effectiveness of ivermectin, an anti-parasitic medication, in treating rosacea provides further evidence of the mites' involvement. By reducing Demodex populations, ivermectin helps control the inflammatory cascade that produces rosacea symptoms. However, the relationship between mites and rosacea is complex, as not everyone with high Demodex counts develops rosacea, and other factors clearly play important roles.

What Are the Symptoms of Rosacea?

Rosacea symptoms include persistent facial redness (erythema), visible blood vessels (telangiectasia), acne-like bumps (papules and pustules), skin thickening, burning or stinging sensations, and eye irritation. Symptoms typically affect the nose, cheeks, chin, and forehead, often worsening with triggers like sun, heat, or stress.

Rosacea presents with a constellation of symptoms that can vary significantly between individuals. Some people experience primarily redness and flushing, while others develop prominent bumps and pustules. Understanding the full spectrum of possible symptoms helps with recognition and appropriate treatment. The condition almost exclusively affects the central face, though some people may notice symptoms extending to the ears, neck, or chest.

The hallmark symptom is persistent facial redness, medically termed erythema. Unlike normal flushing that quickly resolves, rosacea-related redness tends to persist for extended periods and may never fully clear. This redness is most prominent on the nose and cheeks but can extend to the chin, forehead, and between the eyebrows. On darker skin tones, the redness may appear as a dusky violet hue rather than the classic pinkish-red seen on lighter skin.

Many people with rosacea also develop visible blood vessels on their face, known as telangiectasia. These appear as thin, red or purple lines, typically on the cheeks and nose. While telangiectasia don't cause physical discomfort, they contribute to the overall reddened appearance and can be cosmetically concerning. Unlike the background redness, visible blood vessels don't fluctuate with triggers and require specific treatments like laser therapy to improve.

Bumps, Pustules, and Skin Texture Changes

A significant proportion of rosacea patients develop acne-like bumps called papules, as well as pustules containing pus. These lesions can be easily confused with acne, but there are important differences. Rosacea-related bumps occur on a background of diffuse redness, don't include blackheads or whiteheads (comedones), and typically affect older adults rather than teenagers. The pustules tend to be smaller than acne lesions and don't usually leave scars.

Some individuals experience a burning, stinging, or itching sensation on their facial skin, often described as feeling like the skin is too sensitive. This symptom can be particularly troublesome as it may be triggered by skincare products, weather conditions, or even water. The skin may also feel dry, rough, or swollen during flare-ups.

In severe cases, particularly in men, rosacea can cause skin thickening and enlargement of the nose, a condition called rhinophyma. The nose becomes bulbous and bumpy due to overgrowth of sebaceous glands and connective tissue. While this was once considered an inevitable progression, early treatment can prevent rhinophyma from developing, and established cases can be improved with surgical or laser procedures.

Factors That Worsen Symptoms

One of the most frustrating aspects of rosacea is that symptoms can suddenly worsen in response to various triggers. These triggers cause blood vessels to dilate, increasing redness and flushing. Common triggers include sun exposure, hot or cold weather, wind, hot baths or showers, hot beverages, spicy foods, alcohol (particularly red wine), stress, and certain skincare products.

The specific triggers vary considerably between individuals. What causes a significant flare-up in one person may have no effect on another. For this reason, dermatologists recommend keeping a detailed trigger diary to identify personal patterns. Recording activities, foods, weather conditions, and symptom severity helps pinpoint which factors are most problematic for each individual.

• Sun and UV exposure – the most universally reported trigger
• Heat – hot weather, hot baths, saunas, heated rooms
• Cold and wind – particularly affects people in harsher climates
• Alcohol – especially red wine and spirits
• Hot beverages – coffee, tea, hot chocolate
• Spicy foods – capsaicin-containing foods are common triggers
• Emotional stress – anxiety, embarrassment, anger
• Strenuous exercise – particularly in hot environments
• Certain skincare products – alcohol-based, fragranced, or harsh products
• Some medications – vasodilators, some blood pressure medications

Can Rosacea Affect the Eyes?

Yes, ocular rosacea affects approximately 50% of rosacea patients, causing dry, irritated, bloodshot eyes, burning sensations, light sensitivity, blurred vision, and swollen eyelids. Eye symptoms can occur before, during, or independently of skin symptoms. Treatment includes artificial tears, eyelid hygiene, and sometimes oral antibiotics.

Ocular rosacea is an often-overlooked manifestation of the condition that can significantly impact quality of life and, in severe cases, threaten vision. Approximately half of all people with rosacea experience some degree of eye involvement, though the severity ranges from mild irritation to serious complications requiring specialized care. Importantly, some people develop eye symptoms before any skin signs appear, making diagnosis challenging.

The symptoms of ocular rosacea include a sensation of dryness, grittiness, or foreign body in the eyes, as though something is constantly irritating them. Eyes may appear bloodshot and watery, despite feeling dry. Many people experience increased sensitivity to light (photophobia), and some report blurred or fluctuating vision. The eyelids may become swollen, red, and crusty, particularly along the lash line.

The underlying mechanism involves inflammation of the meibomian glands, small oil glands in the eyelids that produce the lipid layer of the tear film. When these glands become blocked or dysfunctional, tears evaporate too quickly, leading to dry eye symptoms despite seemingly adequate tear production. This condition, called meibomian gland dysfunction, is closely associated with rosacea and contributes significantly to ocular symptoms.

Managing Ocular Rosacea

Treatment of ocular rosacea begins with good eyelid hygiene. This involves warm compresses applied to closed eyelids for 5-10 minutes to soften blockages in the meibomian glands, followed by gentle lid massage to express the blocked material. Regular lid scrubs with diluted baby shampoo or specialized lid cleansing products help remove debris and reduce bacterial colonization.

Artificial tears provide symptomatic relief for dryness and irritation. Preservative-free formulations are preferred, as preservatives can further irritate sensitive eyes. In more severe cases, ophthalmologists may prescribe anti-inflammatory eye drops or oral antibiotics, particularly doxycycline, which has both antimicrobial and anti-inflammatory properties. Omega-3 fatty acid supplements may also provide benefit by improving the quality of the tear film.

When Should You See a Doctor for Rosacea?

See a doctor if you notice persistent facial redness, visible blood vessels, acne-like bumps on the face, or eye irritation. Early treatment prevents progression and scarring. Seek care promptly if symptoms significantly affect your quality of life, don't respond to gentle skincare, or if you experience eye problems.

While rosacea is not a dangerous condition, seeking professional evaluation is important for several reasons. Early treatment can prevent progression to more severe forms of the disease, including permanent skin thickening (rhinophyma) and vision-threatening eye complications. Additionally, other conditions can mimic rosacea, so proper diagnosis ensures appropriate treatment.

You should consult a healthcare provider if you experience persistent redness on your face that doesn't resolve, especially if it's accompanied by bumps, pustules, or visible blood vessels. Other reasons to seek care include facial skin that burns or stings regularly, symptoms that don't improve with gentle skincare modifications, or any eye symptoms such as irritation, dryness, or redness.

A dermatologist is the specialist best equipped to diagnose and treat rosacea. Diagnosis is primarily clinical, based on the pattern and appearance of symptoms. There is no specific laboratory test for rosacea. The dermatologist will examine your skin, ask about symptom history and potential triggers, and rule out other conditions that can look similar, such as lupus, seborrheic dermatitis, or allergic contact dermatitis.

How Can You Relieve Rosacea Symptoms at Home?

Relieve rosacea symptoms by using gentle, fragrance-free skincare products, washing with lukewarm water, applying SPF 30-50 sunscreen daily, using non-greasy moisturizers, avoiding known triggers, and never using cortisone cream on your face. Identify personal triggers through a symptom diary and protect skin from temperature extremes.

Self-care measures form the foundation of rosacea management and can significantly reduce symptom severity and flare-up frequency. Even with prescription treatments, these lifestyle modifications remain essential for optimal control. The goal is to minimize irritation, protect sensitive skin, and avoid the triggers that cause symptoms to worsen.

Skincare for rosacea requires a gentle approach that avoids anything potentially irritating. Wash your face with lukewarm water – never hot or cold – using a mild, fragrance-free cleanser. Avoid harsh soaps, exfoliating scrubs, astringents, and alcohol-based toners, as these strip the skin barrier and worsen inflammation. Pat the face dry gently rather than rubbing, and wait a few minutes before applying any products to allow the skin to settle.

Moisturizing is important for rosacea-prone skin, which is often dry and sensitive. Choose a non-greasy, fragrance-free moisturizer formulated for sensitive skin. Some products designed specifically for rosacea contain calming ingredients like niacinamide or green tea extract. Apply moisturizer while skin is still slightly damp to enhance hydration, and use it consistently, even during remission periods.

Sun Protection Is Essential

Sun exposure is the most commonly reported rosacea trigger, affecting the majority of patients. Daily sun protection is therefore crucial, regardless of weather conditions. Use a broad-spectrum sunscreen with SPF 30-50 every day, even when it's cloudy or you're staying mostly indoors. Mineral sunscreens containing zinc oxide or titanium dioxide are often better tolerated by sensitive rosacea-prone skin compared to chemical sunscreens.

In addition to sunscreen, physical sun protection helps minimize exposure. Wear a wide-brimmed hat when outdoors, seek shade during peak UV hours (typically 10 AM to 4 PM), and consider protective clothing. Some people find that the heat from sun exposure is as problematic as the UV rays themselves, so staying cool is equally important.

What to Avoid

Certain products and practices should be strictly avoided when managing rosacea. Topical corticosteroids (cortisone cream) can temporarily improve symptoms but ultimately worsen the condition with continued use, leading to steroid-induced rosacea that is more difficult to treat. Never apply hydrocortisone or other steroid creams to your face unless specifically directed by a dermatologist for a different condition.

• Cortisone cream – can worsen rosacea with continued use
• Strong soaps and scrubs – too harsh for sensitive rosacea skin
• Alcohol-based products – cause dryness and irritation
• Fragranced products – common irritants for sensitive skin
• Menthol, camphor, or eucalyptus – often trigger burning sensations
• Oil-based facial products – may clog pores and worsen pustules
• Very hot water – dilates blood vessels and worsens flushing

How Is Rosacea Treated?

Rosacea treatment includes topical medications (metronidazole, ivermectin, azelaic acid), oral antibiotics (doxycycline) for moderate-severe cases, brimonidine gel for temporary redness reduction, and laser or IPL therapy for persistent blood vessels. Treatment typically lasts 3+ months, and maintenance therapy may be needed to prevent recurrence.

Medical treatment of rosacea aims to reduce inflammation, control visible symptoms, and prevent progression. The approach is tailored to the specific type and severity of rosacea, with different treatments targeting different aspects of the condition. Most patients require a combination of lifestyle modifications and medication to achieve optimal control. Improvement takes time – typically at least 3 months of consistent treatment before significant changes are visible.

For many patients, particularly those with papulopustular (acne-like) rosacea, topical medications form the cornerstone of treatment. These are applied directly to the affected facial skin and work locally to reduce inflammation and the organisms that contribute to symptoms. The most commonly prescribed topical treatments include metronidazole, ivermectin, and azelaic acid, each with slightly different mechanisms of action.

Topical Medications

Metronidazole gel or cream is one of the oldest and most well-established treatments for rosacea. It has anti-inflammatory properties and is effective for reducing both redness and the papules and pustules of rosacea. Available in various concentrations and formulations, it is typically applied once or twice daily and is well-tolerated by most patients. Improvement may take several weeks to become apparent.

Ivermectin cream is a newer option that has shown excellent efficacy in clinical trials. Originally developed as an anti-parasitic agent, it effectively reduces Demodex mite populations while also having anti-inflammatory effects. Studies have shown ivermectin to be particularly effective for the bumps and pustules of rosacea, sometimes outperforming metronidazole. It is typically applied once daily.

Azelaic acid is another effective topical treatment with anti-inflammatory and antimicrobial properties. It helps reduce redness and bumps while also improving skin texture. Azelaic acid is available in various strengths, with higher concentrations available by prescription. Some people experience temporary stinging or burning when first using this product, which typically diminishes with continued use.

Brimonidine gel represents a different approach – rather than treating the underlying inflammation, it temporarily reduces redness by constricting blood vessels. The effect lasts approximately 12 hours after application. While brimonidine provides cosmetically pleasing results, it doesn't treat the underlying condition and some patients experience rebound redness when the effect wears off. It's best used occasionally for important events rather than as daily treatment.

Oral Medications

For moderate to severe rosacea, or when topical treatments alone are insufficient, oral medications may be necessary. The tetracycline family of antibiotics, particularly doxycycline, is most commonly used. At the sub-antimicrobial doses typically prescribed for rosacea, doxycycline works primarily as an anti-inflammatory rather than an antibiotic, which reduces concerns about antibiotic resistance.

A course of oral antibiotics typically lasts several months. During this time, topical treatments are continued, and the plan is usually to maintain improvement with topicals alone after completing the oral course. Some patients require intermittent oral treatment during flare-ups, while others can maintain control with topical medications only.

For the most severe cases of rosacea, particularly those with significant bumps that don't respond to other treatments, isotretinoin may be considered. This powerful medication, also used for severe acne, requires careful monitoring due to potential side effects, including severe birth defects if taken during pregnancy. It is reserved for cases that don't respond to other treatments.

Laser and Light Therapies

While topical and oral medications effectively treat inflammation and pustules, they have limited impact on established visible blood vessels (telangiectasia). Laser and intense pulsed light (IPL) therapies directly target these vessels, causing them to collapse and gradually fade. Multiple treatment sessions are typically needed, spaced several weeks apart.

Laser treatments can also help reduce background redness and improve overall skin appearance. They're generally well-tolerated, with temporary redness and swelling being the most common side effects. Results are often long-lasting, though maintenance treatments may eventually be needed as new vessels develop over time. These procedures are performed by dermatologists or specialized aesthetic practitioners and are typically not covered by insurance.

For rhinophyma (thickening of the nose), more aggressive treatments may be necessary. Surgical reshaping, laser ablation, or electrosurgery can remove excess tissue and restore a more normal nasal appearance. These procedures are typically performed under local anesthesia and, while effective, require a healing period during which the nose appears raw before gradually recovering.

How Do You Live With Rosacea Long-Term?

Living with rosacea involves ongoing trigger avoidance, consistent skincare routines, regular sunscreen use, and maintenance treatment as needed. Many people achieve long periods of remission. The psychological impact is real – seek support if rosacea affects your self-esteem. Regular dermatology check-ups help optimize management.

Rosacea is a lifelong condition, but with proper management, most people can achieve excellent control and enjoy prolonged periods with minimal symptoms. Success requires viewing treatment as an ongoing process rather than a one-time fix. This means maintaining good skincare habits and trigger avoidance even during remission, as the underlying tendency toward inflammation remains.

Many patients find that after achieving control with prescription treatments, they can reduce to maintenance therapy – using medications less frequently or switching to gentler options. The key is working closely with your dermatologist to find the minimum effective treatment that keeps symptoms at bay. Some people eventually manage their rosacea with lifestyle modifications and over-the-counter products alone, while others need ongoing prescription medications.

The psychological impact of rosacea should not be underestimated. Visible facial redness and blemishes can significantly affect self-confidence and social interactions. Studies have shown that people with rosacea have higher rates of anxiety and depression compared to the general population. If you find that rosacea is affecting your mental health or quality of life, discuss this with your healthcare provider. Effective treatment of the skin condition often improves psychological wellbeing, and additional support may be beneficial.

Connecting with others who have rosacea can provide valuable emotional support and practical tips. Patient organizations and online communities offer resources, forums for sharing experiences, and information about the latest research and treatments. Knowing that you're not alone in dealing with this condition can be reassuring.

What Is the Difference Between Rosacea and Acne?

Rosacea and acne differ in several key ways: rosacea typically starts after age 30 while acne begins in adolescence; rosacea features persistent central facial redness and no blackheads, while acne includes comedones and can occur anywhere; rosacea treatment differs significantly, with corticosteroids worsening rosacea but sometimes used for acne.

Rosacea and acne are frequently confused because both can cause facial bumps and pustules. However, they are distinct conditions with different underlying causes, typical patient demographics, and treatment approaches. Correctly distinguishing between them is essential because using the wrong treatments can worsen symptoms.

Acne vulgaris typically begins during puberty, driven by hormonal changes that increase sebum production and affect skin cell turnover. It commonly includes comedones – blackheads and whiteheads formed by plugged pores – along with inflammatory lesions. Acne can occur on the face, chest, back, and shoulders, and often improves during adulthood, though some people continue to experience breakouts throughout life.

Rosacea, by contrast, typically develops in adults over 30, with peak onset between 30-50 years of age. It almost exclusively affects the central face and notably lacks comedones. The persistent background redness and visible blood vessels characteristic of rosacea are not features of acne. Rosacea tends to persist indefinitely if untreated, while acne often resolves naturally with age.

The treatments for these conditions differ significantly. While some medications, like azelaic acid, are used for both, others are specific to each condition. Importantly, topical corticosteroids, which may be used short-term for certain acne types, should be avoided in rosacea as they worsen the condition. Retinoids, a mainstay of acne treatment, must be used cautiously in rosacea due to potential irritation.