> ## Documentation Index > Fetch the complete documentation index at: https://docs.hi-doctor.ai/llms.txt > Use this file to discover all available pages before exploring further. # Rosacea — phenotypes, triggers and treatment > Rosacea explained by phenotype rather than subtype: what drives the flushing and papules, how a doctor assesses it online, and which topicals are considered. Rosacea is a chronic inflammatory condition of the central face — cheeks, nose, chin and forehead — that runs in flares. It is frequently mistaken for acne, and treated as acne it usually gets worse. A registered doctor reviews the questionnaire and photographs, works out which presentation is in front of them, and decides whether a topical treatment fits. ## What rosacea is The visible features are persistent central facial redness, episodes of flushing, visible small blood vessels, and inflammatory papules and pustules. Unlike acne, there are no comedones: no blackheads, no whiteheads. That single absence is often what separates the two on a photograph. Underneath, three things appear to run together. The innate immune system is dysregulated, producing high levels of the antimicrobial peptide cathelicidin and the enzyme that processes it. Neurovascular control of the facial skin is abnormal, which is why heat, alcohol and emotion produce flushing out of proportion to the stimulus. And the density of *Demodex folliculorum* mites in the follicles is higher than in unaffected skin, which is the rationale for the anti-parasitic treatments used in the papulopustular form. ## Phenotypes, not subtypes The older four-subtype scheme has been superseded. The global ROSacea COnsensus panel recommends describing what is actually present, because most people carry features from more than one former subtype at once and the mix changes over time. Background redness that does not fully settle between flares. A diagnostic feature in its own right. It responds least well to treatment, and setting that expectation early prevents a lot of disappointment. Inflammatory lesions on the central face without comedones. This is the phenotype topical prescription treatment addresses best, and the one most likely to be helped by an online consultation. Visible dilated vessels across the cheeks and nose. Topical medicines do not remove these — vascular laser or intense pulsed light is what addresses them, and that is an in-person procedure. Thickening of the skin, most often on the nose, with enlarged pores and an irregular contour. Established phymatous disease is a surgical or laser problem, not a cream problem. **Ocular rosacea.** Grittiness, burning, dryness, a foreign-body sensation, recurrent styes or lid margin inflammation can accompany skin rosacea, and the eye disease can appear before any facial change. Eye symptoms are a red-flag answer in the questionnaire because they need an eye assessment, not a face cream. Any change in vision is an urgent, same-day, in-person matter. ## How a doctor assesses it online The rosacea questionnaire is twelve steps and **the photograph step is mandatory** — the case cannot be submitted without an image. That is deliberate. Distinguishing rosacea from acne, from seborrhoeic dermatitis and from lupus depends on seeing the distribution and the lesion type, and no description substitutes for it. The doctor is grading four things from the photograph and the answers: how much fixed erythema there is, how many inflammatory lesions and where, whether telangiectasia or phymatous change is present, and whether anything in the picture argues against rosacea altogether. Seven answers in the questionnaire are hard stops, most of them clustered around eye involvement and red-flag features. Rosacea has no cure. Treatment controls the inflammatory component and reduces flare frequency. A doctor who tells you the redness will disappear entirely is overselling; a treatment that halves the number of papules and takes the sting out of a flare is doing its job. ## What a doctor may prescribe Anti-inflammatory and anticomedonal, and one of the better-studied topicals in papulopustular rosacea. It can sting on first application, which is common and usually settles. A compounded 30 g cream combining metronidazole 0.75%, niacinamide 4%, micronised azelaic acid 10% and allantoin 0.5% — aimed at the inflammatory and barrier components together. A compounded 30 g gel combining ivermectin 1%, metronidazole 0.75% and niacinamide 2% — built around the two agents with the strongest track record against inflammatory rosacea lesions. The compounded formulations are prepared by a pharmacy against the prescription. Read more about the individual actives: [metronidazole](/library/medicines/metronidazole-topical), [ivermectin](/library/medicines/ivermectin-topical) and [niacinamide](/library/medicines/niacinamide). No oral medicine is prescribed for rosacea here. Oral tetracyclines, whether at antibiotic or sub-antimicrobial dose, and oral isotretinoin for phymatous disease, all sit outside what this service offers. So do brimonidine and oxymetazoline, the topical vasoconstrictors used for background redness. ## Triggers Trigger avoidance is not a treatment, but for most people it is the difference between a flare every week and a flare every few months. Triggers are individual; the commonly reported ones are heat, sunlight, hot drinks, alcohol (red wine especially), spicy food, extremes of temperature, strenuous exercise, emotional stress, and skincare containing alcohol, menthol, camphor or fragrance. A written trigger diary kept for a few weeks is more useful than a general list, because it identifies which of these apply to you rather than which apply to somebody. ## Realistic timelines Stinging and transient redness on application are common, particularly with azelaic acid. Applying to fully dry skin and starting at a reduced frequency is how that is managed. Inflammatory papules and pustules typically begin to reduce. Background erythema and visible vessels are usually unchanged at this point, which is expected. The fair point of assessment for the inflammatory component. Continuing beyond twelve weeks with no change in papule count is a reason to review rather than persist. Rosacea relapses when treatment stops. Maintenance therapy at a reduced frequency is the usual approach, and daily sun protection is the single most consistently useful non-prescription measure. ## What does not work * **Treating it as acne.** Benzoyl peroxide and topical retinoids, the mainstays of acne care, are frequently irritating in rosacea and can drive a flare. * **Scrubs, toners and hot water.** Barrier damage is the shortest route to a flare. * **Waiting for the redness to clear on a papule treatment.** Fixed erythema and telangiectasia respond to light-based procedures, not to anti-inflammatory creams. * **Fragranced skincare.** Fragrance and botanical extracts are among the most common avoidable triggers in reactive facial skin. ## When to see someone in person Seek face-to-face assessment for any eye symptom that is not settling, any change in vision (urgently), thickening or nodularity of the nose, a facial rash with systemic features such as fever, joint pain or a butterfly distribution sparing the nasolabial folds, or a rash that is not responding after a full course of topical treatment. A rash that appeared abruptly after a new medicine is also a face-to-face question. ## Common questions The usual discriminator is comedones. Acne produces blackheads and whiteheads; rosacea does not. Rosacea also centres on the mid-face and brings flushing and background redness that acne does not. The distinction is exactly what the doctor uses the photograph for. Because the differential diagnosis is wider and the consequences of getting it wrong are larger. Seborrhoeic dermatitis, perioral dermatitis, contact dermatitis and lupus can all present as a red central face, and they are not treated the same way. Not usually. Topical anti-inflammatory treatment reduces papules and pustules well and background erythema only modestly. Fixed redness and visible vessels are addressed with vascular laser or intense pulsed light, which are in-person procedures. Demodex density is higher in rosacea-affected skin, and treatments that reduce it help the papulopustular form. That is not the same as the mites being the cause. Everyone carries Demodex; the difference appears to be in how the skin's immune system responds to them. Mineral-based cover applied over fully absorbed treatment is generally tolerated, and green-toned colour correctors are widely used for erythema. Products containing alcohol, fragrance or menthol are the ones worth avoiding. It varies. Some presentations are stable for decades, some progress, and phymatous change in particular tends to develop slowly over years. Consistent treatment and trigger management are what alter that course, not waiting. ## Related reading * [Metronidazole](/library/medicines/metronidazole-topical) · [ivermectin](/library/medicines/ivermectin-topical) · [azelaic acid](/library/medicines/azelaic-acid) · [niacinamide](/library/medicines/niacinamide) * [Side effects of dermatology topicals](/library/guides/side-effects-dermatology) * [How to apply a prescription topical](/library/guides/how-to-apply-topicals) * [Taking your dermatology photos](/library/guides/dermatology-photos) * [Acne](/library/conditions/acne) — the condition rosacea is most often mistaken for * [Safety and eligibility](/essentials/safety) · [how a consultation works](/essentials/how-it-works) ## Start a consultation Answer the rosacea questionnaire and upload the required photograph. A registered doctor reviews the case and decides whether a topical treatment is appropriate — declining is a normal outcome. See [what it costs](/essentials/pricing) and [how the review works](/essentials/how-it-works). This page is reference information, not medical advice and not a prescription. Whether a medicine is appropriate for you is decided by a registered doctor after reviewing your consultation.