A 33-year-old woman entered my office in tears. Her face and nose were red as a beet and she had red pimples on her chin, cheeks, and forehead. “Not only do I look horrible, but when people look at me, I’m sure they think I’m an alcoholic! I’ve always had perfectly clear skin; I didn’t even have a pimple when I was a teenager,” she said.

“I can’t cover it with makeup and I hate to leave the house!” She said that her problem started about a year before when she first noticed a tendency to flush and blush more readily than usual. In time, her face became persistently red, and then she started getting pimples and visible blood vessels on her cheeks, forehead, chin, and nose.

It was an easy diagnosis for me to make: She had all the signs and symptoms of rosacea! Rosacea (pronounced rose-ay-shah) is a common skin disorder that is frequently mistaken for acne. In fact, as recently as 20 years ago, rosacea was referred to as acne rosacea.

I give you details about what rosacea is, how to treat it, and how to cover it up while you’re waiting for it to clear up. I also help you figure out what conditions aren’t rosacea even though they may look like it.

Rosacea 101

It’s easy to understand why rosacea was called “acne rosacea” for so many years, because rosacea and acne look so much alike. They both have red papules and pustules and, of course, appear on the face.

Rosacea occurs at a time in adults’ lives when they don’t expect to have to deal with pimples and the flushing and blushing reactions of the condition. For adults in the prime years of their careers, the psychological effects of rosacea can pose problems. (It seems that rosacea can have a similar psychological impact on people’s lives.)

However, just as with teenage acne, it’s important as an adult to continually remind yourself of an important fact: Your rosacea is treatable and your emotional well-being will improve following successful treatment. Later in here, I show you the many methods that are available to treat your rosacea.

Describing those affected

Anyone can develop rosacea. However, people from certain ethnic backgrounds are most likely to get it. If you have fair skin and have ancestors hailing from Great Britain (including Ireland, Scotland, and Wales), Germany, and Scandinavia, or certain areas of Eastern Europe, you have the greatest tendency to have rosacea. The condition is rare in Hispanic, African, and African-American populations along with other dark-skinned people.

Women are affected with rosacea two to three times more often than men. And if you’re between 30 and 50 years of age, have fair skin, blonde hair, blue eyes, and have the proper hereditary pedigree, you’re in the higher-risk group to develop rosacea.

Heredity plays the major role in whether you develop rosacea. If you flush or blush easily and have a family member who has been diagnosed with rosacea, you’re at greater risk for getting it.

Reporting the signs and symptoms

Rosacea may first appear as erythema (redness of the skin) on your cheeks and forehead that later spreads to your nose and chin. These areas comprise the central one-third of the face. Very often, people who have rosacea describe how they’re inclined to flush and blush easily.

This condition occurs whenever a blood vessel dilates (widens). When the blood vessel dilates, it then contains a greater volume of blood, which produces redness. When a person develops persistent erythema (abnormal redness), the condition usually doesn’t go away on its own.

As rosacea progresses, three main lesions arise against the background of erythema — two of which are very similar and generally indistinguishable in appearance from the acne lesions. However, they look different when examined by a microscope. The three main rosacea lesions are:

• Telangiectasias: Many people refer to telangiectasias (tell-anjek- tay-shas) as broken blood vessels, but there’s nothing broken about them. They’re actually enlarged blood vessels that look like thin red lines on the face, especially on the cheeks.

Sometimes the tiny vessels look like the shape of a spider (spider telangiectasias). Telangiectasias can be more than “tiny” in some folks.

• Papules: These tiny red pimples appear as small, firm, red bumps. Papules are the primary inflammatory lesion in rosacea.

• Pustules: These are mature papules that contain visible pus. Pustules are generally found in the company of papules. Papules are also inflammatory lesions, but they’re not as common as papules in rosacea.

The papules and pustules tend to come and go, but the telangiectasias stay put. Rosacea lesions tend to be spread symmetrically on the face, but on occasion, the lesions may occur on only one side of a person’s face.

Rosacea is typically a longer lasting condition than acne vulgaris (teenage acne) and adult-onset acne because it can go on and on through one’s adult life. Rosacea also requires somewhat different therapy than acne.

The good news is that rosacea is generally easier to treat than are most cases of acne, and I detail the many effective treatments that are available later in here.

Addressing additional signs and symptoms

Lesions of rosacea are most typically seen on the central third of the face — the forehead, the lower half of the nose, the cheeks, and chin. However, additional rosacea-related problems involving the eyes and nose may occur.

Ocular rosacea

Like acne, for the most part, rosacea is a cosmetic problem; however, some people who have rosacea may also have eye involvement, known as ocular rosacea. Ocular rosacea is most frequently noted when rosacea of the skin is also present; however, eye symptoms may precede the skin manifestations in up to 20 percent of people.

The eyes of patients with ocular rosacea may:

• Feel irritated and gritty as if there is something in their eyes
• Tend to look bloodshot
• Become overly sensitive to light

If you have these symptoms, you should consult your doctor or an ophthalmologist (a medical doctor that specializes in eye disorders) to establish the correct diagnosis and to get appropriate therapy.

Sometimes, the use of prescription eye drops will help improve ocular rosacea, and sometimes, oral antibiotics are prescribed to treat it. Many people who have ocular rosacea mistakenly think they have pollen or other airborne allergies.

Rhinophyma

Rhinophyma (rye-no-fie-mah) can be an unsightly manifestation of rosacea. Rhinophyma occurs when oil glands enlarge and a bulbous, red nose develops. This condition usually occurs in men over 40. It consists of knobby bumps that tend, over time, to get larger and swollen.

It is quite uncommon and is rarely seen in women. In jolly old England, this type of nose was referred to as “drinker’s nose” or “grog blossoms.” The usual treatments that are described here to treat rosacea don’t work very well on rhinophyma, but it can be successfully treated with surgery and special lasers that I tell you about in the “Going the surgical route for rhinophyma,” section.

Comparing the appearance to acne

Despite their similarities, rosacea is different from acne vulgaris and adult-onset acne in many ways. Rosacea:

• Lacks the mature comedones (blackheads and whiteheads) seen in acne vulgaris. Lesions are generally small, pimple-like bumps and telangiectasias (tiny, visible blood vessels in the surface of the skin); in contrast, acne lesions are varied and may include comedones, as well as small or large nodules and cysts, but no telangiectasias.

• Doesn’t seem to have a hormonal connection. The microcomedo, the primary lesion of acne vulgaris arises in response to hormonal (androgenic) stimulation, whereas rosacea seems to arise “out of the blue” — or should I say “red” — and doesn’t appear to have any relationship to androgenic hormones. Also, lesions don’t appear to fluctuate with a woman’s menstrual cycle.

• Usually makes its debut well after the acne-prone years. Acne vulgaris is especially common during adolescence.

• Occurs primarily on the central face. Adult-onset acne tends to occur on the lower part of the face and acne vulgaris generally has a much wider distribution such as on the chest and back.

• Is associated with facial redness and flushing. Blushing and flushing reactions aren’t associated with acne vulgaris or adult-onset acne.

• Is generally non-scarring, unless acne vulgaris is also present. Fortunately, the inflammatory lesions of rosacea tend to heal without forming the types of scars that can result from inflammatory acne lesions.

Determining whether it’s just rosy cheeks

If you believe the ads, we have 15 million and counting rosacea sufferers in the United States alone! You may fit the profile — fair-skinned, Celtic ancestry, and all that. You may show varying degrees of facial redness and blushing and flushing, but that doesn’t mean you have rosacea. So don’t be in a rush to volunteer as a poster child for rosacea.

Rosacea is a condition that is regularly overdiagnosed by healthcare providers. What’s more, many people come into my office after having diagnosed themselves as having rosacea. Some of these selfdiagnosers reach their conclusion after seeing ask-your-doctor television advertisements that introduce them to the condition.

In many instances, rosacea can be hard to distinguish from weathered, sun-damaged skin that’s seen in many fair-skinned farmers, gardeners, sailors, or other folks that worked or spent long periods of their lives outdoors.

Such long-term sun exposure can lead to persistent red faces and tiny broken blood vessels that sometimes look quite a bit like rosacea. Then, some people are blushers who don’t have rosacea at all.

In fact, if you carefully evaluate the location of redness on some of their faces, you discover that the redness seems to occur in different places than where it’s commonly seen in rosacea. Their symptoms tend to appear on the sides of the cheeks, the front and side of the neck, and the ears, as opposed to the central area of the face.

Moreover, a red face can be due to a variety of skin disorders such as photo dermatitis (an abnormal reaction to light exposure) and seborrheic dermatitis (a red, scaly rash that can be on the face), and sometimes it can be associated with certain underlying diseases such as systemic lupus erythematosus, as well as rarer disorders (such as carcinoid syndrome and systemic mastocytosis).

The so-called hot flashes of menopause, medication reactions, and allergy to cosmetics can also be confused with rosacea. And sometimes, what has been called “rosacea” on your face — is simply rosy cheeks! You’re just stuck with a healthy looking facial glow. Traditionally, folks like you didn’t receive a medical diagnosis but were described as having a “peaches and cream” complexion.

If rosy cheeks and telangiectasias are your only complaint, you shouldn’t be labeled with the diagnosis of rosacea until other signs or symptoms develop such as those I describe here. Now, if you’ve decided by now that you don’t think you have rosacea, please tell about this blog to a friend or family member who has acne or rosacea.

So, what causes rosacea?

Although the precise cause of rosacea remains a mystery, researchers believe that heredity plays a role in the process. As to the physical causes of the condition, there are many theories, but none of them have been proven. The various theories about the actual causes include:

• Blood vessels: Some investigators believe that there is a natural chemical in the body that has a potent effect on blood vessels and that causes them to swell in people who have rosacea. The result, these scientists believe, is the flushing and redness characteristic of rosacea.

• Bacteria: A bacterium called Helicobacter pylori, which causes intestinal peptic ulcers, was thought to be a cause of rosacea, but that theory has apparently been put to rest. P. acnes, our little bacterial friend that’s been associated with acne, is also believed by some investigators to play a role in rosacea.

• Mites: A mite called Demodex folliculorum, which lives in hair follicles, is thought by some scientists to be the cause of rosacea. The belief is that the mites clog oil glands, which leads to the inflammation seen in rosacea. These mites reside in almost everyone’s skin and, like P. acnes, may just be innocent bystanders.

Examining Irritants and Rosacea-Prone Skin

If you have rosacea, you may also have skin that is unusually vulnerable to chemical and physical irritants. Skin-care should be kept simple so as to avoid the triggers that can worsen the condition.

Handling your skin with care!

Avoid overzealous washing of your face. Be gentle with your skin. You should wash your face with lukewarm water and a mild, nonirritating soap, by using your fingertips to apply the soap gently. Check out my complete instructions for proper face washing in Your Skin.

Cosmetics can irritate rosacea; so don’t use skin-care products with harsh ingredients. Before using any skin-care products, carefully read the labels. Go for the fragrance-free products that are gentle and have the fewest ingredients. The following ingredients seem to cause the most irritation:

• Alcohol
• Witch hazel
• Menthol
• Peppermint
• Eucalyptus oil
• Clove oil
• Salicylic acid

In choosing cosmetics, also keep the following points in mind:

• Select cosmetics that are water soluble, so that they require no strong solvents to remove them.
• Avoid astringents and exfoliating agents.
• Look for water-based moisturizers.
• Look for makeup and moisturizers with a sunscreen already added.
• Opt for powdered blushes because, unlike creams, they’re unlikely to contain emulsifiers that can irritate rosacea.
• Discard your old, spoiled cosmetic products.

As for sunscreens, try to stick with the ones that contain zinc oxide or titanium dioxide, the barrier sunscreens, especially if other sunscreens irritate or worsen your rosacea (see the section “Making it worse — fact and fiction,” where I describe them).

For men who have difficulty shaving around the bumps of rosacea, try using an electric razor rather than a blade to reduce abrasion. Also avoid using after-shave lotions, especially those containing alcohol. I describe shaving bumps and shaving techniques later.

Making it worse — fact and fiction

In the following sections, I investigate some things that may make rosacea worse. I start off with the stuff that most dermatologists tend to agree about and then I discuss more questionable items.

Avoiding the triggers

If you do have rosacea, you can take steps to avoid making your condition worse. Here are common triggers you should avoid:

• Sun exposure: You should avoid excessive sun exposure, particularly during the midday. Steer clear of UV tanning lamps and beds. Sun protection is extremely important for anyone with rosacea. Sunscreens and sun blockers should be used regularly and liberally to protect the face.

Use sunscreens with an SPF factor of 15 or higher. If chemical sunscreens cause stinging, irritation, or worsening of your rosacea, switch to physical barrier sun blocks, which contain titanium dioxide or zinc oxide.

• Medications: The use of topical corticosteroids (anti-inflammatory medications used for many skin conditions) can cause a condition similar to rosacea known as steroid-induced rosacea. I discuss this condition in “Being aware of topical steroid-induced ‘rosacea’”.

• Excess alcohol ingestion: First of all, let’s get one thing straight: Rosacea is not caused by drinking excessive amounts of alcohol! That’s a serious misconception that’s been around for ages and should be put to rest! Traditionally, most doctors believed that many, if not most, cases of rosacea were caused by excessive alcohol intake.

It’s an unfortunate belief that still persists among the general public. Hold on, not so fast! That doesn’t mean that you should go dashing to your liquor cabinet for that single malt or to your fridge to reach for that six-pack!

Though drinking habits have nothing to do with causing rosacea, it is accepted that the blushing and flushing of rosacea may flare up when some people drink alcohol — especially red wine. It’s questionable, however, that the drinking of alcoholic beverages causes a long-term worsening of the condition.

Questioning the doubtful candidates

There is no convincing evidence as to whether the following factors — I call them my “doubtful candidates” — have any longterm harmful effects on rosacea. But, they do increase the redness of the face temporarily:

• Spicy foods, smoking, and caffeine: These items have been known to cause facial reddening in some people who have rosacea.

• Cooking over a hot stove or oven: Overheating or flushing from high temperatures in the kitchen has been reported as a reason for rosacea to flare up.

• Emotional stress: Just cry or get angry and your face may turn red. Just as in the case of acne, some dermatologists think stress worsens rosacea. They believe that at times of stress, the body releases lots more glucocorticoids (the body’s natural steroids), which can worsen rosacea.

• Physical exertion: Exercise if you’re fair and you’ll flush. Yes, some folks who have rosacea feel that exercise makes it worse.

Of course, a hot shower also makes your face turn red! You obviously can’t avoid some of the things on the list — and in some cases, doing so would be bad for your health and turn you into a “couch potato.”

However, because I’m a doctor, I must recommend changing important lifestyle habits such as giving up smoking and cutting back on your caffeine intake. Remember, you’ll receive many more health benefits besides possible improvement in your rosacea by doing so.

Treating Rosacea

Most mild cases of rosacea can be treated and controlled with topical agents alone. (Topical refers to a product that is used on the skin, such as a cream, ointment, lotion, foam, gel, or a cleanser.) However, if topical treatment isn’t doing the job, an oral antibiotic is generally prescribed (systemic therapy).

Compared with topical therapy, systemic therapy has a more rapid onset of action. If possible, your doctor will try to control your rosacea on a longterm basis with topical therapy alone. Oral antibiotics (check out the next section) are reserved for initial control of rosacea and for breakthrough flare-ups.

In my practice, I start patients off with both an oral antibiotic such as a tetracycline as well as a topical medication such as a metronidazole. That’s because it may take a topical agent six to eight weeks for an acceptable therapeutic response, whereas oral antibiotics start working in a week or two.

As my patient improves, the dosage of the oral antibiotic is gradually reduced and then stopped. The goal of combination topical/oral treatment is to produce clearing of rosacea and to maintain it, if possible, with topical therapy alone.

The topical and oral drugs that I describe in the following sections have an anti-inflammatory action that helps to clear up the papules and pustules of mild to moderate rosacea.

However, these drugs aren’t effective in clearing up the flushing, blushing, and persistent redness (telangiectasias) of rosacea. I talk about treatment of these signs and symptoms of rosacea in “Managing the Redness”. All of the medications that I mention in that section require a prescription.

Taking a look at the topicals

Some of the topical medications that are used to treat acne can be used very effectively on rosacea; however, some precautions must be taken because many people who have rosacea also have very sensitive skin. Consequently, standard acne medications such as topical retinoids and benzoyl peroxide can be drying and irritating.

Retinoids may sometimes even sensitize the skin to the sun and worsen rosacea. Despite my reservations, if your skin tolerates these products without any irritation, there’s no reason not to use them, particularly if they work.

Just as we use topical agents in combination with each other (or in combination with oral agents) in the treatment of acne, this approach has become popular for managing rosacea too.

On the subject of combining topical treatments, Noritate cream applied at night and a sodium sulfacetamide/sulfur product such as Ovace, Klaron, or Avar applied in the morning appear to work better than when each of these agents is used alone.

In this section, though, I discuss topical medications that are used to treat rosacea. You may recognize a few familiar friends such as azelaic acid and sodium sulfacetamide and sulfur that are sometimes used to treat acne.

Doctors and researchers aren’t sure exactly how the following medications work in the treatment of rosacea, but it does appear that it’s mostly due to an anti-inflammatory effect. Each of these products is considered to be as effective as the others in the treatment of rosacea.

Metronidazole

Metronidazole is the most frequently prescribed first-line topical therapy for rosacea. Irritation and burning are uncommon from these topical medications, especially when the creams are used. They’re generally prescribed as one of the following:

• MetroCream, MetroGel, and MetroLotion: Commonly referred to as the Metros, all of these products contain 0.75 percent metronidazole. The Metros are applied twice a day to clean dry skin on the rosacea-prone areas. The latest Metro is the higher strength 1 percent MetroGel that’s applied once daily.

Besides having a higher concentration of metronidazole, it’s a water-based formulation that contains niacinamide, which is thought to have anti-inflammatory effects.

• Noritate cream: This product is similar to MetroCream, but with 1 percent metronidazole, it’s 25 percent stronger than the Metros. Noritate (“no irritate,” get it?) is used only once a day, a routine that helps patients use it regularly.

Azelaic acid

This gel is used to improve the inflammatory pimples of mild to moderate rosacea. Finacea and Skinoren (in Europe) are the brand names available. Finacea is available in a 15 percent azelaic acid gel.

They’re applied twice a day to clean dry skin. Some patients report temporary burning or stinging with this treatment. If you have a dark complexion, your doctor should monitor you for signs of skin lightening.

Sodium sulfacetamide and sulfur

Medications containing sodium sulfacetamide and sulfur are also effective for rosacea. Brand names include Klaron, Plexion, Rosula, Rosac, Rosanil, Novacet, and Ovace, to name a few. Sodium sulfacetamide and sulfur products are available as lotions, creams, and washes.

Some of these products contain a humectant (a substance that promotes retention of moisture) and can be used in rosacea patients who have dry, sensitive skin. These products are generally applied twice a day to clean dry skin. Itching, stinging, and irritation may occur with these preparations.

Treating rosacea by mouth

The same systemic oral antibiotics used to treat acne also calm the papules and pustules of your rosacea. Here, I provide you with the rosacea-specific information and tips associated with these drugs. Of course, your doctor always has the last word on these prescription drugs.

Whenever any systemic drugs are taken, the potential dangers — including side effects, drug allergy, drug intolerance, drug interactions, and fetal exposure in women who are, or may become pregnant — must be carefully considered. Tetracycline and tetracycline derivatives, such as minocycline and doxycycline, are the first-line oral drugs of choice in the management of moderate to severe rosacea.

The tetracyclines are antibiotics. They have antibacterial properties and many uses besides treating rosacea, but as far as rosacea is concerned, this antibiotic has a powerful anti-inflammatory action that helps to clear up the papules and pustules.

With the tetracyclines, improvement of rosacea is usually noticeable in a matter of a week or two. The papules and pustules begin to flatten and disappear and new ones stop popping up. Tetracyclines are then tapered when this improvement becomes persistent (usually after three to four weeks).

Minocycline is probably the most effective oral medication to treat rosacea. It’s also the most expensive. None of the tetracyclines should be used if you’re pregnant or breastfeeding. Other oral medications that may be prescribed include:

• Other antibiotics: A variety of other oral antibiotics (such as erythromycin, azithromycin, clarithromycin, and amoxicillin) have been used to treat rosacea successfully. Typically they’re prescribed as second-line alternatives when a tetracycline fails or isn’t tolerated.

• Oral metronidazole: This drug’s brand name is Flagyl, and it may be used when antibiotics aren’t working.

• Trimethoprim sulfasoxazole (TMZ): Trimethoprim sulfasoxazole is reserved for unusually stubborn cases of severe rosacea that don’t respond to any of the other antibiotics listed. Rarely, TMZ has been associated with severe side effects and may precipitate severe allergic reactions.

Although isotretinoin, better known as Accutane, is extremely effective in the treatment of severe acne, it hasn’t been very useful in rosacea. It may clear rosacea, but the improvement is often temporary and the rosacea tends to rebound.

In other words, the risks — which are plentiful — are probably not worth the benefits in the treatment of rosacea! Isotretinoin (Accutane) has many potential side effects and I review the ups and downs of this powerful drug in later.

While isotretinoin (Accutane) hasn’t been proven to be very helpful for severe inflammatory rosacea, there have been instances where the drug has demonstrated a reduction of some of the volume of rhinophyma lesions. I talk about the treatment of rhinophyma later in here.

Because rosacea doesn’t seem to have a relationship to hormonal fluctuations, the use of hormonal therapy for the treatment of acne has no place in the treatment of rosacea. Herbs reported to help clear rosacea include neem, cat’s claw, tea tree, ginger, and lavender. There’s no scientific evidence to back up these claims, however.

Managing the Redness

While you’re waiting for the medicine to work to relieve you of those bumpy papules and pustules, why not try to conceal the redness? The next section gives you a few helpful pointers, and later in here, I suggest some more permanent ways to get rid of the red.

Covering up with camouflage

Because treatment isn’t enough to handle the redness, you may want to consider strategic camouflage techniques. Green-tinted foundations can hide the red. Green neutralizes red. It’s that simple.

That explains why your normal shade of beige or other neutral skin tone foundation doesn’t quite conceal the redness that peeks out from underneath. Cosmetic foundations that have a green tint are included in the products made by companies such as Este Lauder, Clinique, and Prescriptives.

Other nonprescription products that may be used to cover up the redness are Dermablend and Covermark. They can be matched to your normal skin color. These products can be found in makeup counters in some department stores and also can be obtained online at Dermablend.com and Covermark.com.

The prescription cover-up products, Avar (tinted green) and Sulfacet-R, both are tinted and thus offer ways to hide the red. Sulfacet-R is also available in a tint-free preparation and is particularly useful for oily skin.

These products can serve as a cosmetic cover-up to hide the “broken” blood vessels and redness of rosacea. Sulfacet-R comes with a color blender so that you can match your skin tones. Both of these are types of sodium sulfacetamide, which I discuss in the section of the same name earlier.

Buzzing the telangiectasias away

Your dermatologist can treat your telangiectasias by electrocautery— destroying them with a tiny electric needle using extremely low voltage electricity. The needle zaps along the length of the blood vessel and destroys it.

Simple electrocautery tends to be sufficient for most small telangiectasias; it is relatively painless, and is the most cost effective approach to get rid of telangiectasias.

For the larger variety of telangiectasia, lasers such as I describe in the next section may be the treatment of choice. Your insurance will probably not cover these procedures, because they’re considered to be cosmetic in nature.

Light-based therapies

Topical and oral therapies don’t treat the telangiectasias or the larger, persistent erythematous (red) areas of rosacea. Special lasers known as vascular lasers and intense pulsed light (IPL) therapy are now being used by dermatologists and plastic surgeons to “erase” this red background away. Light-based therapies use various wavelengths of light to penetrate the skin and target the blood vessels on the face and cause the vessels to heat up and collapse.

These light treatments haven’t proven to be effective for flushing and blushing reactions, nor do they seem to be superior to oral antibiotics in treating the inflammatory component of rosacea. All of this is still in an early, investigational phase. The treatments are very expensive and generally not covered by health insurance plans. I shed more light on lasers and IPL in "Acne Treatment With Lasers".

Going the surgical route for rhinophyma

Recontouring procedures with a scalpel or a carbon dioxide laser have been used successfully to “sculpt” the excess nose tissue of rhinophyma back down to a more normal shape and appearance.

This may also be accomplished by electrocautery, a process of destroying tissue by using a small electric probe to cauterize (burn or destroy) unwanted tissue, or by dermabrasion. Results can last for many years and sometimes may be permanent.

I explain dermabrasion, carbon dioxide lasers, and other surgical measures in "Physical Scars". Dermatologic or plastic surgeons perform these procedures. Health insurance plans are generally very reluctant about covering such treatments, which they consider to be “cosmetic” in nature.

Identifying Rosacea Look-Alikes

The conditions that I mention in the following sections are really impossible to differentiate from rosacea except in three respects: they’re usually easy to treat, they generally disappear on their own (self-limiting), and they tend to show up in different areas of the face than does rosacea.

Recognizing perioral dermatitis

Also known as periorificial dermatitis, this condition is a rosacea-like skin eruption seen almost exclusively in women. Like rosacea, nobody knows its cause. Fluoridated toothpastes and bacteria have occasionally been implicated, but without any consistent evidence.

Perioral dermatitis occurs in a characteristic circular pattern around the mouth, chin, and lower cheek in women between the ages of 15 and 40 years. Less commonly, it can occur in young children. The lesions look just like those of rosacea or acne and consist of papules and pustules, except there are no telangiectasias.

The papules and pustules tend to be very small, and sometimes whitish scales can be associated with it. The biggest difference between rosacea, acne, and perioral dermatitis is that the latter often clears up permanently after treatment. Perioral dermatitis is usually found clustered around the mouth, but it may appear around the eyes and nose.

Treatment is similar to that of rosacea. The use of topical MetroGel or Noritate cream or topical antibiotics such as Cleocin T or Emgel can help to clear up this condition, especially for mild cases. An oral antibiotic such as one of the tetracyclines or erythromycin is used if topical treatment fails.

Being aware of topical steroid-induced “rosacea”

Also called steroid rosacea, this type of “rosacea” isn’t really rosacea, and I can tell you the cause of this condition — the inappropriate use of topical steroids (cortisone) on the face. The steroid creams are often prescribed for other skin conditions such as eczema or psoriasis and then overused by the unsuspecting person who continues to apply them.

The condition typically worsens when the topical steroids are discontinued (an occurrence known as rebound rosacea). Here’s what happens: There is a rapid flare of papules and pustules when the topical steroid is stopped, so the unsuspecting person reapplies the offending medication and the condition improves.

When the treatment is stopped again, the lesions appear again and reestablish the vicious cycle. Some of my dermatology colleagues refer to this as steroid-use dermatitis (others replace the term “use” with “abuse” or “misuse”).

It looks just like ordinary rosacea, but a history of long-term, indiscriminate misuse of potent topical steroids on the face helps to confirm the diagnosis. This condition is treated by stopping the topical steroids and by taking a tetracycline derivative for a few weeks or more to get over the hump of the rebound.