Rosacea UK: A Complete Guide to Causes, Subtypes & Treatment
A NICE NG198-aligned guide to Skinoren (azelaic acid) — covering its mechanism, clinical evidence, licensed indications, cream vs gel selection, and how to use it safely alongside other actives.
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Rosacea UK: A Complete Guide to Causes, Subtypes & Treatment
What rosacea is, what causes it, the four subtypes, common triggers, how it progresses, how it is diagnosed, and how it is treated in the UK.
Part of our rosacea health guides. Looking for treatment? See our rosacea treatments.
Key fact: Rosacea is a common long-term skin condition that mainly affects the face. It is more common in women and in people with lighter skin, although symptoms can be worse in men (NHS). It can't be cured, but treatment matched to your main symptom, together with avoiding your own triggers, controls it well for most people.
Get rosacea treatment online
Access Doctor provides rosacea treatment following a GPhC-regulated online consultation with our pharmacist independent prescribers. For adults 18 and over.
See rosacea treatments →What is rosacea?
Rosacea is one of those conditions that people often live with for years before they get a name for it. The redness gets dismissed as "easily flushed skin", the bumps get treated as adult acne, and the burning or stinging gets blamed on the wrong moisturiser. It is in fact a distinct long-term inflammatory condition of the central face (the cheeks, nose, forehead and chin), and identifying it properly is the first step towards bringing it under control.
Rosacea usually starts after the age of 30, although it can appear earlier. It is more common in women and in people with lighter skin, but it occurs in all skin tones. In darker skin the redness is harder to see, which is one reason rosacea is often missed in those groups.
The main symptoms are:
- Flushing: the face goes red for a few minutes at a time, often with a hot or burning feeling
- Persistent redness across the cheeks, nose, forehead and chin that doesn't fully fade
- Small visible blood vessels (thread veins, or telangiectasia)
- Red bumps (papules) and pus-filled spots (pustules), without blackheads or whiteheads
- Skin that stings, burns or feels dry, especially with ordinary skincare
- Sore, gritty or dry eyes and crusty eyelids (ocular rosacea)
- Over many years, thickened skin, most often on the nose (rhinophyma)
There is no cure for rosacea, but it is manageable in most people. Identifying your own triggers, daily sun protection, gentle skincare and the right prescription treatment together make a real difference.
What causes rosacea?
The exact cause of rosacea is still not fully understood, but research has identified several factors that interact:
Blood vessel changes
Blood vessels in the face widen more easily and stay widened for longer than in unaffected skin. This explains the flushing, persistent redness and thread veins.
An overactive immune response
The skin's built-in defences, particularly a protein called cathelicidin (LL-37), are overactive and drive inflammation, redness and bumps.
Demodex mites
Demodex mites live in the hair follicles of most adults, but people with rosacea tend to have more of them. They, and bacteria they carry, may trigger an exaggerated immune response.
Genes
Rosacea often runs in families, and twin studies suggest a substantial inherited component.
The common triggers people talk about, such as sun, alcohol, spicy food, heat and stress, don't cause rosacea. They provoke flare-ups in people who already have it. Rosacea isn't caused by poor hygiene, and it isn't infectious.
The four subtypes of rosacea
Clinicians describe four subtypes of rosacea. Most people have features of more than one, and the main pattern can change over time. Knowing your main features matters because the treatments differ: what works for the bumps doesn't help the redness, and the other way round.
| Subtype | Key features | Usually treated with |
|---|---|---|
| Erythematotelangiectatic (ETR) | Persistent central facial redness, flushing, thread veins, sensitive skin | Brimonidine gel for redness; laser or IPL for thread veins; avoiding triggers and daily SPF |
| Papulopustular (PPR) | Redness with red bumps and pus-filled spots on the central face; no blackheads or whiteheads | Ivermectin cream first; metronidazole or azelaic acid as alternatives; doxycycline 40mg capsules added for more severe spots |
| Phymatous | Thickened skin, especially on the nose (rhinophyma), with enlarged oil glands and an uneven surface | Specialist referral: dermatology or plastic surgery |
| Ocular | Gritty, dry or sore eyes, inflamed eyelids (blepharitis), recurrent styes; can occur with or without skin symptoms | Eyelid hygiene and lubricating eye drops; referral to an eye specialist if severe |
Subtypes overlap: someone with persistent redness often also gets bumps and spots, and some people have eye symptoms they haven't connected with their skin. A full assessment looks for features of all four.
How rosacea progresses
Rosacea tends to move through recognisable stages, but not everyone develops every feature:
Flushing
Easy flushing in response to triggers such as alcohol, heat, embarrassment or spicy food. It settles within minutes to hours, and may go on for years before lasting changes develop.
Persistent redness
The flush no longer fully fades between triggers. Redness across the centre of the face becomes constant, often with stinging or burning, and thread veins appear.
Bumps and spots
Red bumps and pus-filled spots develop on the central face. They're often mistaken for adult acne, but there are no blackheads or whiteheads. This stage responds best to treatment.
Skin thickening (uncommon)
After many years, mainly in men, the skin can thicken, most noticeably on the nose (rhinophyma). This is uncommon but harder to reverse once established, which is one reason earlier diagnosis and treatment matter.
Common rosacea triggers
Working out your own triggers and avoiding them makes a real difference alongside any prescription treatment. Triggers vary from person to person, but some come up again and again:
- Sunlight: one of the most common triggers. A broad-spectrum SPF 30 or higher every day helps.
- Alcohol: particularly red wine. Even small amounts cause flushing in many people.
- Spicy food and hot drinks: both the heat and chilli can bring on flushing.
- Extreme temperatures: hot baths, saunas, cold wind and sudden changes in temperature.
- Hard exercise: moderate exercise somewhere cool is usually better tolerated.
- Skincare irritants: alcohol-based toners, fragrance, menthol, witch hazel, scrubs and strong retinoids.
- Stress.
- Some medicines: steroid creams on the face, and some medicines that widen blood vessels.
Steroid creams and the face: using a steroid cream, especially a strong one such as Betnovate or Dermovate, on the face for long periods can cause or worsen rosacea, with a severe flare when it's stopped. Don't use steroid creams on your face unless a doctor has told you to.
Keeping a short diary of flare-ups for a few weeks is usually enough to show your own pattern. Our guide to rosacea triggers and skincare goes into more detail.
How rosacea is diagnosed
There's no blood test for rosacea. It's diagnosed from what the skin looks like and your history. A prescriber looks for:
- Redness and spots centred on the cheeks, nose, forehead and chin
- No blackheads or whiteheads (these point to acne instead)
- A history of flushing, or redness lasting weeks or longer
- Typical triggers
- Starting after the age of 30, in most people
Other conditions that can look similar include adult acne, seborrhoeic dermatitis, perioral dermatitis, contact dermatitis, lupus and, rarely, carcinoid syndrome. For help telling rosacea from acne, see what else looks like acne.
How rosacea is treated
Treatment depends on your main symptoms. UK guidance (NICE CKS) recommends avoiding triggers and gentle skincare for everyone, then prescription treatment matched to the main feature: redness, spots, or both.
For persistent redness
Brimonidine gel (Mirvaso), applied once a day, narrows the small blood vessels in the skin and reduces redness for several hours. It can be used every day for as long as the redness lasts, but it doesn't treat spots, and in some people redness comes back worse as it wears off, so it's started at a low amount. Thread veins don't respond to creams; laser or intense pulsed light (IPL) treatment, usually from a dermatologist or private clinic, can reduce them.
For bumps and spots
For mild to moderate spots, NICE recommends ivermectin cream (Soolantra) once a day as the first choice. Metronidazole (Rozex, Metrogel or generic metronidazole gel or cream) or azelaic acid 15% gel (Finacea), each twice a day, are the alternatives. If spots don't improve enough, or are more severe, a low-dose doxycycline capsule (40mg, modified-release) is added for 8 to 12 weeks. Creams and gels usually take several weeks to work, and a course often lasts 3 to 4 months. Rosacea tends to come back, so repeat courses are common.
Our guides compare the options in detail: rosacea creams and gels compared, ivermectin cream for rosacea and metronidazole for rosacea.
For thickened skin (phymatous rosacea)
This needs a specialist. Your GP can refer you to a dermatologist or plastic surgeon, who may use laser, surgery or, for inflamed early changes, tablets such as isotretinoin.
For eye symptoms (ocular rosacea)
Mild eye symptoms are helped by warm compresses, gentle eyelid cleaning and lubricating eye drops. Severe symptoms, or a painful red eye, need an eye specialist, because rosacea can occasionally damage the surface of the eye.
Where to get treatment
Many people with rosacea redness or spots can be treated online after a clinical assessment: see our rosacea treatments. We don't treat eye symptoms, flushing on its own or thickened skin online, and we don't supply rosacea treatment in pregnancy or while breastfeeding; see your GP for these.
Daily skincare for rosacea-prone skin
Rosacea-prone skin has a fragile barrier and reacts to ingredients other skin handles without trouble. Keep it simple:
Gentle cleansing
A fragrance-free, non-foaming cleanser with lukewarm (not hot) water. Pat dry. Avoid scrubs, sodium lauryl sulfate and strong acid toners.
Prescription treatment (if you have one)
Apply it as directed to clean, dry skin and let it dry before the next step.
A plain moisturiser
Fragrance-free moisturisers, such as those containing ceramides, are usually well tolerated and help the skin barrier.
SPF 30 or higher every morning
All year round, not just in summer. Many people with rosacea find mineral sunscreens (zinc oxide or titanium dioxide) less irritating.
Rosacea vs acne: how to tell them apart
Mistaking rosacea for adult acne is common, and it matters, because some acne treatments, such as benzoyl peroxide and strong exfoliants, usually make rosacea worse.
| Rosacea | Acne | |
|---|---|---|
| Blackheads and whiteheads? | No | Yes |
| Where | Central face (cheeks, nose, forehead, chin) | Face, chest, back and shoulders |
| Usual age it starts | After 30 | Teenage years; can continue into adulthood |
| Flushing | Common | Not a feature |
| Thread veins | Common | Not a feature |
| First treatment for spots | Ivermectin; or metronidazole or azelaic acid | Retinoid or benzoyl peroxide combinations |
For more on acne, see our acne guide.
When to see a doctor
See a prescriber or your GP if you have:
- Facial redness that has lasted weeks or longer
- Frequent flushing without an obvious cause
- Red bumps or spots on the central face that haven't responded to acne treatment
- Eye symptoms, such as grittiness, dryness or recurrent styes, alongside facial redness
- Thickening of the skin on your nose or face
- Rosacea that hasn't improved after a full course of treatment
Get help the same day from your GP, an optician or NHS 111 if your eye is painful, very red or sensitive to light, or your vision changes. Also get urgent advice if redness comes on suddenly with swelling, blistering, fever or feeling unwell, which points to something other than rosacea.
Rosacea guides
Rosacea creams and gels compared
Ivermectin, metronidazole, azelaic acid and brimonidine side by side.
Ivermectin cream for rosacea
How it works, how to use it and what to expect.
Metronidazole for rosacea
Gel or cream, how long it takes, and alcohol.
Rosacea redness and flushing
What helps persistent redness, and when flushing needs a GP.
Rosacea triggers and skincare
Finding your triggers and a simple routine.
Azelaic acid (Skinoren and Finacea) guide
Cream vs gel, and acne vs rosacea.
Frequently asked questions
What is rosacea?
Rosacea is a long-term inflammatory skin condition affecting the central face: the cheeks, nose, forehead and chin. It usually begins after the age of 30 and causes flushing, persistent redness, visible blood vessels and, in some people, red bumps and pus-filled spots. Unlike acne, rosacea doesn't cause blackheads or whiteheads.
What causes rosacea?
The exact cause isn't fully understood. Rosacea involves blood vessels in the face that widen too easily, an overactive immune response in the skin, larger numbers of Demodex mites, and genes. Triggers such as sunlight, alcohol, heat, spicy food and stress bring on flare-ups but don't cause the condition itself.
What are the four subtypes of rosacea?
Rosacea is described in four subtypes that often overlap. Erythematotelangiectatic (ETR): persistent redness and visible blood vessels. Papulopustular (PPR): redness with red bumps and pus-filled spots. Phymatous: thickened skin, especially on the nose (rhinophyma). Ocular: sore, gritty or dry eyes and inflamed eyelids, which can occur with any of the others.
What is the difference between rosacea and acne?
Rosacea affects the central face, usually starts after 30, causes flushing and persistent redness, and doesn't cause blackheads or whiteheads. Acne can affect the face, chest, back and shoulders, usually starts in the teenage years, and causes blackheads and whiteheads as well as inflamed spots. Some acne treatments, such as benzoyl peroxide and harsh scrubs, usually make rosacea worse.
Can rosacea be cured?
No, but it can be controlled well. Most people get good control with a combination of avoiding their triggers, daily sun protection, prescription creams or gels matched to their symptoms, and, for visible blood vessels, laser or IPL treatment. Rosacea tends to come back, so repeat or ongoing treatment is common.
What triggers rosacea flares?
Common triggers include sunlight, alcohol (especially red wine), spicy food, hot drinks, extreme temperatures, hard exercise, some skincare ingredients (alcohol-based toners, fragrance and scrubs) and stress. Triggers vary from person to person, and keeping a short diary of flare-ups for a few weeks usually shows your own pattern.
When should I see a doctor about rosacea?
See a prescriber or your GP if you have facial redness lasting weeks, frequent flushing, red bumps on the central face that haven't responded to acne treatment, eye symptoms alongside facial redness, or thickening skin on your nose. Get help the same day if your eye is painful, very red or sensitive to light, or your vision changes.
Is rosacea linked to other health conditions?
Studies have found links between rosacea and some other conditions, including migraine, inflammatory bowel disease and heart disease. These links don't mean one causes the other, and most people with rosacea don't develop these conditions. If you have other unexplained symptoms alongside rosacea, mention them to your GP.
What is acne rosacea?
Acne rosacea is an older name for rosacea, especially the type with red bumps and pus-filled spots (papulopustular rosacea). Despite the name, it isn't a type of acne: it doesn't cause blackheads or whiteheads, and it's treated differently. Doctors now simply call it rosacea.
How do I get rid of rosacea?
Rosacea can't be cured, but you can usually get it under control. Avoid your own triggers, use a gentle skincare routine with SPF 30 or higher every day, and get treatment matched to your main symptom: a cream or gel such as ivermectin for spots, or a brimonidine gel for persistent redness. Most treatments take several weeks to work.
Is rosacea contagious?
No. Rosacea can't be passed on by touch, sharing towels or kissing. It isn't an infection and isn't caused by poor hygiene, even though some treatments for it are antibiotics or act on skin mites.
Ready to treat your rosacea?
Complete a short online consultation about your skin and anything you have tried. A GPhC-registered pharmacist prescriber checks your answers and, if treatment is suitable, we dispatch it from our UK pharmacy. For adults 18 and over.
Start Rosacea Consultation →References
- NICE Clinical Knowledge Summaries. Rosacea. cks.nice.org.uk/topics/rosacea
- NHS. Rosacea. nhs.uk/conditions/rosacea
- British Association of Dermatologists. Rosacea: patient information leaflet. bad.org.uk
- Schaller M et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465–471.
- Taieb A et al. Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea. Br J Dermatol. 2015;172(4):1103–1110.
- Steinhoff M et al. New insights into rosacea pathophysiology: a review of recent findings. J Am Acad Dermatol. 2013;69(6 Suppl 1):S15–S26.
- Summaries of product characteristics (eMC): Soolantra 10mg/g Cream; Rozex 0.75% Gel and Cream; Metrogel 0.75% Gel; Finacea 15% Gel; Mirvaso 3mg/g Gel; Efracea 40mg MR Capsules. medicines.org.uk/emc
Medical disclaimer: This page is for information only and isn't a substitute for medical advice. Rosacea treatments are prescription-only medicines and need a clinical consultation before they can be supplied. We don't supply rosacea treatment online in pregnancy, while breastfeeding, for eye symptoms or for flushing on its own. Always follow your prescriber's advice and the leaflet. In a medical emergency, call 999.
