Rosacea

In short: Rosacea is a chronic, relapsing skin disease with persistent redness of the central face, flushing, visible small blood vessels and, in some people, acne-like lesions. Current classification looks at the features that dominate in each person rather than at subtypes. Managing triggers, gentle skincare and sun protection are fundamental; different treatments are supported by evidence for redness, papules and pustules, and visible vessels. Eye symptoms need separate assessment. Rosacea can be controlled, but a permanent cure vary.

What is rosacea?

Rosacea is a common chronic inflammatory skin disease in adults that affects the cheeks, nose, forehead and chin. According to the 2017 update by the US National Rosacea Society expert committee, persistent centrofacial redness in a characteristic pattern that may periodically intensify, or phymatous changes (most often thickening of the nose, rhinophyma), is sufficient for diagnosis. Flushing, papules and pustules, telangiectasia and eye signs are major features; burning, stinging, oedema and dryness are minor features (Gallo et al., 2018).

The old "erythematotelangiectatic", "papulopustular", "phymatous" and "ocular" subtypes have given way to a phenotype approach, because one person can have several features at once. The international ROSCO panel likewise recommends diagnosing and treating feature by feature (Schaller et al., 2017).

Causes and mechanism

Rosacea is not contagious and is not caused by poor hygiene. It is currently understood as a multifactorial disease in which several processes work together (Gallo et al., 2018):

• Over-reactive innate immunity: Dysregulation of certain defence peptides that amplify inflammation in the skin.
• Neurovascular dysregulation: Exaggerated responses of nerve endings and blood vessels to stimuli such as heat, spice or alcohol; flushing and burning or stinging are attributed to this.
• Microorganisms: The density of Demodex mites in the skin is often increased in rosacea and may contribute to inflammation.
• Genetic predisposition and sun: A family history is common; UV light is both a trigger and a factor that increases vascular damage.

Commonly reported triggers are sun, heat, sudden temperature changes, hot drinks, spicy food, alcohol, exercise, stress and irritating skincare products. Triggers vary between people; a trigger diary kept for a few weeks helps to reveal an individual pattern.

How is it assessed? Differential diagnosis and referral

The diagnosis is clinical; there is no single blood test that proves rosacea. The physician records the distribution of redness, flushing episodes, papules and pustules, visible vessels, skin thickening and eye symptoms separately; photographic follow-up makes it easier to monitor response.

Conditions that can resemble rosacea include:

• Acne vulgaris: Blackheads and whiteheads (comedones) suggest acne; they are usually absent in rosacea.
• Seborrhoeic dermatitis and perioral dermatitis: Scaling, involvement of the sides of the nose and around the mouth.
• Steroid-induced dermatitis: Prolonged use of cortisone creams on the face can cause a rosacea-like picture and worsens rosacea.
• Contact dermatitis: Itching and onset linked to a product.
• Lupus erythematosus and other connective tissue diseases: Further tests are needed if there is sun sensitivity, joint pain, fatigue or mouth ulcers.

When should you see another specialist? Burning or gritty eyes, eye redness, swollen eyelid margins or light sensitivity need an ophthalmologist's assessment; the ROSCO panel recommends ophthalmology referral for all but the mildest eye features (Schaller et al., 2017). Eye pain or reduced vision should be assessed the same day. If flushing comes with diarrhoea, wheezing, palpitations or feeling faint, causes other than rosacea should be investigated. Uncertain diagnoses, moderate-to-severe papulopustular disease that may need oral treatment, and nasal thickening should be assessed by a dermatologist. A single lesion that does not heal, bleeds or grows should not be assumed to be rosacea; a biopsy should be done if necessary.

Management options by level of evidence

An updated systematic review that assessed 152 randomised trials (20,944 participants) with the GRADE method classified treatments by phenotype (van Zuuren et al., 2019). The evidence levels below are mainly summarised from that review.

1. General care and trigger management — all phenotypes

Soap-free, fragrance-free, gentle cleansers; moisturisers that support the skin barrier; broad-spectrum sunscreen suitable for sensitive skin; and avoiding personal triggers. The ROSCO panel regards these general skincare measures as the foundation of all treatment (Schaller et al., 2017). Evidence: mostly expert consensus. Limitation: on their own they are usually not enough to control moderate-to-severe features.

2. Persistent redness: topical vasoconstrictors

There is high-certainty evidence for brimonidine gel and moderate-certainty evidence for oxymetazoline cream (van Zuuren et al., 2019). In two pivotal randomised trials of brimonidine, the effect began 30 minutes after the first application and lasted through the day (Fowler J et al., 2013). Limitations: the effect is temporary and lasts only while the product is used; it does not treat papules, pustules or visible vessels. Although no rebound was seen in the trials, later case reports described marked rebound redness in some patients as the effect wore off (Ilkovitch & Pomerantz, 2014). Regulatory note: in the US, a specific brimonidine gel and a specific oxymetazoline cream are FDA-approved for persistent facial erythema of rosacea in adults; licensing and availability in Türkiye vary by product.

3. Papules and pustules: prescription topical and oral treatments

There is high-certainty evidence for topical azelaic acid and topical ivermectin, and moderate-certainty evidence for topical metronidazole (van Zuuren et al., 2019). In a randomised trial of 962 patients, ivermectin cream reduced inflammatory lesion counts more than metronidazole cream at week 16 (83.0% versus 73.7%) (Taieb et al., 2015). In the US, a specific ivermectin cream is FDA-approved for the inflammatory lesions of rosacea.

For more extensive or resistant disease, oral treatment is considered: moderate-to-high-certainty evidence has been reported for sub-antimicrobial-dose, modified-release doxycycline and for low-dose isotretinoin (van Zuuren et al., 2019). These are prescription decisions and are usually managed together with a dermatologist. Doxycycline can cause sun sensitivity and is not used in pregnancy; isotretinoin must never be used in pregnancy and requires strict pregnancy prevention and monitoring. The choice of medicine, dose and duration are set by the physician. Limitation: relapse is common when treatment stops; a maintenance plan is needed.

4. Visible vessels and persistent redness: vascular lasers and IPL

The evidence for laser and IPL treatment of redness and especially telangiectasia is of low-to-moderate certainty (van Zuuren et al., 2019). In a randomised, single-blind, split-face trial of 29 patients, three monthly sessions of non-purpuric pulsed dye laser and IPL produced significant and similar improvements in redness, telangiectasia and patient-reported symptoms (Neuhaus et al., 2009). Other vascular lasers such as Nd:YAG and KTP are also used. Limitations: studies are small; several sessions are needed; vessels can re-form over time; the effect on flushing episodes is more limited; temporary redness, swelling and bruising, and rarely crusting, burns and pigment change, can occur. Because bruising risk can be affected, tell your physician about all medicines and supplements, including blood thinners. Never stop a prescribed medicine without asking the doctor who prescribed it.

5. Eye and nose involvement

In ocular rosacea, eyelid hygiene and artificial tears are the basic measures; other medicines are planned by the ophthalmologist (Schaller et al., 2017). Nasal thickening (phyma) improves only partly with medicines; advanced cases may need surgery or ablative laser, which is assessed within the relevant specialty.

Risks in darker skin types

Because redness is less visible in darker skin, rosacea can be missed or mistaken for acne; burning or stinging, dryness and papules become more important for diagnosis. With vascular lasers and IPL, light is absorbed not only by haemoglobin in blood but also by melanin in the epidermis, so Fitzpatrick IV–VI skin has a higher risk of burns, blisters, post-inflammatory hyperpigmentation and lightening. Procedures are therefore not performed on tanned skin; longer wavelengths, cautious settings and a small test area first are preferred. Whatever the skin type, irritating peels, harsh retinoid routines and applying cortisone creams to the face can make rosacea flare.

Realistic expectations and recurrence

Rosacea is a chronic disease with a fluctuating course; the goal is long-term control, not cure. With topical and oral treatment, meaningful improvement in papules and pustules usually starts within weeks; persistent redness and visible vessels, on the other hand, often need procedures and may not disappear completely. Periodic maintenance sessions may be needed to keep the gains after laser or IPL. According to the ROSCO panel, maintenance treatment is planned according to the modality used and the patient's preferences (Schaller et al., 2017). Flares can occur while triggers persist; this does not mean treatment has failed.

When is a procedure not appropriate?

• When the diagnosis is unclear (lupus, contact dermatitis or steroid-induced dermatitis have not been ruled out).
• During a severe papulopustular flare or active infection; medical control comes first.
• When eye involvement is untreated; ophthalmology assessment comes first.
• When the skin is tanned or sun protection after the procedure will not be possible.
• With photosensitising medicines or recent isotretinoin use, until assessed with the physician.
• During pregnancy, elective procedures are generally postponed.
• When expectations are unrealistic (such as a permanent result in one session).

How this clinic approaches rosacea

Dr. Hamza Gemici is a medical aesthetics physician, not a dermatologist. The initial assessment identifies which features the rosacea presents with and whether ophthalmology, dermatology or another specialist assessment is needed. The plan usually starts with gentle skincare, sun protection and trigger management; vascular laser or IPL for persistent redness and visible vessels is considered only after the skin type and any active inflammation have been assessed, and with cautious settings. When oral treatment is needed, the clinic works together with a dermatologist. Response is monitored with photographs; no promises are made about results, number of sessions or price.

Sources and references

This content is based on the peer-reviewed publications in this page's reference list; it is not a personal diagnosis or treatment instruction.

Status: Last physician review: 23 September 2026 · Medical editor: Dr. Hamza Gemici