What Is Acne Rosacea? What It Looks Like and How to Treat It

Is it acne, rosacea—or acne rosacea?

If you’ve started noticing a breakout of pimples on your face, it could be acne. Although the skin condition mainly affects teenagers, older adults can get it, too. However, the bumps could also be caused by something altogether different: an inflammatory skin condition called rosacea.

“Both rosacea and acne can cause pimples and redness on the face, but they are distinct entities,” says Lisa Anthony, MD, a dermatologist at Westmed Medical Group in Westchester, New York.

While people with rosacea often develop bumps that contain pus and look like acne, the redness tends to be widespread across the face. With acne, however, the redness is often concentrated on individual pimples.

What’s officially known as papulopustular rosacea (aka, “acne rosacea”) is a subtype of rosacea since the pimples usually occur in combination with other symptoms of rosacea. The pimples “are often accompanied by background facial redness, and/or intermittent flushing and blushing,” says Julie C. Harper, MD, a dermatologist at the Dermatology and Skin Care Center of Birmingham, in Birmingham, Alabama.

The redness or flushing is often the earliest sign of this form of acne-like rosacea. According to the National Rosacea Society, the pimples often follow the onset of these first symptoms if rosacea isn’t treated. Visible blood vessels, burning or stinging skin, a thickening of skin on the nose, or irritated, red eyes may also develop.

If you think you have rosacea, see a dermatologist who can diagnose you. Here’s what you need to know about acne-like rosacea.

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What does acne rosacea look like, and who gets it?

“Papules and pustules are the pimple-like lesions of rosacea,” Dr. Harper says. Papules are raised bumps on the skin, and pustules are bumps filled with pus.

“They are red, inflamed, and can be tender, and most commonly occur on the middle third of the face: nose, cheeks, chin, and forehead,” she says.

Acne rosacea tends to affect middle-aged women, although men can get it, too.

“Rosacea is an inflammatory condition that can occur any time in life, but is much more likely to occur in your mid-thirties, forties, and fifties,” says Mona Gohara, MD, a board-certified dermatologist in Connecticut and an associate clinical professor in the department of dermatology at Yale School of Medicine.

It’s unclear why that demographic is most affected, says Channa Ovits, MD, a dermatologist at Westmed Medical Group in Westchester, New York. Rosacea is also more common in fair skin—possibly because it’s easier to see—but all skin types can have it. (Here are other rosacea facts you should know.)

Acne rosacea versus acne: The differences

Both the appearance and the underlying causes of acne rosacea are different from acne, which is an important distinction when treating it.

“Rosacea and acne both affect the face and both may present with red bumps, a.k.a. pimples, but there are more differences than similarities,” Dr. Harper says. “The lesions of acne include blackheads and whiteheads, inflammatory bumps, and/or nodules. These lesions can be seen anywhere on the face and upper trunk. Unfortunately, acne lesions may scar.”

With rosacea, however, “blackheads and whiteheads are conspicuously absent,” Dr. Harper says.

Why? It’s because of how they’re formed. Acne develops when hair follicles under the skin become blocked with dead skin cells and an overproduction of oil. That creates whiteheads (if under the skin) or blackheads (if open to the skin).

Bacteria may grow, which leads to inflammation and pimples. The pimples of rosacea, although also due to inflammation in the skin, aren’t caused by bacteria or a buildup of oil. With rosacea, the skin actually tends to be dry.

The underlying reasons rosacea develops isn’t well understood.

“The exact cause of rosacea isn’t known, but may involve genetic factors, abnormal immune signals, hyper-reactive blood vessels, and inflammation from skin microbes,” says Dr. Anthony. These skin microbes are Demodex mites that have been linked to rosacea, although the exact relationship isn’t clear.

When to see a dermatologist

If you think you have acne but really have rosacea, and then start treating yourself with over-the-counter acne products, you could be making things worse.

“You have to have a trained eye to distinguish between what is acne and what is rosacea, because the way you treat rosacea is very different than the way you treat acne,” Dr. Gohara says. “The medications you put on the face with acne can really stoke the fire with rosacea.”

Dermatologists will look for the presence or absence of whiteheads and blackheads, and consider your age, as well as other symptoms.

“While acne can affect adults, it frequently starts in adolescence,” says Dr. Harper. “Rosacea more commonly presents in those between the ages of 30 and 50, and may persist for decades. Background redness and flushing and blushing are associated with rosacea, and the red bumps, or papules, are usually confined to the middle third of the face, vertically.”

Along with the additional redness of rosacea, “there are usually broken blood vessels and tiny pinpoint pustules,” Dr. Anthony says.

Treatments for acne rosacea

Topical treatments

Prescription creams—including ivermectin, azelaic acid, minocycline, and metronidazole—address the underlying mechanisms of rosacea, says Dr. Ovits.

• Ivermectin (brand name Soolantra) reduces the amount of Demodex mites on the skin. A review of studies, published in 2017 in the journal American Family Physician, found that ivermectin is effective in patients with moderate to severe pustular rosacea.
• Azelaic acid decreases inflammation. Studies show that 70 to 80 percent of patients who used azelaic acid had less rosacea, according to the American Academy of Dermatology (AAD).
• Minocycline, an antibiotic cream, decreases inflammation.
• Metronidazole also decreases inflammation, and reduces both the redness and acne-like breakouts of rosacea.

Oral treatments

If your rosacea breakouts are especially bad, you may be prescribed an oral antibiotic such as doxycycline.

“Oral antibiotics, as well as topical antibiotics, can be very effective for the treatment of the acne-like component of rosacea,” Dr. Gohara says.

And they can be used together, adds Dr. Harper. For example, “if background redness is a problem, topical oxymetazoline may be helpful, as well.” For best results, notes the AAD, antibiotics should be used only for a short time or in low doses to prevent antibiotic resistance.

In addition, the retinoid treatment isotretinoin (commonly known by the discontinued brand name Accutane) can be effective for severe cases, adds Dr. Ovits.

Your doctor will help figure out the right combination of medications to best treat your pimples and the other symptoms of rosacea. These rosacea treatments can help end redness.

Home treatments

As with other signs and symptoms of rosacea, there are a few rosacea home remedies or things you can do yourself to calm your rosacea breakouts.

“Rosacea skin is inherently sensitive to triggers like sunlight, heat, stress, and spicy foods,” Dr. Harper says. “While these trigger factors would not lead to inflammation under the skin in people without rosacea, they certainly do lead to an inflammatory response in those who do have rosacea.”

So identifying and avoiding your triggers, including using daily sun protection, is very important, she says. That’s one of a few strategies that helped this patient find rosacea treatments that work for her.

Other tips: “Avoid irritating the skin,” suggests Dr. Harper. “A mild cleanser with warm water is recommended for routine skin care, and scrubs and toners should be avoided. Moisturizers and sunscreen are recommended. And it’s best to avoid products that contain potential irritants, like salicylic acid or glycolic acid.” (This is the best skin care routine for rosacea, according to dermatologists.)

The takeaway

Rosacea is a skin condition that can cause redness and pimples, which is a subtype known as acne rosacea. Acne rosacea mainly affects middle-age to older adults, specifically women and those with fair skin.

It’s still unclear what causes rosacea. But treatments—both prescription and over-the-counter—are available to help alleviate symptoms and reduce flare-ups.

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