Differentiating Between Rosacea and Acne

W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD candidate


US Pharmacist. 2004;29(4) 

Pharmacists regularly receive many questions from patients who are understandably confused when two medical conditions resemble each other. This is the case with rosacea and acne. Both affect the face, but they are radically different in most other respects. This month's column will explain their similarities and differences.

Rosacea is a relapsing, chronic cutaneous disorder first described over 200 years ago that affects as many as 13 million people in the United States (about one in every 20 adults).[1,2,3] Because facial reddening is often associated with alcohol ingestion, many patients with rosacea worry that they will be labeled unjustly as alcoholics.[4]

Rosacea often has a positive family history.[2] The disorder affects those of northern or eastern European descent, especially those who are blond and fair-skinned, more than other groups.[1,2,3] The prevalence in those of English and Scottish descent is abnormally high, and the prevalence in Sweden is 10% of adults.[3] Because of this geographic distribution, rosacea is referred to as the curse of the Celts.[5] It is rare in patients with darker skin, such as African-Americans and Koreans.[3,6]

The peak age of occurrence is in the fourth to seventh decades of life.[7] Women ages 20 to 60 are the predominant epidemiological group (the ratio of females to males is 3:1).[1,5] When males contract rosacea, physicians expect the condition to be more serious, developing such complications as rhinophyma (rounded tumors of the skin affecting the nose).[2] Patients with rosacea often relate a history of vascular overreactivity, manifested by frequent blushing and flushing. This may have made them the focus of teasing from a young age.

In the earliest phases of rosacea, the patient may notice gradual reddening of the skin, often mistaking these changes for acne, sunburn, or dermatitis.[1] Rosacea is often divided into four stages, according to the progressive nature of the condition.[8,9] However, the progression is not absolute. For unknown reasons, certain patients may skip a stage. Others experience ocular symptoms as the first manifestation of the condition.

Prerosacea: Most patients with rosacea have been afflicted since youth with an episodic, sudden reddening of the face that passes quickly.[3] Flares are brought about by such triggers as weather (ultraviolet radiation/sun, cold, strong winds, excessive humidity), emotional influences (eg, strong emotions, stress, anxiety), heat (saunas, hot baths, overheating, warm environments), beverages (eg, alcohol [especially red wine, beer, bourbon, gin, vodka, champagne], hot drinks [hot cider, hot chocolate, tea, coffee]), foods (liver, dairy products, hot or spicy foods, vegetables, fruits), tobacco, certain medications (injected radioopaque iodides, topical corticosteroids), or physical exertion such as exercise or jobs requiring lifting and/or loading.[1,2,7]

Stage I (Vascular Stage): Symmetric facial erythema persisting for hours or days signals the onset of Stage I rosacea.[7] The nose, cheeks, and nasolabial folds also begin to develop pronounced telangiectasia (permanent dilation of small blood vessels).[1,2] The skin develops sensitivity to previously tolerated cosmetics, cleansers, perfumes, and sunscreens. Following application of these products, the skin may start to sting or burn. Ocular manifestations may begin at this stage.

Stage II (Acneiform Stage): Stage II rosacea may develop about a year after the onset of Stage I.[5] It is marked by the permanency of the changes and by their extension. The erythema does not regress as it did in prerosacea and Stage I rosacea but becomes a permanent part of the patient's appearance. Unless treatment is obtained, it extends to the entire face, scalp, and palmar surfaces. The facial appearance can be disfiguring at this stage, with erythema assuming a butterfly pattern. This understandably causes confusion with systemic lupus erythematosus or facial seborrheic dermatitis. The face becomes edematous, especially around the eyes.

The physiological changes of Stage II accelerate with enlargement of facial pores to the point of prominence. The sebaceous follicles develop inflammatory pustules and papules; smaller hair follicles may also eventually undergo this progressive lesion development.

Stage III: Stage III is the apex of rosacea. Most patients stabilize at a less severe stage, so that Phase III is absent.[5] In Phase III, facial edema deepens. Facial lesions progress to large inflammatory nodules and furuncles. Connective tissue hypertrophies, with collagen accumulating to coarsen and thicken the facial features of the chin, cheeks, forehead, ears, and nose. The contours of the face are obscured and become irregular when compared to the precondition features.[5] The ultimate disfigurements are phymas, especially prone to affect the nose (rhinophyma) of male rosacea sufferers.[1] The eventual result is the development of a bulbous, rounded nose. Medical opinion holds that the prominent nose of actor W.C. Fields was the result of rhinophyma.

Certain facts about rosacea are well known. It is incurable and progressive and includes an inflammatory component. However, the etiology is open to question. Investigators have explored transmissible diseases such as infestation with Demodex folliculorum mites or infection with bacteria such as Helicobacter pylori.[1] Further, research on such potential etiologies as vasomotor changes, connective tissue disorders (eg, solar elastosis resulting from sun exposure-induced damage), medications, psychogenic problems, and the menopausal syndrome have yielded little concrete data.[2] A potential causal role attributed to solar elastosis explains the low incidence in people of dark skin, since darker skin is less prone to sun damage.[3]

Over 50% to 58% of those with rosacea develop ophthalmic manifestations.[1,5,10] Its development varies in relation to the dermatologic symptoms of rosacea. For those with both forms, 27% experience a simultaneous onset, whereas 53% have the dermatological manifestations first, and 20% the ocular symptoms first.[7] Ophthalmic symptoms peak in incidence during the sixth and seventh decades, and men and women are affected in equal numbers.

Ophthalmic symptoms vary, but the following are reported: inflamed eyelid margins (which may be painful), telangiectasias of the eyelids, foreign body sensation, dry eye or tearing, photophobia, eye pain, contact lens intolerance, dry mucus on the eyelids, scaliness of the eyelids, scratchiness, reduced visual acuity, stinging, burning, blurred vision, blepharitis, sties, and conjunctivitis.[1,3,5,6,7,11]

Patients should be taught to avoid triggers of rosacea. For those with disfigurement due to rhinophyma or telangiectasia, physicians may choose surgical ablation, electrocautery, or carbon dioxide laser treatment.[5,7,12] The latter allows the physician to remove hypertrophied tissue and reshape the nose. A pulsed-dye laser removes telangiectasias.

The underlying rosacea may be treated with long-term oral tetracycline (initially 1 to 1.5 g/day), minocycline (100 mg twice daily), or doxycycline (100 mg once or twice daily).[7] Patients who should not receive tetracyclines (eg, pregnant women) may benefit from erythromycin. Daily applications of metronidazole 0.75% to 1% gel, lotion, or cream are beneficial in reducing the severity of inflammatory lesions but do not affect telangiectasias.[5,13] If rosacea is severe or recurrent, isotretinoin in a dose of 0.5 to 1 mg/kg/ day is an alternative that may be of benefit.

Those with ocular rosacea may require hygiene of the lids in addition to the oral antibiotic regimen. Blepharitis may be treated successfully with baby shampoo or warm soaks.

It should be apparent that there are abundant differences in acne and rosacea, in terms of etiology, epidemiology, manifestations, prognosis, and treatment. The presence of comedones is characteristic of acne, and they are absent in rosacea.[14] However, if a patient has other acne-like lesions that occur in both disorders (papules, pustules), the pharmacist may ask him or her a series of questions. If the answers are affirmative, the problem is more likely to be rosacea. For instance:

  • Is the patient obviously of Celtic background?

  • Is the patient outside the usual age range for onset of acne (ie, puberty)?

  • Does the patient have a history of blushing or facial reddening?

  • Do the lesions occur in a symmetric distribution?

  • Can the patient list obvious triggers that cause the condition to flare?

  • Is telangiectasia present?

  • Does the patient have a persistent overall reddening of the entire face?

  • Does the face have an abnormal sensitivity to cosmetics, cleansers, perfumes, and/or sunscreens?

  • Does the patient have ophthalmic symptoms?

If there is any doubt about the patient's problem, a referral to a dermatologist is wise, especially since there are no products for the self-treatment of rosacea.


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