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Rosacea Clinical Presentation

  • Author: Agnieszka Kupiec Banasikowska, MD; Chief Editor: William D James, MD  more...
Updated: May 03, 2016


Patients are likely to have a background of facial flushing, often dating to childhood or the early teens. In adult life, flushing may be increasingly precipitated by hot drinks, heat, emotion, and other causes of rapid body temperature changes. Some patients report flushing with alcohol, which is not specific.

The symptoms are usually intermittent but can progressively lead to permanently flushed skin. The latter may be described as high color and is associated with the development of permanent telangiectasia. Additionally, a few individuals report a gritty quality of the eyes and facial edema.



The disease consists of a spectrum of symptoms and signs, with most patients failing to develop every stage of disease. Variable erythema and telangiectasia are seen over the cheeks and the forehead. Inflammatory papules and pustules may be predominantly observed over the nose, the forehead, and the cheeks. Extrafacial involvement uncommonly occurs over the neck and the upper part of the chest. Prominence of sebaceous glands may be noted, with the development of thickened and disfigured noses (rhinophyma) in extreme cases. Unlike acne, patients generally do not report greasiness of the skin; instead, they may experience drying and peeling. The absence of comedones is another helpful distinguishing feature. Ocular lymphedema may be prominent but is uncommon. The condition generally does not produce scarring.

Rhinophyma may occur as an isolated entity, without other symptoms or signs of rosacea. Rhinophyma can be disfiguring and therefore distressing for patients. Some authorities consider rhinophyma to represent a different disease process, although phymatous rosacea is considered one of the four subtypes of rosacea.[15]

Lymphedema may be marked periorbitally, and, on occasion, it is the presenting symptom.

Symptoms of ocular rosacea may be accompanied by conjunctival injection, and, rarely, chalazion and episcleritis may occur.

Rosacea fulminans (pyoderma faciale) is fortunately a rare complication and is characterized by the development of nodules and abscesses with sinus tract formation accompanied by systemic signs. Patients often have low-grade fever, elevated ESR, and possibly elevated white blood cell count.

Both seborrhea and seborrheic dermatitis/blepharitis are not uncommonly observed in patients with rosacea. The reasons for these associations are not well understood.

A rare granulomatous variant of rosacea (acne agminata/lupus miliaris disseminatus faciei) can manifest with inflammatory erythematous or flesh-colored papules distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. The lesions tend to be discrete, and surrounding erythema is not a marked feature but may be present. These patients often do not have a history of flushing. This pattern of rosacea is sometimes associated with scarring and may be resistant to conventional treatment. See the image below.

Lupus miliaris disseminatus faciei. Courtesy of Di Lupus miliaris disseminatus faciei. Courtesy of Dirk Elston, MD.


A rosacealike syndrome (including perioral dermatitis) can result from the indiscriminate use of potent corticosteroids on the face. A number of aggravating factors may be recognized. Excess wind and UV light (weathering) exposure may accelerate the disease process. See Pathophysiology for more information.

Contributor Information and Disclosures

Agnieszka Kupiec Banasikowska, MD Consulting Staff, Georgetown Dermatology, PLLC

Agnieszka Kupiec Banasikowska, MD is a member of the following medical societies: American Academy of Dermatology, European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.


Saurabh Singh, MD Staff Physician, Department of Dermatology, Georgetown University/Washington Hospital Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Andrea Leigh Zaenglein, MD Professor of Dermatology and Pediatrics, Department of Dermatology, Hershey Medical Center, Pennsylvania State University College of Medicine

Andrea Leigh Zaenglein, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology

Disclosure: Received consulting fee from Galderma for consulting; Received consulting fee from Valeant for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Anacor for consulting; Received grant/research funds from Stiefel for investigator; Received grant/research funds from Astellas for investigator; Received grant/research funds from Ranbaxy for other; Received consulting fee from Ranbaxy for consulting.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Ravi Ratnavel, MD, Mana Ogholikhan, MD, and Saurabh Singh, MD, to the development and writing of this article.

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Acne rosacea. Courtesy of Dirk Elston, MD.
Pustular rosacea. Courtesy of Dirk Elston, MD.
Histopathology of rosacea. Perifollicular chronic inflammation and vascular ectasia. Courtesy of Dirk Elston, MD.
Lupus miliaris disseminatus faciei. Courtesy of Dirk Elston, MD.
Caseating granuloma in lupus miliaris disseminatus faciei. Courtesy of Dirk Elston, MD.
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