Diagnostic Considerations

The differential diagnosis largely depends on the pattern of rosacea. Erythematotelangiectatic rosacea (ETR) can resemble seborrheic dermatitis, lupus erythematosus, and other photodermatoses. Carcinoid syndrome and mitral valve incompetence are overlooked causes of erythema and telangiectasia. Acneiform rosacea may be simulated by acne, bromoderma and iododerma, perioral dermatitis, and pustular folliculitis. Acne agminata can be indistinguishable from lupus vulgaris and cutaneous sarcoidosis.

Differential Diagnoses

Workup

Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors. J Am Acad Dermatol. 2015 May. 72 (5):749-58; quiz 759-60. [QxMD MEDLINE Link].
Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part II. Topical and systemic therapies in the treatment of rosacea. J Am Acad Dermatol. 2015 May. 72 (5):761-70; quiz 771-2. [QxMD MEDLINE Link].
Gallo RL, Granstein RD, Kang S, Mannis M, Steinhoff M, Tan J, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018 Jan. 78 (1):148-155. [QxMD MEDLINE Link].
Greaves MW, Burova E. Flushing: causes, investigation and clinical consequences. J Eur Acad Dermatol Venereol. 1997. 8:91-100.
Higgins E, du Vivier A. Alcohol intake and other skin disorders. Clin Dermatol. 1999 Jul-Aug. 17(4):437-41. [QxMD MEDLINE Link].
Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24. 352(8):793-803. [QxMD MEDLINE Link].
Bamford JT, Gessert CE, Renier CM. Measurement of the severity of rosacea. J Am Acad Dermatol. 2004 Nov. 51(5):697-703. [QxMD MEDLINE Link].
Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. 2004 Sep. 51(3):327-41; quiz 342-4. [QxMD MEDLINE Link].
Dahl MV. Rosacea subtypes: a treatment algorithm. Cutis. 2004 Sep. 74(3 Suppl):21-7, 32-4. [QxMD MEDLINE Link].
Laquer V, Hoang V, Nguyen A, Kelly KM. Angiogenesis in cutaneous disease: part II. J Am Acad Dermatol. 2009 Dec. 61(6):945-58; quiz 959-60. [QxMD MEDLINE Link].
Bonnar E, Eustace P, Powell FC. The Demodex mite population in rosacea. J Am Acad Dermatol. 1993 Mar. 28(3):443-8. [QxMD MEDLINE Link].
Tisma VS, Basta-Juzbasic A, Jaganjac M, et al. Oxidative stress and ferritin expression in the skin of patients with rosacea. J Am Acad Dermatol. 2009 Feb. 60(2):270-6. [QxMD MEDLINE Link].
Jones DA. Rosacea, reactive oxygen species, and azelaic acid. J Clin Aesthetic Derm. Jan 2009. 2(1):26-30.
Cuevas P, Arrazola JM. Therapeutic response of rosacea to dobesilate. Eur J Med Res. 2005 Oct 18. 10(10):454-6. [QxMD MEDLINE Link].
Schauber J, Gallo RL. Antimicrobial peptides and the skin immune defense system. J Allergy Clin Immunol. 2008 Aug. 122(2):261-6. [QxMD MEDLINE Link].
Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000Res. 2018. 7:[QxMD MEDLINE Link].
Aloi F, Tomasini C, Soro E, Pippione M. The clinicopathologic spectrum of rhinophyma. J Am Acad Dermatol. 2000 Mar. 42(3):468-72. [QxMD MEDLINE Link].
Lonne-Rahm S, Nordlind K, Edstrom DW, Ros AM, Berg M. Laser treatment of rosacea: a pathoetiological study. Arch Dermatol. 2004 Nov. 140(11):1345-9. [QxMD MEDLINE Link].
[Guideline] Hampton PJ, Berth-Jones J, Duarte Williamson CE, Hay R, Leslie TA, Porter I, et al. British Association of Dermatologists guidelines for the management of people with rosacea 2021. Br J Dermatol. 2021 May 15. [QxMD MEDLINE Link]. [Full Text].
van Zuuren EJ, Kramer S, Carter B, Graber MA, Fedorowicz Z. Interventions for rosacea. Cochrane Database Syst Rev. 2011 Mar 16. 3:CD003262. [QxMD MEDLINE Link].
Ceilley RI. Advances in the topical treatment of acne and rosacea. J Drugs Dermatol. 2004 Sep-Oct. 3(5 Suppl):S12-22. [QxMD MEDLINE Link].
Ertl GA, Levine N, Kligman AM. A comparison of the efficacy of topical tretinoin and low-dose oral isotretinoin in rosacea. Arch Dermatol. 1994 Mar. 130(3):319-24. [QxMD MEDLINE Link].
Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Dermatol Venereol. 2005 May. 19(3):273-85. [QxMD MEDLINE Link].
Fowler J Jr, Jackson M, Moore A, Jarratt M, Jones T, Meadows K, et al. Efficacy and Safety of Once-Daily Topical Brimonidine Tartrate Gel 0.5% for the Treatment of Moderate to Severe Facial Erythema of Rosacea: Results of Two Randomized, Double-blind, and Vehicle-Controlled Pivotal Studies. J Drugs Dermatol. 2013 Jun 1. 12(6):650-6. [QxMD MEDLINE Link].
Rhofade (oxymetazoline topical) [package insert]. Irvine, Calif: Allergan. January 2017. Available at [Full Text].
Stein L, Kircik L, Fowler J, et al. Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol. 2014 Mar. 13(3):316-23. [QxMD MEDLINE Link].
Allen KJ, Davis CL, Billings SD, Mousdicas N. Recalcitrant papulopustular rosacea in an immunocompetent patient responding to combination therapy with oral ivermectin and topical permethrin. Cutis. 2007 Aug. 80(2):149-51. [QxMD MEDLINE Link].
Forstinger C, Kittler H, Binder M. Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream. J Am Acad Dermatol. 1999 Nov. 41(5 Pt 1):775-7. [QxMD MEDLINE Link].
Karincaoglu Y, Bayram N, Aycan O, Esrefoglu M. The clinical importance of demodex folliculorum presenting with nonspecific facial signs and symptoms. J Dermatol. 2004 Aug. 31(8):618-26. [QxMD MEDLINE Link].
Brown M, Hernández-Martín A, Clement A, Colmenero I, Torrelo A. Severe demodexfolliculorum-associated oculocutaneous rosacea in a girl successfully treated with ivermectin. JAMA Dermatol. 2014 Jan. 150(1):61-3. [QxMD MEDLINE Link].
Galderma. Randomized, double-blind, parallel-group, vehicle-controlled, dose-finding study investigating the pharmacodynamics and safety of three concentrations of CD07805/47 topical gel (0.07%, 0.18%, and 0.50%), applied in subjects with moderate to severe erythematotelangiectatic rosacea. ClinicalTrials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT00989014. Accessed: August 21, 2014.
Galderma. A phase 3 randomized, double blind, 12 week vehicle controlled, parallel group study assessing the efficacy and safety of CD5024 1 % cream versus vehicle cream in subjects with papulopustular rosacea, followed by a 40 week investigator blinded extension comparing the long term safety of CD5024 1% cream versus azelaic Acid 15 % gel. ClinicalTials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT01493687. Accessed: August 21, 2014.
Galderma. Efficacy and safety of CD5024 1% cream versus metronidazole 0.75% cream in subjects with papulopustular rosacea over 16 weeks treatment, followed by a 36-week extension period (ATTRACT). ClinicalTrials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT01493947. Accessed: August 21, 2014.
Baldwin HE. Systemic therapy for rosacea. Skin Therapy Lett. 2007 Mar. 12(2):1-5, 9. [QxMD MEDLINE Link].

Media Gallery

Histopathology of rosacea. Perifollicular chronic inflammation and vascular ectasia. Courtesy of Dirk Elston, MD.
Mild papules and erythema. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2367).
Moderate papules and early pustules. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2369).
Severe erythema, papules, and pustules. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2371).

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Author

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.

Coauthor(s)

Danielle Bolton, BS Medical Assistant, Georgetown Dermatology

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

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

Disclosure: Nothing to disclose.

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.

Acknowledgements

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.

Rosacea Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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