Rosacea: why it appears, what makes it worse and the best treatment

Rosacea is a chronic inflammatory condition affecting mainly the central face: nose, cheeks, forehead and chin. It presents with persistent redness, visible vessels, a burning sensation and, in some forms, spots resembling acne. There is no definitive cure, but it is well controlled with the right treatment and by identifying personal triggers. It mostly affects people with fair skin, more women than men, and usually appears after the age of 30. The earlier it is treated, the less likely it is to progress to forms that are harder to reverse.

Why does rosacea appear?

There is no single cause. Rosacea results from several mechanisms combined:

Vascular change. Facial vessels dilate easily and are slow to return to normal. This explains the redness that comes and goes, and then stops going.

Inflammation and innate immunity. There is an exaggerated inflammatory response to stimuli that would cause nothing in other skin, mediated by antimicrobial peptides such as cathelicidin.

Demodex folliculorum. This mite lives on everyone's skin, but is found in greater numbers in skin with rosacea. It is not an infestation caught from outside, and rosacea is not contagious.

Genetic predisposition. Family members with the same condition are common.

Weakened skin barrier. The skin loses water faster and becomes more reactive to products and to the environment.

External factors such as sun, heat, alcohol or stress do not cause rosacea. They trigger flares in those who already have it.

What are the symptoms of rosacea?

It usually begins with episodes of sudden redness — flushing — triggered by heat, alcohol, spicy food or emotion. These last minutes to hours and pass.

Over time, the redness becomes permanent across the central face. Fine visible vessels appear: telangiectasias. The skin becomes sensitive, with burning or stinging, and reacts badly to products it once tolerated.

In inflammatory forms, papules and pustules appear, similar to acne but without comedones — there are no blackheads, and that is the difference that separates the two.

There may also be facial swelling, dryness, flaking and a feeling of tightness.

Which types of rosacea are there?

Erythematotelangiectatic rosacea (type 1)

Persistent redness and visible vessels predominate. The skin is highly reactive, burning and stinging easily. It is the most common form and the one that benefits most from light and laser treatments.

Papulopustular rosacea (type 2)

Alongside the redness there are papules and pustules in flares. This is the form most often mistaken for acne, and the one that responds best to topical treatment and to oral antibiotics at anti-inflammatory doses.

Phymatous rosacea (type 3)

There is thickening of the skin, particularly of the nose, where it is called rhinophyma. The sebaceous glands enlarge and the skin takes on an irregular texture. It is more common in men and, at an advanced stage, is corrected only with ablative laser or surgery.

Ocular rosacea (type 4)

Affects the eyes, with redness, burning, a gritty sensation and blepharitis. It can appear before any skin changes, which delays diagnosis. It is underdiagnosed and deserves specific attention.

There are also less common forms: granulomatous rosacea, rosacea fulminans and corticosteroid-induced rosacea.

What makes rosacea worse?

Triggers vary from person to person, but the most frequent are:

• Sun exposure — the number one factor

• Heat: sauna, hot baths, heating, cooking

• Intense cold and wind

• Alcohol, particularly red wine

• Hot drinks

• Spicy and heavily seasoned food

• Stress and anxiety

• Intense physical exercise

• Topical corticosteroids on the face

• Products with alcohol, strong acids, menthol, camphor or fragrance

Keeping a record for a few weeks is worthwhile. Your personal pattern is usually more revealing than any general list.

How should I wash my face with rosacea?

The cleansing routine is part of the treatment, not a detail.

Wash twice a day with lukewarm water — never hot. Use a gentle cleanser, soap-free, alcohol-free and fragrance-free, applied with your hands rather than sponges or brushes.

Pat dry with a towel, without rubbing. Rubbing is among the most aggravating habits.

Avoid exfoliants, astringent toners, cleansing brushes and very hot water. If a product burns or stings, that is not a sign it is working: it is a sign it should not be used.

What is the best cream for rosacea?

There is no single best cream. There are two different categories, and it helps not to confuse them.

Daily care, available over the counter: a moisturiser for sensitive skin with ceramides, niacinamide or hyaluronic acid, and a mineral sunscreen with zinc oxide or titanium dioxide, SPF 30 or above, used every day. This does not treat rosacea — it maintains the skin barrier and reduces the frequency of flares.

Topical medication, on prescription: metronidazole, azelaic acid, ivermectin and brimonidine. These are what act on the disease. The choice depends on the subtype and on what predominates.

A well-chosen pharmacy cream makes a difference. It does not replace treatment when there are inflammatory lesions or persistent redness.

What is the best treatment for rosacea?

It depends on the subtype, which is why the same question has different answers for different people.

Topicals. Metronidazole and azelaic acid in inflammatory forms. Ivermectin where Demodex is involved. Brimonidine for redness, with temporary effect.

Oral. Doxycycline at sub-antimicrobial dose, used for its anti-inflammatory effect rather than as an antibiotic as such. Low-dose isotretinoin in resistant or phymatous forms.

Light and laser. Intense pulsed light and vascular laser are the most effective treatment for visible vessels and fixed redness, which do not respond to creams.

Ocular rosacea. Eyelid hygiene, artificial tears and, in some cases, oral medication. Ophthalmological assessment is warranted.

Daily sun protection. This is the measure with the best ratio of effort to result, and the one most often neglected.

Can rosacea be cured?

There is no definitive cure. There is control, and control can be very good.

It is a chronic disease, with periods of flare and remission. With appropriate treatment and trigger avoidance, it is possible to keep the skin stable for long periods, with little or no visible redness.

What does not reverse on its own: telangiectasias already formed and phymatous changes. Those are treated with laser or surgery, not creams.

You will find accounts online of "how I cured my rosacea". These almost always correspond to periods of remission — which are real, but are not a cure.

Do natural treatments work?

Some measures help. Others are dangerous.

May help: cold compresses during a flare, gentle moisturisers, topical green tea, avoiding known triggers, stress management. None replaces medical treatment when there is active disease.

Never apply to the face: hydrogen peroxide, vinegar, lemon juice, bicarbonate of soda, alcohol, toothpaste or undiluted essential oils.

Hydrogen peroxide deserves a specific note, because it circulates as a "definitive cure" in forums and on social media. It does not cure rosacea. It is an irritant that damages the skin barrier, causes chemical burns and aggravates precisely the inflammatory mechanism underlying the disease. In skin with rosacea, the outcome is predictable: it gets worse.

Rosacea or acne?

They are confused, and the treatment differs.

Rosacea has no comedones. There are no blackheads or whiteheads. If there are, it is acne — or both at once, which also happens.

Rosacea sits on the central face and comes with background redness and visible vessels. It typically appears after the age of 30. Acne appears in adolescence, is more widely distributed and also affects the back and chest.

The mistake with consequences is treating rosacea as acne: some treatments used for acne, particularly the more irritating ones, make rosacea worse.

When should I see a dermatologist?

• When facial redness has stopped going away

• When visible vessels or spots appear on the central face

• When the skin burns or stings with products it once tolerated

• When there are eye symptoms: burning, grittiness, redness of the eyelids

• When the nose starts changing in texture or shape

• When appearance is affecting social life or mood

Dr Ellene Papazis is a dermatologist accredited in Portugal and Brazil, and treats patients with rosacea in Porto, Portugal.

Sources

• National Rosacea Society — phenotype-based classification

• American Academy of Dermatology — rosacea treatment recommendations

• European Academy of Dermatology and Venereology

• Portuguese Society of Dermatology and Venereology (SPDV)

Written and reviewed by Dr Ellene Papazis, dermatologist accredited in Portugal and Brazil. Consultations in Porto, Portugal.

Updated 25 July 2026.