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Rosacea

Also known as: rosacea, facial redness

Rosacea is a chronic inflammatory condition of the central face. Two features are independently diagnostic: persistent centrofacial erythema with periodic intensification, and phymatous change. Flushing, telangiectasia, inflammatory lesions and ocular signs are not individually diagnostic.

Evidence status

Strong

The 2015 Cochrane review graded 106 randomised trials, but its search ran only to July 2014 — read it as a dated synthesis, not the whole 2026 picture. Its awkward pattern for aesthetic practice still stands: high quality for prescription treatments, low for laser and IPL. The BAD 2021 guideline, working from evidence to February 2020, nonetheless recommends considering vascular laser or IPL where persistent erythema is the main feature. Diagnosis rests on Galderma-funded Delphi consensus, not trial evidence.

What it is#

Rosacea is a chronic inflammatory condition of the central face. Beyond that, the useful definition is diagnostic rather than descriptive — and it changed in 2017.

The two diagnostic features#

Rosacea is a clinical diagnosis, made against a real differential list — acne vulgaris, seborrhoeic dermatitis, perioral dermatitis, lupus erythematosus, carcinoid syndrome, nasal sarcoidosis, acne agminata, pyoderma faciale, steroid rosacea and facial dysaesthesia.[5] Within that assessment, international consensus holds that two features are independently diagnostic:

  • Persistent centrofacial erythema associated with periodic intensification
  • Phymatous changes[2]

And — more useful in a treatment room — a list of things that are not individually diagnostic: flushing, telangiectasia, inflammatory lesions and ocular manifestations.[2]

So a client who flushes at a glass of wine does not have rosacea on that basis. Nor does one with a few visible vessels on the cheeks. The word “persistent” is doing real work: it is redness that is there between the flushes, in the centre of the face, that gets worse in episodes.

Beyond the primary features sit the secondary ones: burning or stinging, erythematous plaques, facial dryness and scaling, oedema, peripheral location and ocular manifestations. They may accompany the primary features or turn up on their own, and they are not diagnostic.[2, 5] That matters because product intolerance is so often read as a give-away. It is a secondary feature at best, and it points equally at contact or seborrhoeic dermatitis.

Note what this is. The scheme comes from a modified Delphi process — 17 dermatologists and three ophthalmologists, blinded electronic voting, agreement set at 75%. That is expert opinion formalised, which is a legitimate and useful thing, and it is not trial evidence.[2, 3] It is also not disinterested: the project was funded by Galderma, which markets rosacea products, and every panellist received honoraria from Galderma for attending. That does not invalidate the work. It belongs on the page next to it.

Phenotype, not subtype#

The older approach sorted people into subtypes — erythematotelangiectatic, papulopustular, phymatous, ocular — and treated the box. The problem is that real faces do not respect the boxes.

The current approach treats individual features on their own merits: transient erythema, persistent erythema, inflammatory papules and pustules, telangiectasia, phyma. Multiple features in one person can be treated simultaneously with multiple agents, all of it “underpinned by general skincare measures”.[2, 3]

For a skincare professional this is the more workable model anyway. You are looking at what is in front of you and asking what each element needs — which is closer to how a consultation actually runs than reaching for a subtype label.

The 2019 update went further and set clear skin rather than almost-clearas the preferred primary objective — then qualified it in the same passage: clearance may not be possible for every patient because of cost or access, and some patients are satisfied with subtotal improvement. The delayed-relapse benefit behind the objective was established for papules, pustules and erythema; the panel said other features need further evaluation.[4] The panel was funded by Galderma. Read “complete clearance” as a commercially funded aspiration to agree with the patient, not as a universal evidence-based endpoint.

Telling it from acne#

Papulopustular rosacea and acne are confused constantly, and the shorthand everybody teaches — rosacea has no comedones — is not what the consensus actually says.

What it says is that inflammatory lesions in rosacea consist of papules and pustules and exclude comedones, “although the presence of comedones may not exclude a diagnosis of rosacea as acne and rosacea can coexist”.[2]So comedones favour acne, and their absence supports rosacea — but finding blackheads does not close the rosacea question. It may simply mean the person has both.

The distinction is not academic, because the treatments diverge. And the products a client has already reached for — often the strongest acne actives on the shelf — are frequently making it worse. Rosacea skin is characteristically intolerant of routine products; treat that as useful information about what you can offer, not as a diagnostic finding.[2, 5]

One evidence point worth carrying into that conversation: topical clindamycin combined with tretinoin was not effective compared with placebo in rosacea, at moderate quality of evidence.[1] The instinct to treat inflammatory facial lesions with acne combinations has been tested here, and it failed.

What the evidence base looks like#

Rosacea is unusually well studied for a skin condition: 106 randomised studies, 13,631 participants, across 67 comparisons.

Which is not the same as 106 good studies. Sample sizes of 30 to 100 and durations of two to three months were most common; 57 of the 106 were at unclear risk of bias and 37 at high risk, leaving 12 at low risk; and 22 provided no usable data at all.[1]

And it is a dated map. The Cochrane review was published in 2015, but its databases were searched only to July 2014. Its grading is a valid result for the literature up to that point; it is not a picture of where the evidence stands in 2026, and we corrected this page in August 2026 for treating it as one. The current UK guideline — BAD 2021, working from evidence to February 2020 — sits alongside it and sometimes points the other way.[5]

Mean age was 48.6, more women than men were included, and most participants had papulopustular rosacea, followed by erythematotelangiectatic. Worth remembering when generalising to a younger or more male clientele.

Where the quality sits#

This is the part of the entry that matters to anyone working in aesthetics, and the pattern is uncomfortable.

High-quality evidence

Topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin. Moderate-quality evidence for topical metronidazole and oral tetracycline.[1]

Every one of those is a prescription decision in the UK. The best-evidenced things you can do for a client with rosacea are things you refer them for.

Two findings worth knowing anyway

Topical azelaic acid beat placebo in papulopustular rosacea on participants’ own assessments (RR 1.46, 95% CI 1.30–1.63).[1]

Topical brimonidine reduced erythema at every timepoint across 12 hours, at high quality of evidence. The two pooled trials also reported no rebound or worsening of erythema after cessation.[1]

Do not carry that further than it goes. Those trials were short, and a null result in controlled trials is not evidence that post-cessation flare does not happen. The current product information says that in some patients erythema and flushing returned with greater severity than was present at baseline — mostly within the first two weeks — and that across all clinical studies 16% of patients experienced an event of symptom exacerbation. BAD recommends warning patients that redness may flare after discontinuation.[5, 6] Brimonidine is a prescription decision, and the flare question belongs to the prescriber — but it is a real, labelled reaction, not a myth to correct a client about.

And one that helps a client tolerate treatment: doxycycline 40 mg was no less effective than 100 mg, with evidence of fewer adverse effects at the lower dose (RR 0.25, 95% CI 0.11–0.54, low quality).[1] If someone has abandoned doxycycline over side effects, that is a conversation for their prescriber, not a dead end.

Laser and IPL#

The treatments most often offered for rosacea in a clinic setting sit at the bottom of the quality table.

In the Cochrane synthesis of literature to July 2014, evidence for laser and intense pulsed light in rosacea was graded low. Pulsed dye laser was more effective than Nd:YAG on one study, and appeared about as effective as intense pulsed light — both low-quality findings.[1]

Read that properly. Low-quality evidence is not evidence of no effect; it means the studies were too few, too small or too flawed to be confident. Vascular lasers plainly do something to visible vessels, and telangiectasia is one of the phenotypes the consensus panel treats.

And the current UK guideline recommends it anyway

This is where the first draft of this entry went wrong, and it is worth being explicit about. BAD 2021 — the current UK guideline, assessing evidence to February 2020 — recommends considering pulsed dye laser, Nd:YAG or intense pulsed light where persistent facial erythema is the main presenting feature. It is a weak recommendation, made in full knowledge of the limited certainty, and it comes with a condition: an appropriately qualified laser practitioner should be consulted.[5]

So the honest position is not “the evidence-based answer starts with a referral, not a package”. It is that the highest-quality evidence is for prescriptions, that light treatment is a reasonable option the UK guideline endorses weakly, and that the confident comparative claims made in this market — this device over that one, this many sessions, this much clearance — are still not supported by anything.

The eyes#

The most commonly missed part of the condition, and the one with the clearest instruction attached.

The 2017 global consensus says ophthalmological referral should be considered for all but the mildest ocular features. Lid hygiene and artificial tears are used alongside medication, and the evidence for ciclosporin ophthalmic emulsion in ocular rosacea is low quality.[1, 3]

The UK triggers, which are more specific

BAD 2021 turns that sentence into criteria, as a strong recommendation. Refer to an ophthalmologist where there is:

  • eye discomfort or sticky discharge persisting for more than 12 months despite frequent topical lubricant use (more than six times daily) and adequate lid hygiene; or
  • symptoms such as reduced vision, pain on eye movement, or pain that keeps the person awake at night.[5]

That second group are red flags. A skincare practitioner’s job is to stop treatment and route the concern medically — not to grade how severe it is.

Ocular signs are not individually diagnostic of rosacea[2] — but in someone who already has the diagnosis, gritty, dry, burning or persistently red eyes are not a separate complaint to be shrugged at. Asking about them takes ten seconds and is one of the more valuable things a skincare professional can do in this condition.

In professional practice#

  • Look for persistent centrofacial erythema that intensifies in episodes — not for flushing alone.
  • Check for comedones — but do not treat finding some as ruling rosacea out. Acne and rosacea coexist.[2]
  • Ask about the eyes at every rosacea consultation, and refer on the BAD triggers — urgently for reduced vision, pain on eye movement or night-waking pain.[5]
  • Treat intolerance as practical information, not a diagnosis. It shapes what you can offer; it does not establish what they have.[2, 5]
  • Be honest about where the evidence is. The best-evidenced treatments are prescriptions, and referral is part of good practice rather than lost revenue — but do not tell a client that light treatment is unsupported, because the UK guideline recommends considering it.[5]
  • Skincare measures underpin everything in the consensus algorithm — which is your territory, and it is not a consolation prize.
  • Defer elective peeling or resurfacing during a flare. This is an MSTA precaution, not a trial-derived interval — we looked and found no trial defining safe timing in either direction.[no source found]

What remains uncertain#

  • How effective laser and intense pulsed light actually are. The evidence is graded low, and the comparative claims outrun it badly.
  • Time to response and duration of remission — Cochrane notes both were incompletely or not reported across the literature.
  • How well findings from a mean age of 48.6, mostly women, transfer to other populations.
  • Ocular rosacea treatment generally. Cochrane calls explicitly for further study.
  • Whether any professional skincare protocol changes the course of the condition rather than its comfort.

Common misconceptions#

“They flush after wine, so it's rosacea.”

Flushing is expressly not individually diagnostic. The diagnostic feature is persistent centrofacial erythema with periodic intensification.[2]

“It's adult acne.”

Rosacea’s inflammatory lesions are papules and pustules rather than comedones — though comedones do not rule rosacea out, because the two conditions can coexist.[2] And the acne combination of clindamycin with tretinoin was found not effective against placebo in rosacea.[1]

“IPL is the evidence-based treatment for rosacea.”

The highest-quality evidence is for topical azelaic acid, ivermectin, brimonidine, and oral doxycycline and isotretinoin; laser and IPL sat at low quality in the 2014-search Cochrane review.[1] But the reverse claim is wrong too: BAD 2021 recommends considering vascular laser or IPL where persistent erythema is the main feature.[5] It is an option with weak support, not a discredited one.

“Rosacea is just sensitive skin that needs gentler products.”

It is a chronic inflammatory condition with two independently diagnostic features, and the treatments with high-quality evidence behind it are prescriptions.[1]

“Complete clearance is the evidence-based endpoint.”

It is the preferred objective of a Galderma-funded consensus panel, which said in the same passage that clearance may not be possible for every patient and that some are satisfied with subtotal improvement — and whose delayed-relapse evidence covered papules, pustules and erythema rather than every feature.[4] Agree the goal with the patient.

“Brimonidine rebound is a myth — the trials found none.”

The short pivotal trials found no rebound trend.[1] The product information reports that erythema and flushing returned more severely than baseline in some patients, that 16% experienced symptom exacerbation across studies, and BAD recommends warning patients about it.[5, 6] Do not correct a client who reports it.

Frequently asked questions#

Can I treat rosacea?

You own the skincare measures the consensus algorithm says underpin everything, and you are often the person who spots it first. The best-evidenced treatments are prescriptions, so referral is part of treating it well.[2, 3]

Is it rosacea or acne?

Papules and pustules on persistent centrofacial erythema, without comedones, point at rosacea.[2] Comedones point at acne — but they do not exclude rosacea, because the two can be present together.[2] It is a clinical diagnosis with a real differential list behind it.[5]

Should I offer IPL for the redness?

The UK guideline says consider it where persistent facial erythema is the main feature — weakly, and with an appropriately qualified laser practitioner involved.[5] What you cannot do is sell a course on a number nobody has established: the comparative evidence was graded low and has not firmed up since.[1]

My client's eyes are always gritty and sore.

Refer, on the BAD triggers: discomfort or sticky discharge past 12 months despite frequent lubricants and lid hygiene, or any of reduced vision, pain on eye movement, or pain waking them at night.[5] The 2017 consensus puts it more broadly — refer for all but the mildest ocular features.[1, 3] Either way, this is not yours to grade.

How do I ask about the impact without prying?

The 2019 consensus recommends discussing disease burden during consultations using four structured questions, precisely so that impact is assessed rather than inferred from how bad the skin looks.[4]

References#

Each source is graded by evidence tier. Tier 4 material (manufacturer documents, expert consensus, practitioner experience) is useful for protocol and context, and is never presented as equivalent to independent clinical evidence.

  1. van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database of Systematic Reviews. 2015;(4):CD003262.Tier 1Supports: SEARCH DATE JULY 2014 — the review was published in April 2015 but its databases were searched only to July 2014. Everything below is a synthesis of the literature to that date and must not be presented as the current evidence base. 106 studies, 13,631 participants, 67 comparisons. Sample sizes of 30–100 and durations of two to three months were most common; mean age 48.6; more women than men; most had papulopustular rosacea, then erythematotelangiectatic. Risk of bias: 57 of 106 unclear, 37 high, 12 low; 22 studies provided no usable data. HIGH-QUALITY evidence supports topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin. MODERATE for topical metronidazole and oral tetracycline. LOW for low-dose minocycline, laser and intense pulsed light therapy, and ciclosporin ophthalmic emulsion for ocular rosacea. Specific findings: azelaic acid more effective than placebo on participants' assessments (RR 1.46, 95% CI 1.30–1.63); topical ivermectin better than placebo (RR 1.78, 1.50–2.11 and RR 1.92, 1.59–2.32) and slightly better than topical metronidazole on one study; brimonidine reduced erythema at all timepoints over 12 hours with NO rebound or worsening after cessation; doxycycline 40 mg was no less effective than 100 mg but had fewer adverse effects (RR 0.25, 0.11–0.54, low quality); low-dose isotretinoin slightly more effective than doxycycline 50–100 mg; pulsed dye laser more effective than Nd:YAG on one study and about as effective as intense pulsed light, both low quality. Topical clindamycin with tretinoin was NOT effective versus placebo.
  2. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. British Journal of Dermatology. 2017;176(2):431–438.Tier 4Supports: Modified Delphi consensus, 17 dermatologists and three ophthalmologists, blinded electronic voting, consensus defined as ≥75% agree or strongly agree. Consensus was achieved for moving from subtype-based to phenotype-based diagnosis. TWO features were independently considered diagnostic: (i) persistent, centrofacial erythema associated with periodic intensification; and (ii) phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were NOT considered individually diagnostic. ON COMEDONES, verbatim: 'inflammatory lesions consist of inflammatory papules/pustules and exclude comedones, although the presence of comedones may not exclude a diagnosis of rosacea as acne and rosacea can coexist.' SECONDARY features, which may accompany primary features or appear independently: phymatous changes, burning or stinging sensations, erythematous plaques, facial dryness and scaling, oedema, peripheral location and ocular manifestations — these are secondary, NOT diagnostic. This is expert consensus, not trial evidence.Funding / interest: 'The planning and delivery of this project was funded by Galderma.' All panellists received honoraria from Galderma for participating in the meeting; several also held advisory board, speaker or consulting relationships with Galderma and other companies.
  3. Schaller M, Almeida LM, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. British Journal of Dermatology. 2017;176(2):465–471.Tier 4Supports: Same panel and method. Agreed phenotype-based treatments for individual features — transient and persistent erythema, inflammatory papules and pustules, telangiectasia, and phyma — 'underpinned by general skincare measures'. Multiple features in one patient can be treated simultaneously with multiple agents. If treatment is inadequate after an appropriate duration, another first-line option or the addition of one should be considered. 'Ophthalmological referral for all but the mildest ocular features should be considered.' Lid hygiene and artificial tears are used in addition to medications for ocular rosacea. General skincare 'underlies the treatment approach': sunscreen SPF 30+, frequent moisturiser, gentle over-the-counter cleansers and trigger avoidance.Funding / interest: 'The planning and delivery of this project was funded by Galderma. The sponsor was not involved in the voting, discussion or handling of data.' All panellists received honoraria from Galderma for participating in the meeting; full disclosures, including advisory board, speaker and consulting relationships, are listed in the paper's appendix.
  4. Schaller M, Almeida LM, Bewley A, et al. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. British Journal of Dermatology. 2020;182(5):1269–1276.Tier 4Supports: Delphi update, same ≥75% consensus threshold. Recommends discussing disease burden with patients during consultations, using four questions to assist the conversation (impact of signs and symptoms on quality of life in the past month; impact of time lost to rosacea; impact on workplace or educational productivity; how well controlled the rosacea has been). On the treatment objective, verbatim: 'Achieving clear skin vs. almost clear should be the primary objective when treating rosacea' — IMMEDIATELY QUALIFIED: 'While achieving skin clearance of rosacea is ideal, this may not be possible for all patients due to limitations such as cost or access and some patients are satisfied with subtotal improvement.' The delayed-relapse benefit behind the objective concerned 'rosacea with papules/pustules and erythema'; 'further evaluation is required for other rosacea features'. Recommends combination therapy for patients with multiple features, and ongoing monitoring and dialogue.Funding / interest: 'The planning and delivery of this project was funded by Galderma. The sponsor was not involved in the voting, discussion or handling of data.' Galderma markets rosacea products including brimonidine (Mirvaso) and ivermectin, so a commercially funded panel setting complete clearance as the objective is disclosed here rather than presented as a neutral endpoint.
  5. Hampton PJ, Berth-Jones J, Duarte Williamson CE, et al. British Association of Dermatologists guidelines for the management of people with rosacea 2021. British Journal of Dermatology. 2021;185(4):725–735.Tier 1Supports: The current UK guideline. Literature assessed to FEBRUARY 2020 — six years later than the Cochrane search. States that it 'does not cover the diagnosis of rosacea', describes rosacea as a clinical diagnosis, and recommends classifying by the Gallo et al. phenotypes while taking the older sign-based classification into account. Differentials it covers: acne vulgaris, seborrhoeic dermatitis, lupus erythematosus, carcinoid syndrome, nasal sarcoidosis (lupus pernio), perioral dermatitis, acne agminata, pyoderma faciale, steroid rosacea and facial dysaesthesia. R11 (weak): 'Consider topical brimonidine in people with rosacea where the main presenting feature is facial erythema. Warn patients that there are reports that redness may flare after discontinuation of treatment.' R17 (weak): 'Consider pulsed dye laser, neodymium-doped yttrium aluminium garnet (Nd:YAG) laser or intense pulsed light in people with rosacea where the main presenting feature is persistent facial erythema' — adding that 'an appropriately qualified laser practitioner should be consulted to ensure safe and high-quality practice'. R23 (STRONG): 'Refer people with ocular rosacea to an ophthalmologist if they are (i) experiencing eye discomfort, sticky eye discharge persisting for > 12 months despite frequent (> 6 times daily) topical lubricant use and adequate lid hygiene; or (ii) experiencing symptoms such as reduced vision, pain on eye movement and pain that keeps the patient awake at night.' The guideline makes no mention of chemical peels or resurfacing.
  6. Galderma (U.K.) Limited. Mirvaso 3 mg/g gel: Summary of Product Characteristics. Electronic Medicines Compendium. Last revised 16 October 2023.Tier 1Supports: Section 4.4, verbatim: 'The effect of Mirvaso topical gel begins to diminish hours after application. In some patients, erythema and flushing were reported to return with greater severity than was present at baseline.' Most such cases were observed within the first two weeks of starting treatment, and in most cases resolved after discontinuation. 'Across all clinical studies, 16% of patients receiving Mirvaso experienced an event of symptom exacerbation.' Erythema is a common (≥1/100 to <1/10) adverse reaction.