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InflammatoryCommon BCC mimicICD-10 L71.x

Rosacea

Acne rosacea (historical) · phymatous rosacea · ocular rosacea

Rosacea is a chronic inflammatory skin disorder of the central face affecting an estimated 5-10% of UK adults, with peaks in fair-skinned middle-aged and older patients. The 2017 ROSCO phenotype-led classification recognises four overlapping subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular. Phymatous rosacea — particularly rhinophyma — is the principal mimic of basal cell carcinoma of the nasal tip, and chronic actinic damage with sebaceous hyperplasia can overlap clinically. NICE CKS rosacea guidance underpins UK primary-care management.

CurrentLast reviewed 16 May 2026
Clinical image of Rosacea
Rosacea. Image sourced from DermNet New Zealand. Used under CC BY-NC-ND 4.0. No endorsement implied.

Subtypes (ROSCO 2017 phenotype-led)

  • Erythematotelangiectatic — persistent central facial erythema, flushing, telangiectasia.
  • Papulopustular — inflammatory papules / pustules on background erythema; spares perioral skin (cf. perioral dermatitis).
  • Phymatous — sebaceous-gland hypertrophy and fibrosis; rhinophyma (nose), gnathophyma (chin), metophyma (forehead), otophyma (ear), blepharophyma (eyelid). Predominantly affects men.
  • Ocular — blepharitis, conjunctivitis, recurrent chalazia, dry eye, marginal keratitis.
  • Other phenotypes (granulomatous, neuro-inflammatory, lupus miliaris disseminatus faciei) recognised by some classifications.

Clinical features and triggers

  • Onset 30-60 years; female preponderance (except phymatous).
  • Triggers: hot drinks, alcohol, spicy food, sun exposure, extremes of temperature, stress, topical irritants, vasoactive drugs.
  • Demodex folliculorum density is increased and contributes to inflammation; rationale for topical ivermectin.
  • Pearly papules of granulomatous rosacea may mimic BCC clinically.

Differentials important in skin-oncology

  • Basal cell carcinoma of the nasal tip — pearly nodule, telangiectasia, ulceration; high index of suspicion within rhinophyma background — dermoscopy and biopsy any persistent papule.
  • Cutaneous sarcoidosis — granulomatous papules; consider in resistant disease.
  • Lupus erythematosus (malar rash) — photodistribution; lacks pustules; ANA positive.
  • Polymorphous light eruption.
  • Cutaneous T-cell lymphoma (folliculotropic MF) — facial / scalp; rosaceiform variant rare but described.
  • Acne vulgaris — comedones (absent in rosacea); broader age range.
  • Perioral dermatitis — sparing of vermilion; less central face.

Management

  • Lifestyle: trigger avoidance, daily sun protection (SPF 30+), gentle skincare.
  • Topical first-line:
    • Metronidazole 0.75% gel/cream BD.
    • Azelaic acid 15-20% BD.
    • Ivermectin 1% cream OD.
    • Brimonidine 0.33% / oxymetazoline 1% for transient erythema control.
  • Oral:
    • Low-dose doxycycline 40 mg modified release OD (sub-antimicrobial dose) for papulopustular.
    • Lymecycline / standard doxycycline 100 mg OD for 6-12 weeks for moderate-severe.
  • Phymatous: oral isotretinoin (low-dose), surgical decortication, CO2 laser, dermabrasion.
  • Telangiectasia: pulsed dye laser, intense pulsed light.
  • Ocular: lid hygiene, ocular lubricants, topical ciclosporin / azithromycin; ophthalmology referral.

Practical points

  • Always examine the nasal tip carefully in rhinophyma — BCC may hide within phymatous tissue; dermoscopy / biopsy any persistent papule.
  • Sun protection is a critical adjunct because UV both exacerbates rosacea and promotes nasal-tip skin cancer.
  • Refer to ophthalmology if any ocular symptoms — untreated ocular rosacea can cause corneal scarring.
  • Phymatous decortication: combination of cold-steel debulking and CO2 / Er:YAG laser planing has best aesthetic outcome.

References

  1. Tan J et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-438.
  2. NICE CKS. Rosacea. London: NICE; accessed 18 May 2026.
  3. van Zuuren EJ et al. Interventions for rosacea. Cochrane Database Syst Rev. 2019;3:CD003262.
  4. Layton AM et al. British Association of Dermatologists guidelines for the management of rosacea. Br J Dermatol. 2024 (in press).

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