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Skin and nail

Rosacea

Last revised in October 2025

Acne rosacea is a chronic relapsing skin condition affecting the face, characterized by episodes of facial flushing, erythema, telangiectasia.

Rosacea - acne: Summary

  • Rosacea (previously known as 'acne rosacea') is a chronic, inflammatory skin condition predominantly affecting the convexities of the centrofacial region (cheeks, chin, nose, and central part of forehead).
  • Rosacea should be diagnosed and managed using a 'phenotype approach', based on the presenting features in each person if there is at least one 'diagnostic' or two 'major' clinical features present:
    • Diagnostic features — phymatous changes, persistent erythema.
    • Major features — flushing/transient erythema, papules and pustules, telangiectasia, eye symptoms (ocular rosacea).
    • Minor features — skin burning and/or stinging sensation, skin dryness, oedema.
  • Ocular rosacea may be characterized by eye discomfort, irritation, tearing, foreign body sensation, dryness, itching, photophobia, or blurred vision, and present as lid margin telangiectasia, blepharitis or acute lid infection (chalazion or hordeolum), conjunctivitis, keratitis, or anterior uveitis.
    • Eye symptoms or signs may present with or without skin disease.
  • Rosacea may progress in severity and change to include additional phenotypes, and is often characterized by repeated remissions and exacerbations.
  • The exact cause of rosacea remains unclear, and is likely to be multifactorial involving genetic and environmental risk factors, such as:
    • Increasing age.
    • Photosensitive skin types.
    • Ultraviolet radiation exposure.
    • Smoking, alcohol.
    • Spicy foods and hot drinks.
    • Heat or cold temperature.
    • Emotional stress and exercise.
    • Colonization with Demodex folliculorum mites.
  • Assessment of a person with suspected rosacea should include:
    • Asking about symptoms and their onset, distribution, duration, and severity; the frequency and duration of relapses; any psychosocial impact; any trigger factors; previous treatments and symptom response.
    • Examining to assess the phenotype, extent, and severity of facial skin involvement, and for features of ocular rosacea.
  • Management of suspected rosacea should include:
    • Providing advice on sources of information and support.
    • Providing advice on self-management measures, including trigger factor avoidance, effective sun protection, and general skincare measures.
    • Offering referral to a skin camouflage service, if appropriate.
    • Managing any psychosocial co-morbidities. 
    • Prescribing first-line topical and/or oral drug treatments, depending on the clinical phenotype and severity of disease, and the person's preferences. This may include topical brimonidine for persistent erythema, topical ivermectin for mild-to-moderate papules/pustules, and the addition of oral doxycycline for moderate-to-severe papules/pustules, depending on contraindications.
    • Reviewing the person following first-line treatment(s), to assess the clinical response and need for maintenance or alternative therapy.
  • Referral to a dermatologist should be considered if there is:
    • Persistent erythema or papules/pustules that have not responded to optimal management in primary care.
    • Severe telangiectasia that have not responded to self-management advice.
    • An uncertain diagnosis.
  • Referral to a plastic surgeon should be considered if there is:
    • Prominent non-inflamed phymatous disease.
  • Referral to an ophthalmologist should be arranged, the urgency depending on clinical judgement, if:
    • A serious eye complication, such as keratitis or anterior uveitis, is suspected.
    • Other ocular symptoms are severe or have not responded to optimal management in primary care, such as lid hygiene measures and the use of artificial tears/ocular lubricants.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the diagnosis and management of rosacea in primary care.

This CKS topic does not cover the detailed management of rosacea in secondary care.

There are separate CKS topics on Blepharitis, Conjunctivitis - infective, Dry eye syndrome, Meibomian cyst (chalazion), Red eye, Styes (hordeola), and Uveitis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2025 — minor update. Added information on drug interaction between rifampicin and doxycycline.

Previous changes

July 2025 — reviewed. A literature search was conducted in June 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

December 2024 — minor update. Sunsense cream discontinued and removed from the recommendations for self-management options. 

March 2024 — minor update. Fixed eruption added as an adverse effect of doxycycline as per the manufacturer's updated SPC.

December 2023 — minor update. Update to drug interactions section for erythromycin to include information on interactions with Lomitapide and Corticosteroids, as per the manufacturer's Summary of Product Characteristics (SPC).

February 2023 — minor update. Information about alternative first-line antibiotic options have been added to this topic in line with The British Association of Dermatologists guidelines for the management of people with rosacea.

January 2021 — minor update. Contraindications and drug interactions for erythromycin have been updated in line with an MHRA drug safety update. 

May to June 2020 — reviewed. A literature search was conducted in May 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic name has been changed from Acne rosacea to Rosacea, in line with current literature. The topic has undergone minor restructuring. A new section on Assessment has been added to the Diagnosis section. The sections on Self-care advice and Follow-up have been deleted and the content has been incorporated into the Management node. The sections on the diagnosis and management of rosacea have been updated to recommend a phenotype approach based on individual clinical features, rather than the previous subtype approach, in line with international consensus publications from the ROSacea COnsensus (ROSCO) panel. The option of prescribing topical ivermectin in primary care has been included, and the choice of oral antibiotics has been amended, in line with current literature. The Prescribing information section has been updated.

October 2018 — minor update. The adverse effects section of the drug metronidazole has been updated in the section on Prescribing information.

June 2017 — minor update. Text added on the contraindications and adverse effects of brimonidine gel following the Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update Brimonidine gel (Mirvaso): risk of systemic cardiovascular effects; not to be applied to damaged skin (2017).

November 2016 — minor update. Information added on the risk of exacerbation of rosacea with brimonidine gel. 

December 2015 to January 2016 — reviewed. A literature search was conducted in December 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has been updated in line with a Cochrane systematic review Interventions for rosacea, and topical brimonidine 0.5% gel has been added as a treatment option. Minor restructuring of the topic has also been undertaken.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

October 2009 — minor update. Text updated to include doxycycline 40 mg modified-release capsules, which have been recently licensed in the UK for the treatment of rosacea. 

May to August 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

May 2007 — minor update. Topical azelaic acid 15% gel has recently been launched and is licensed for use in papulopustular rosacea. The prescription for topical azelaic acid 20% cream (unlicensed for this indication) has been substituted for azelaic acid 15% gel (licensed). 

November 2005 — minor technical update. 

March 2005 — written. Validated in June 2005 and issued in July 2005.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2025.

Economic Appraisals

No new economic appraisals relevant to England since 1 June 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 June 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2025.

New policies

No new national policies or guidelines since 1 June 2025.

New safety alerts

No new safety alerts since 1 June 2025.

Changes in product availability

No changes in product availability since 1 June 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of rosacea or ocular rosacea.
  • Assess the phenotype, severity, and extent of rosacea.
  • Provide appropriate self-management advice.
  • Offer management with topical and/or oral drug treatment in primary care, depending on the clinical phenotype, severity, and preferences of the person.
  • Arrange specialist referral to dermatology, plastic surgery, a skin camouflage service, and/or ophthalmology, if appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Rosacea (previously known as 'acne rosacea') is a chronic, inflammatory skin condition predominantly affecting the convexities of the centrofacial region (cheeks, chin, nose, and central part of forehead) [Tan, 2017; Gallo, 2018; Schaller, 2020; Hampton, 2021; Thiboutot, 2020].
    • It may be characterized by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules, and pustules [Schaller, 2020].
    • Previously, rosacea was classified into different subtypes (erythematotelangiectatic, inflammatory papulopustular, phymatous, and ocular), however, it is now accepted that a person may show signs of transformation or progression between subtypes, or different subtypes may co-exist [Gallo, 2018; Tan, 2018; Schaller, 2020].
  • The ROSacea COnsensus (ROSCO) international panel of experts recommends a transition from a subtype categorization of rosacea to a more individualized, person-centred phenotype approach, based on the presenting clinical features in each person [Schaller, 2017; Schaller, 2020]:
    • Diagnostic features — phymatous changes, persistent erythema. 
    • Major features — flushing/transient erythema, papules and pustules, telangiectasia, eye manifestations.
    • Minor features — skin burning and/or stinging sensation, skin dryness, oedema. 
  • The British Association of Dermatologists (BAD) also recommends using this newer phenotype classification system, but taking into account the older system to characterize the clinical subtypes and symptoms [Hampton, 2021].
  • There may be associated eye symptoms (ocular rosacea), characterized by [Schaller, 2020]:
    • Lid margin telangiectasia — visible vessels around the eyelid margins. 
    • Blepharitis — inflammation of the eyelid margin. See the CKS topic on Blepharitis for more information.
    • Conjunctivitis — inflammation of the mucous membranes lining the inner surface of the eyelids and bulbar conjunctiva. See the CKS topic on Conjunctivitis - infective for more information.
    • Keratitis — inflammation of the cornea. See the CKS topic on Red eye for more information.
    • Anterior uveitis — inflammation of the iris and/or ciliary body. See the CKS topic on Uveitis for more information.

How common is it?

The prevalence of rosacea varies depending on the populations studied, diagnostic tools used, and study methodological approach [Gether, 2018].

  • A global systematic review of 32 population-based and secondary care studies (n = 26,519,836) found [Gether, 2018]:
    • The pooled prevalence of rosacea in the general population was 5.46%, and 2.39% in dermatology outpatients.
    • Women were affected more commonly than men (prevalence rates of 5.41% and 3.9%, respectively).
    • Rosacea mainly affected people aged 45–60 years.
  • A multi-centre, interventional, cross-sectional study in Germany (n = 3052) and Russia (n = 3013) found a prevalence of rosacea of 12.3% and 5%, respectively. The demographic profile of people affected was similar between the two countries [Tan, 2016]:
    • 75% of people affected were women, and the mean age was 40 years.
    • People with fair skin were predominantly affected (skin phototype II and III).
  • Rosacea usually develops in people aged between 30–50 years [van Zuuren, 2017; Gallo, 2018].
  • Rosacea is most frequently observed in people with fair skin types [Gallo, 2018; Thiboutot, 2020].  
    • It may be under-reported and under-diagnosed in people with darker skin types, owing to the difficulty in identifying erythema and telangiectasia [Tan, 2018; Alexis, 2019].
  • Women are affected more often than men, but men are more likely to have more severe presentations, such as phymatous changes, especially rhinophyma [Oge, 2015; Gallo, 2018; Hampton, 2021].
  • Ocular rosacea is estimated to occur in more than 50% [Thiboutot, 2020] and up to three-quarters of people with skin involvement [van Zuuren, 2017]. 

What are the risk factors?

The exact cause of rosacea remains unclear and is likely to be multifactorial, involving genetic and environmental factors [Aldrich, 2015; Tan, 2017; van Zuuren, 2017; Gallo, 2018; Hampton, 2021].

  • Genetic factors, dysregulation of the innate and adaptive immune system, vascular and neuronal dysfunction, and colonization with Demodex folliculorum mites may be involved in the pathogenesis of rosacea, causing dysregulation of the inflammatory response [Tan, 2017; van Zuuren, 2017; Gallo, 2018]. 
    • Expert opinion in a review article notes that the different clinical presentations of rosacea may be phenotype manifestations of the same underlying inflammatory continuum through different molecular pathways and cell activities [Gallo, 2018]. 
    • A US twin cohort study (n = 275 twin pairs) calculated that genetics contributed 46% to rosacea grading scores, and there were also correlations with environmental factors [Aldrich, 2015]. 
    • A systematic review of 23 case-control studies (n = 1513) found that compared with controls, people with rosacea were more likely to be infested with Demodex mites (odds ratio 9.039) and had significantly higher skin density of Demodex mites than controls. The authors noted, however, that variability between studies was high and a causal relationship could not be confirmed [Chang, 2017]. 
  • Additional factors that may trigger or worsen rosacea include [Steinhoff, 2013; Aldrich, 2015; Oge, 2015; Tan, 2017; van Zuuren, 2017; Gether, 2018; Hampton, 2021; Thiboutot, 2020]:
    • Alcohol. 
    • Emotional stress and exercise. 
    • Heat or cold ambient temperature. 
    • Increasing age.
    • Photosensitive skin types. 
    • Smoking. 
    • Spicy foods and hot drinks. 
    • Topical corticosteroids. 
    • Ultraviolet radiation exposure. 

What are the complications?

Possible complications of rosacea include:

  • Psychosocial impact:
  • Ocular conditions, such as [Oge, 2015; Schaller, 2020]:
    • Lid margin telangiectasia — visible vessels around the eyelid margins. May be difficult to detect visually in darker skin phototypes (V and VI). 
    • Blepharitis — inflammation of the eyelid margin, most commonly arising from meibomian gland dysfunction. See the CKS topics on Blepharitis and Meibomian cyst (chalazion) for more information. 
    • Keratitis, scleritis, or iritis — inflammation of the cornea (which may present as eye pain, blurred vision, and photosensitivity). See the CKS topic on Red eye for more information.
    • Conjunctivitis — inflammation of the mucous membranes lining the inner surface of the eyelids and bulbar conjunctiva. Typically associated with injection or vascular congestion and conjunctival oedema. See the CKS topic on Conjunctivitis - infective for more information.
    • Anterior uveitis — inflammation of the iris and/or ciliary body. See the CKS topic on Uveitis for more information.
  • Rosacea fulminans (pyoderma faciale):
    • A severe, rare form of rosacea characterized by the sudden onset of multiple erythematous papules, pustules, cysts, and nodules, which may cause scarring [Coutinho, 2016]. 
  • Lymphoedema — this is rare, but can develop over the face and ears, resulting in a coarsening of features (known as leonine facies) [Hampton, 2021].   
    • Chronic upper facial erythematous oedema is also known as Morbihan disease. The orbital skin may be affected, resulting in severe eyelid swelling and sometimes ectropion. 
  • Malignancy — basal cell carcinoma may occur as a complication of rhinophyma [Hampton, 2021].

What is the prognosis?

The long-term prognosis of rosacea varies depending on the person, disease phenotype and severity, and response to treatment.

  • Rosacea usually follows a fluctuating course and may progress in severity and also transform to include additional clinical phenotypes, and is often characterized by repeated remissions and exacerbations [Gallo, 2018; Hampton, 2021]. 
  • A retrospective study of 234 people with different presentations of rosacea in dermatology clinics, with a median follow up of 17.5 months, found [Lee, 2016]: 
    • Partial remission was noted in 61.5% of all participants.
    • Complete remission was noted in 20.9% of all participants. The median time to complete remission was 56 months.
    • People with inflammatory papules and pustules alone had a more favourable prognosis than other subtypes or mixed clinical presentations.

Diagnosis

When should I suspect a diagnosis of rosacea?

The clinical manifestations of rosacea often vary in nature and severity over time, and the diagnosis is usually made on the basis of clinical features alone.

  • Make a diagnosis of rosacea if there is at least one 'diagnostic' or two 'major' clinical features (phenotypes) present: 
    • Diagnostic clinical features:
      • Phymatous changes — facial skin thickening due to fibrosis and/or sebaceous glandular hyperplasia. Most commonly affects the nose, where it may have a bulbous appearance (so-called rhinophyma). May be clinically inflamed (‘active’) or non-inflamed (‘fibrotic’ or ‘burnt out’). 
      • Persistent erythema — persistent centrofacial redness that may periodically intensify in response to various trigger factors. Note: in darker skin phototypes (V and VI), erythema may be difficult to detect visually. 
    • Major clinical features (which are not individually diagnostic): 
      • Flushing/transient erythema — a temporary increase in centrofacial redness, which may include sensations of warmth, heat, burning, and/or pain. It usually lasts for less than 5 minutes and may spread to the neck and chest. 
      • Inflammatory papules and pustules — red papules and pustules, usually in the centrofacial area. Some may be larger and deeper and may become nodules.
      • Telangiectasia — visible vessels in the centrofacial region, but not only in the alar area (side of nose). In darker skin phototypes (V and VI) telangiectasia may be difficult to detect visually and may require examination with a dermatoscope. 
      • Ocular manifestations. 
    • Minor clinical features (which may be subjective and are not individually diagnostic): 
      • Burning sensation — an uncomfortable or painful feeling of heat, typically in the centrofacial region. 
      • Stinging sensation — an uncomfortable or painful sharp, pricking sensation, typically in the centrofacial region.
      • Skin dryness sensation or appearance — skin that feels rough. May be tight, scaly, and/or itchy. 
      • Oedema — localized facial swelling that may accompany or follow prolonged erythema or flushing. May be soft or firm (non-pitting), and may be transient or persistent. 
  • Suspect a diagnosis of ocular rosacea if:
    • There are eye symptoms such as:
      • Burning or stinging, tearing, foreign body sensation, dryness, itching, photophobia, or blurred vision. 
    • There are eye signs of:
      • Lid margin telangiectasia — visible vessels around the eyelid margins. Note: this may be difficult to detect visually in darker skin phototypes (V and VI). 
    • There is suspected:
      • Blepharitis or acute lid infection (chalazion or hordeolum). See the CKS topics on Blepharitis, Meibomian cyst (chalazion), and Styes (hordeola) for more information.
      • Conjunctivitis — inflammation of the mucous membranes lining the inner surface of the eyelids and bulbar conjunctiva. Typically associated with injection or vascular congestion and conjunctival oedema. See the CKS topic on Conjunctivitis - infective for more information. 
      • Keratitis. See the CKS topic on Red eye for more information.
      • Anterior uveitis — inflammation of the iris and/or ciliary body. See the CKS topic on Uveitis for more information. 
    • Note: be aware that eye symptoms or signs may present with or without skin disease. 

Basis for recommendation

These recommendations are based on the ROSacea COnsensus (ROSCO) international consensus publications Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel [Schaller, 2017], Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel [Tan, 2017], and Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel [Schaller, 2020], the US National Rosacea Society (NRS) publications Standard classification and pathophysiology of rosacea [Gallo, 2018], and Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee [Thiboutot, 2020], the American Acne and Rosacea Society (AARS) publication Update on the management of rosacea from the American Acne and Rosacea Society (AARS) [Del Rosso, 2019], the British Association of Dermatologists (BAD) guidelines for the management of people with rosacea 2021 [Hampton, 2021], a systematic review Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments [van Zuuren, 2019], and expert opinion in reviews Rosacea: diagnosis and treatment [Oge, 2015], Rosacea [van Zuuren, 2017], Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and practical clinical experience [Alexis, 2019], and Applying the phenotype approach for rosacea to practice and research [Tan, 2018].

  • The information that there are multiple clinical manifestations of rosacea that may change over time is based on the ROSCO consensus publications [Schaller, 2017; Schaller, 2020], the NRS publication [Gallo, 2018], the AARS publication [Del Rosso, 2019], and expert opinion in a review article [Tan, 2018].
  • The recommendation to make a diagnosis of rosacea based on the presence of diagnostic, major and/or minor clinical features is largely based on the ROSCO consensus publications [Tan, 2017; Schaller, 2017; Schaller, 2020], and the NRS publications [Gallo, 2018; Thiboutot, 2020].
    • The NRS publication notes there has been a change in the literature from a subtype to a phenotype classification for the diagnosis and management of rosacea. This has partly been in response to the fact a person may have more than one subtype co-existing, the potential for progression from one subtype to another, and the difficulty in assessing severity of different subtypes simultaneously and their response to interventions.
    • A systematic review of interventions for rosacea notes the phenotype approach should improve the accuracy of diagnosis, and improve patient-centred care [van Zuuren, 2019]. This is supported by the ROSCO consensus publications that note that the subtype classification may not fully cover the full range of clinical presentations of rosacea [Tan, 2017], and skin clinical feature descriptions can help improve and standardize disease diagnosis and monitoring [Schaller, 2020]. In addition, expert opinion in a review article proposes that a phenotype approach may improve patient outcomes by targeting the clinical features that are most troublesome for the person [Tan, 2018].

How should I assess a person with suspected rosacea?

If a person presents with suspected rosacea:

  • Ask about:
    • Symptoms such as flushing, skin burning, stinging, and dryness, and their onset, duration, and severity.
    • The distribution, extent, and severity of facial skin involvement, including daily fluctuation of features.
    • Symptoms of ocular rosacea, and their onset, duration, and severity.
    • The frequency and duration of relapses.
    • Any psychosocial impact on quality of life, including work, education, social, or leisure activities.
    • Any known trigger factors, including sun exposure, diet, and activities that cause symptoms or relapses.
    • Any known family history. 
    • Any previous treatments and symptom response.
  • Examine the person:
    • Assess for facial skin involvement, the distribution, extent, and severity of clinical features, including: 
      • Phymatous changes (skin thickening, deformation, sites of involvement, inflamed or non-inflamed).  
      • Erythema (transient or persistent).
      • Oedema (depth, pitting, distortion). 
      • Telangiectasia. 
      • Inflammatory papules, pustules, or nodules.
    • Assess for possible clinical features of ocular rosacea. 

Basis for recommendation

These recommendations are based on the ROSacea COnsensus (ROSCO) international consensus publication Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel [Schaller, 2020], the US National Rosacea Society (NRS) publications Standard classification and pathophysiology of rosacea [Gallo, 2018], and Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee [Thiboutot, 2020], and expert opinion in narrative reviews Rosacea: diagnosis and treatment [Oge, 2015], and Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: Review and clinical practice experience [Alexis, 2019].

What else might it be?

Other conditions that may present similarly to rosacea include:

  • Acne vulgaris — usually features comedones, without telangiectasia, flushing, or facial erythema, or ocular symptoms. It can also affect the back and chest, and typically presents in teenagers and young adults. See the CKS topic on Acne vulgaris for more information.
  • Carcinoid syndrome — atypical (prolonged, generalized or severe) flushing. Other symptoms may include sweating, bronchospasm, abdominal pain, and diarrhoea. 
  • Contact dermatitis — itchy rash with dry skin, scaling, and possible vesicles. Often improves if the causative irritant or allergen is removed, and it may affect a person of any age. See the CKS topic on Dermatitis - contact for more information.
  • Erysipelas —  a form of cellulitis involving more superficial dermal structures distinguished clinically by raised and well-demarcated borders. See the CKS topic on Cellulitis - acute for more information.
  • Folliculitis — a superficial infection of the hair follicles, which develop into small inflammatory papules or pustules. May occur in isolation or in association with rosacea. See the CKS topic on Boils, carbuncles, and staphylococcal carriage for more information.
  • Keratosis pilaris — marked erythema and keratotic follicular papules covering cheeks and proximal arms.
  • Lupus erythematosus — discoid lupus heals with atrophy and scarring which does not occur in rosacea, systemic lupus erythematosus (SLE) can present with an erythematous butterfly rash. Rarely presents with pustules.
  • Mastocytosis — may present as flushing, abdominal pain, diarrhoea, and musculoskeletal pain.
  • Peri-oral and peri-ocular dermatitis — self-limiting small red papules and pustules near the mouth, nose, and eyes, often in the absence of flushing and telangiectasia. Often in young women. 
  • Photodermatitis/photodamage — general erythema in a sunlight-exposed distribution, more prominent at sides of face instead of centrofacial area, does not present with flushing, inflammatory lesions, or phyma. May co-exist with rosacea. 
  • Sarcoidosis — a rare granulomatous condition with facial manifestations characterized by persistent plaques with papules and nodules. There may be systemic involvement.
  • Seborrhoeic dermatitis — yellow greasy scales on an erythematous base, usually found on the sebum-rich areas of the scalp and face (including the ears, eyebrows, and nasolabial folds). See the CKS topic on Seborrhoeic dermatitis for more information.
  • Topical corticosteroid-induced dermatitis —  application of topical corticosteroids can induce symptoms resembling erythematotelangiectatic rosacea and/or inflammatory rosacea. This is usually associated with the use of potent and very potent corticosteroids, although may occasionally occur with less potent compounds. 

Basis for recommendation

This information is based on the US National Rosacea Society (NRS) publication Standard classification and pathophysiology of rosacea [Gallo, 2018], the American Acne and Rosacea Society (AARS) publication Update on the management of rosacea from the American Acne and Rosacea Society (AARS) [Del Rosso, 2019], the British Association of Dermatologists (BAD) guidelines for the management of people with rosacea 2021 [Hampton, 2021], and expert opinion in narrative reviews Rosacea: a review [Culp, 2009], Rosacea: diagnosis and treatment [Oge, 2015], Rosacea [van Zuuren, 2017], and Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and practical clinical experience [Alexis, 2019], and the BMJ Best Practice guide Rosacea [BMJ Best Practice, 2025].

Management

Scenario: Rosacea

From age 16 years onwards.

How should I manage a person with rosacea?

If a person has a suspected diagnosis of rosacea, management should be based on the presenting clinical phenotype, and may involve more than one treatment.

  • Advise that:
    • Rosacea is a chronic condition that may improve with treatment, but intermittent relapses may occur.
    • The aim of treatment should be complete skin clearance, where possible. 
  • Provide advice on sources of information and support, such as: 
  • Provide advice on self-management measures:
    • Advise on the importance of avoiding trigger factors wherever possible. 
      • Suggest that a diary may be helpful to identify stimuli and triggers that may exacerbate rosacea.
    • Advise on the importance of effective sun protection and to avoid the use of sunbeds. 
      • High-factor sunscreen with protection against ultraviolet A and B can be prescribed (these are classified as 'borderline substances' and the prescription must be endorsed 'ACBS'). See the BNF for further information.  
      • Ultraviolet protection sunglasses may be helpful for people with features of ocular rosacea. 
    • Advise on general skincare measures such as: 
      • The use of regular non-oily emollients if the skin is dry. See the CKS topic on Eczema - atopic for detailed prescribing information on emollients.
      • The use of gentle soap-free over-the-counter cleansers.
      • The possible use of yellow- or green-tinted cosmetics to help camouflage skin erythema.
  • Offer referral to a skin camouflage service if appropriate. See the section on Referral for more information. 
  • Manage any associated psychosocial comorbidities. See the CKS topics on Generalized anxiety disorder and Depression for more information. 
  • Offer first-line treatments, depending on the clinical phenotype and severity of disease, and the person's preferences.
    • Transient facial flushing — consider offering oral propranolol 20–40 mg two to three times daily.  
    • Persistent erythema — consider offering topical brimonidine 0.5% gel once daily as required, for temporary relief of symptoms, depending on local prescribing guidelines. See the section on Brimonidine in Prescribing information for more information, including contraindications and cautions. 
      • Advise that topical brimonidine may reduce erythema within 30 minutes, reaching peak action at 3–6 hours, after which the effect diminishes and erythema returns to baseline.
    • Mild-to-moderate papules and/or pustules — offer topical ivermectin once daily for 8–12 weeks, depending on local prescribing guidelines. See the section on Ivermectin in Prescribing information for more information. 
      • If ivermectin is not available or inappropriate (for example, for pregnant or breastfeeding women), alternative topical preparations are metronidazole 0.75% applied twice daily, or azelaic acid 15% applied twice daily. See the sections on Metronidazole and Azelaic acid in Prescribing information for more information. 
    • Moderate-to-severe papules and/or pustules — offer a combination of topical ivermectin (or an alternative if necessary), depending on local prescribing guidelines, together with oral doxycycline 40 mg once daily as a modified-release preparation for 8–12 weeks. See the section on Doxycycline in Prescribing information for more information. 
      • Alternative oral antibiotics (depending on local protocols) may include azithromycin 250–500 mg two to three times weekly, clarithromycin 250 mg on alternate days, doxycycline 100 mg daily, lymecycline 408 mg once daily, oxytetracycline 500 mg twice daily, or erythromycin 500 mg twice daily.  
      • If oral antibiotic treatment is considered necessary in women who are pregnant or breastfeeding, offer erythromycin 500 mg twice daily. 
    • Clinically inflamed phymatous disease — consider offering oral doxycycline 40 mg once daily as a modified-release preparation (off-label indication) for 6 weeks.
  • For people with suspected ocular rosacea:
    • Identify systemic medicines that could be triggering eye dryness (for example, antidepressants, anxiolytics), and adjust treatment as necessary. 
    • Provide advice about:
      • Minimizing exposure to aggravating factors, such as air conditioning, excessive central heating, smoky atmospheres, and periocular cosmetics.
      • Lid hygiene measures. See the CKS topic on Blepharitis for more information.
      • The use of artificial tears or ocular lubricants (for mild ocular burning and stinging symptoms and dry eyes). See the CKS topic on Dry eye syndrome for more information. 
  • Arrange to review the person following first-line treatment(s), to assess the clinical response, need for maintenance therapy, alternative treatment, or referral. 
    • For mild-to-moderate papules and/or pustules:
      • If there is clinical improvement — continue maintenance treatment with topical preparations as needed, ideally until the skin is clear. 
      • If there is little or no improvement — consider offering a combination of topical preparation together with an oral antibiotic for 8–12 weeks.
    • For moderate-to-severe papules and/or pustules:
      • If there is clinical improvement — continue combination treatment up to 12–16 weeks, then reassess the need for ongoing oral antibiotic treatment and continue topical treatment, depending on clinical judgement. 
      • If there is little or no improvement — consider arranging referral to dermatology, depending on clinical judgement. See the section on Referral for more information. 
    • For suspected ocular rosacea following 2–4 weeks of self-care treatment:
      • If there is clinical improvement — continue management as needed.
      • If there is little or no improvement — consider arranging referral to ophthalmology, depending on clinical judgement. See the section on Referral for more information. 

Basis for recommendation

These recommendations are based on the ROSacea COnsensus (ROSCO) international consensus publications Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel [Schaller, 2017] and Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel [Schaller, 2020], the US National Rosacea Society (NRS) expert committee publications Standard classification and pathophysiology of rosacea [Gallo, 2018], and Standard management options for rosacea: the 2019 update by the National Rosacea Society Expert Committee [Thiboutot, 2020], the British Association of Dermatologists (BAD) guidelines for the management of people with rosacea [Hampton, 2021], a Dutch clinical guideline Rosacea treatment guideline for the Netherlands [van Zuuren, 2020], the National Institute for Health and Care Excellence (NICE) evidence summaries Facial erythema of rosacea: brimonidine tartrate gel [NICE, 2014] and Inflammatory lesions of papulopustular rosacea: ivermectin 10 mg/g cream [NICE, 2016], a systematic review Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments [van Zuuren, 2019], and expert opinion in narrative reviews Rosacea: diagnosis and treatment [Oge, 2015], Rosacea [van Zuuren, 2017], and Applying the phenotype approach for rosacea to practice and research [Tan, 2018], the British National Formulary (BNF) [BNF, 2025], and what CKS considers good medical practice. 

Beta-blockers for transient flushing
  • BAD recommends that oral propranolol can be considered for people with transient flushing [Hampton, 2021]. However, the ROSCO consensus panel, advises that there is limited evidence to support the use of beta blockers for treatment of flushing/transient erythema, but they can be considered in certain situations [Schaller, 2020]. Similarly, a narrative review advises that there is a lack of evidence on interventions for transient erythema and flushing. However, on the basis of empirical evidence, when flushing is bothersome, beta-blockers are often prescribed [van Zuuren, 2017]. 
Oral antibiotic treatments
  • The recommendation to offer oral doxycycline 40 mg modified release first-line is based on a Dutch guideline [van Zuuren, 2020], the American Acne and Rosacea Society (AARS) guideline [Del Rosso, 2019], and the British Association of Dermatologists (BAD) guideline [Hampton, 2021].
    • CKS notes that the Dutch clinical guideline does not recommend a treatment duration for clinically inflamed phymatous disease. CKS has therefore extrapolated its recommendation from the BNF on the treatment of papules and/or pustules, which recommends low-dose modified-release doxycycline for 6 weeks initially, and to discontinue treatment after this time if there is no clinical response.
  • BAD recommends that an oral antibiotic should be offered as a first-line treatment option for more severe papulopustular rosacea: azithromycin, clarithromycin, doxycycline 40 mg (modified release), doxycycline 100 mg daily, erythromycin, lymecycline or oxytetracycline, but it does not recommend a preference from these options. However, it advises that:
    • These antibiotics (especially tetracyclines) are considered safe and have been prescribed for rosacea for decades.
    • There is insufficient evidence to establish the superiority of one over another, especially in the absence of head-to-head trials or a network meta-analysis. 
    • Currently, only the modified-release formulation of doxycycline is licensed specifically for papulopustular rosacea in the UK.
  • The recommendations on alternative antibiotic treatments and doses are also based on the Dutch clinical guideline [van Zuuren, 2020], the ROSCO consensus publication [Schaller, 2017], the British National Formulary (BNF) [BNF, 2025], a narrative review [van Zuuren, 2017], and an MHRA evidence review on macrolides in pregnancy [MHRA, 2021].
    • The recommendation to offer erythromycin to pregnant or breastfeeding women if treatment is considered necessary is because use of tetracyclines is contraindicated in these people. An MHRA evidence review advises that if a prescriber views that the potential benefits of treatment will outweigh the risks, and that no suitable and safe alternative is available, a macrolide can be used during pregnancy. In these circumstances, erythromycin is recommended as the preferred choice [MHRA, 2021]. BAD does not recommend a specific rosacea treatment option for women who are pregnant, although a Dutch guideline advises that azithromycin is an option during pregnancy [van Zuuren, 2020]. 
Ocular rosacea treatment

When should I refer a person with rosacea?

  • Consider arranging referral to a dermatologist for possible specialist management if there is: 
    • Persistent erythema that has not responded to optimal management in primary care. 
    • Persistent inflammatory papules and/or pustules that have not responded to optimal management in primary care. 
    • Severe telangiectasia that have not responded to self-management advice, depending on clinical judgement and local referral guidelines. 
    • An uncertain diagnosis.
  • Consider arranging referral to a local skin camouflage service (which may be available through the local dermatology service). 
    • Advise that people may self-refer to the charity Changing Faces, which provides education from skin camouflage practitioners on the use and application of cosmetic camouflage creams and powders. The website (available at www.changingfaces.org.uk) provides patient information on Skin camouflage, details of local skin camouflage services, a telephone helpline, and online support forum.
  • Consider arranging referral to a plastic surgeon if there is:  
    • Prominent non-inflamed phymatous disease.
  • Arrange referral to an ophthalmologist, the urgency depending on clinical judgement, if: 
    • The person has severe ocular rosacea. 
    • If eye discomfort and sticky eye discharge persist for over 12 months despite frequent (over six times daily) use of topical lubricants and lid hygiene measures.   
    • A serious eye complication, such as keratitis or anterior uveitis, is suspected (for example, suggested by sudden pain, red eye, and/or visual disturbance). See the CKS topics on Red eye and Uveitis for more information. 
    • Other associated ocular symptoms are severe or do not respond to optimal management in primary care. See the CKS topics on Blepharitis, Meibomian cyst (chalazion), Styes (hordeola), Conjunctivitis, and Dry eye syndrome for more information.

Specialist management

Specialist treatment options may include:

  • Oral isotretinoin for severe inflammatory papules and/or pustules, or clinically inflamed phymatous disease. 
  • Electrodessication, intense pulsed light (IPL) therapy, or pulsed dye/Nd:YAG laser therapy for persistent erythema and/or telangiectasia. 
  • Topical alpha-adrenergic modulating agents, such as brimonidine for flushing or transient erythema, in specific situations.  
  • Laser therapy or non-laser physical modalities, such as electrosurgery, microdermabrasion, excision, loop cautery, or scissor sculpting, for clinically non-inflamed severe phymatous disease.

[Oge, 2015; Schaller, 2017; Del Rosso, 2019; van Zuuren, 2019; Schaller, 2020; van Zuuren, 2020; Hampton, 2021]

Basis for recommendation

These recommendations are based on the ROSacea COnsensus (ROSCO) international consensus publications Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel [Schaller, 2017], Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel [Tan, 2017], and Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel [Schaller, 2020], the US National Rosacea Society (NRS) expert committee publications Standard classification and pathophysiology of rosacea [Gallo, 2018], and Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee [Thiboutot, 2020], the British Association of Dermatologists (BAD) guidelines for the management of people with rosacea 2021 [Hampton, 2021], a Dutch clinical guideline Rosacea treatment guideline for the Netherlands [van Zuuren, 2020], expert opinion in narrative reviews Rosacea [van Zuuren, 2017], and Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and practical clinical experience [Alexis, 2019], and what CKS considers good medical practice.

Arranging referral to dermatology
  • These recommendations are extrapolated from a Dutch clinical guideline [van Zuuren, 2020], the ROSCO consensus publications on treatment [Schaller, 2017], and on diagnosis [Tan, 2017], the NRS  publication [Gallo, 2018], and expert opinion in narrative reviews [Alexis, 2019; van Zuuren, 2017].
    • The Dutch clinical guideline notes that if a person has severe papules and/or pustules that have not responded to combination therapy in primary care including oral tetracyclines, they may be offered specialist treatment with oral isotretinoin.
    • The ROSCO consensus publication on diagnosis notes that skin biopsy may be needed if there is an uncertain diagnosis, for example in people with darker skin phototypes, where diagnostic features of erythema and telangiectasia may be difficult to detect. Similarly, the NRS publication and expert opinion in a review article state that use of a dermatoscope may allow for detection of telangiectasia in people with darker skin types [Gallo, 2018; Alexis, 2019].
Arranging referral to plastic surgery
  • This recommendation is extrapolated from the ROSCO consensus publication on treatment [Schaller, 2017] and the Dutch clinical guideline [van Zuuren, 2020].
Arranging referral to ophthalmology
  • These recommendations are based on the ROSCO consensus publication [Schaller, 2020], the Dutch clinical guideline [van Zuuren, 2020], the BAD guideline [Hampton, 2021], an NRS publication [Thiboutot, 2020], and expert opinion in a narrative review [van Zuuren, 2017].
    • Expert opinion in a review article notes that specialist referral is appropriate if symptoms persist despite primary care management if other diagnoses need to be ruled out and to prevent rare complications, such as sight-threatening keratitis [van Zuuren, 2017].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Topical treatments

Brimonidine

Contraindications and cautions

  • Do not prescribe brimonidine to women who are pregnant or breastfeeding. 
  • Prescribe brimonidine with caution to people with:
    • Cerebral insufficiency.
    • Coronary insufficiency or severe cardiovascular disease.
    • Depression.
    • Hepatic or renal impairment.
    • Postural hypotension.
    • Raynaud's syndrome.
    • Thromboangiitis obliterans.

Adverse effects

  • Common adverse include:
    • Flushing, pallor, erythema, pruritus, rosacea, skin burning sensation
  • Uncommon or rare adverse effects include:
    • Angioedema, eyelid oedema.
    • Bradycardia. 
    • Dizziness.
    • Dry mouth.
    • Headache. 
    • Possible exacerbation of rosacea symptoms (very common) — initiate treatment with a small amount of gel (less than the maximum dose) for at least 1 week, then increase gradually, based on tolerability and response. The maximum daily dose (1 g of gel per day) should not be exceeded, and the person should stop treatment and seek medical advice if symptoms worsen during treatment.

Drug interactions

  • There are no relevant drug interactions with topical brimonidine.

[MHRA, 2016; MHRA, 2017; EMC, 2023a; BNF, 2025]

Ivermectin

Contraindications and cautions

  • Do not prescribe ivermectin to women who are pregnant or breastfeeding.
  • Prescribe topical ivermectin with caution to people with:
    • Severe hepatic impairment.

Adverse effects

  • Possible adverse effects include:
    • Skin burning sensation, skin irritation, rosacea aggravation.
    • Erythema, contact dermatitis.

Drug interactions

  • There are no relevant drug interactions with topical ivermectin.

[EMC, 2024; BNF, 2025]

Azelaic acid

Adverse effects

  • Common or very common adverse effects include:
    • Application site burning, pain, rash, oedema, dryness, paraesthesia, or pruritus. 
  • Uncommon adverse effects include:
    • Erythema, exfoliation, warmth, discolouration, discomfort, urticaria. 

Drug interactions

  • There are no relevant drug interactions with topical azelaic acid.

[EMC, 2023b; BNF, 2025]

Metronidazole

Adverse effects

  • Common adverse include:
    • Dry skin, erythema, pruritus, skin discomfort, worsening of rosacea. are skin reactions.
  • Severe bullous skin reactions, such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), or acute generalised exanthematous pustulosis (AGEP), have been reported. If symptoms/signs are present, treatment must be immediately discontinued.

Drug interactions

  • Interaction with systemic medication is unlikely because absorption of metronidazole following cutaneous application is low. However, very rare cases of modification of INR values have been reported with concomitant use with coumarin anticoagulants.

[EMC, 2022; BNF, 2025]

Oral antibiotics

Doxycycline

Contraindications and cautions

  • Do not prescribe doxycycline to:
    • Pregnant women.
    • Breastfeeding women.
    • Children younger than 12 years of age — tetracyclines can bind to calcium ions and be deposited in growing bone and teeth, causing staining. Enamel hypoplasia has also been reported.
      • In children aged under 8 years, use only in severe or life-threatening conditions (such as Rocky Mountain spotted fever) when there are no adequate alternatives.
      • In children aged 8–11 years, use only in acute or severe infections when there are no adequate alternatives.
  • Prescribe doxycycline with caution to people with:
    • Hepatic impairment (or concurrently receiving potentially hepatotoxic drugs).
    • Myasthenia gravis — muscle weakness may be increased.
    • Systemic lupus erythematosus — symptoms may be exacerbated.
    • Alcohol dependence — alcohol may decrease the half-life of doxycycline.

Adverse effects

  • Blood disorders
    • Rare: haemolytic anaemia, thrombocytopenia, neutropenia, and eosinophilia.
  • Gastrointestinal 
    • Common: diarrhoea, nausea, and vomiting
    • Uncommon: dyspepsia, diarrhoe,a, and tooth discolouration and enamel hypoplasia in children
    • Rare: abdominal discomfort, dysphagia, oesophagitis, oesophageal irritation, and pseudomembranous colitis. For more information, see the CKS topic on Diarrhoea - antibiotic associated.
  • Hepatic disorders
    • Rare: hepatotoxicity, hepatitis, jaundice, and hepatic failure.
  • Skin 
    • Common: photosensitivity and rash.
    • Rarely: toxic epidermal necrolysis, Stevens-Johnson syndrome, angioedema, erythema multiforme, exfoliative dermatitis, photo-onycholysis, drug reaction with eosinophilia and systemic symptoms (DRESS), and fixed eruption.
  • Other rare adverse effects include:
    • Anaphylaxis.
    • Anxiety.
    • Arthralgia and myalgia.
    • Blood urea increased.
    • Bulging fontanelles in infants.
    • Flushing.
    • Intracranial hypertension.
    • Jarisch-Herxheimer reaction.
    • Porphyria and reduced appetite.
    • Severe headache and/or visual disturbances — may be an early symptom of benign intracranial hypertension, a rare but serious adverse effect.
    • Tinnitus.

Drug interactions

  • Drug interactions for doxycycline include:
    • Antacids — the absorption of doxycycline may be impaired by concurrently administered antacids containing aluminium, calcium, or magnesium, or other drugs containing these cations, as well as oral zinc, iron salts, or bismuth preparations.
      • Separate the doses by at least 2–3 hours to avoid this interaction.
      • Histamine H2-receptor antagonists do not interact and could be a suitable alternative.
    • Carbamazepine and phenytoin — serum levels of doxycycline are reduced and may fall below the accepted therapeutic minimum in people on long-term treatment with carbamazepine or phenytoin. 
      • Doxycycline dose may need to be doubled.
    • Ciclosporin — doxycycline is predicted to increase ciclosporin concentrations.
      • Monitor ciclosporin concentrations and effects (for example, on renal function) more frequently when starting or stopping doxycycline, and adjust the ciclosporin dose as needed.
    • Lithium — doxycycline is predicted to increase the risk of lithium toxicity.
      • If concurrent use cannot be avoided, monitor for lithium toxicity (tremors, dysarthria, ataxia, and confusion), and adjust the lithium dose as needed.
    • Retinoids — there is a possible increased risk of benign intracranial pressure if tetracyclines are used concurrently with retinoids (such as isotretinoin). Concurrent use is contraindicated.
    • Rifampicin — doxycycline levels are markedly reduced, which may lead to treatment failure. Monitor the effects and increase doxycycline dose if necessary.
    • Coumarin anticoagulants (for example, warfarin) — doxycycline may increase the anticoagulant effect of warfarin. Consider increasing monitoring of INR.
    • Live cholera vaccine — efficacy of the vaccine may be reduced.
      • Avoid antibiotics from 14 days before to 10 days after receiving live cholera vaccine.
    • Live typhoid vaccine — immune response to the vaccine may be reduced.
      • Avoid antibiotics from 3 days before to 3 days after receiving live typhoid vaccine.

[BNF, 2025; EMC, 2025a; Preston, 2025]

Erythromycin

Contraindications and cautions

  • Do not prescribe erythromycin to people with:
    • A history of QT interval prolongation or ventricular arrhythmia (including torsade de pointes) — risk of QT interval prolongation.
    • Electrolyte disturbances (hypokalaemia or hypomagnesaemia) — risk of QT interval prolongation. 
    • Acute porphyrias.
  • Prescribe erythromycin with caution to:
    • People with:
      • Impaired hepatic function (or concurrently receiving potentially hepatotoxic drugs) — erythromycin is excreted principally in the liver.
      • Moderate to severe renal impairment — consider dosage reduction due to the risk of ototoxicity.
      • With cardiac disease or heart failure, conduction disturbances, or clinically relevant bradycardia (or concurrently receiving drugs associated with QT interval prolongation) — risk of QT interval prolongation.
      • Myasthenia gravis — macrolides may aggravate symptoms.

 Adverse effects

  • Gastrointestinal 
    • Common or very common: diarrhoea, GI discomfort/disorders, nausea, vomiting, and pancreatitis.
    • Uncommon: constipation.
    • Rare or very rare: antibiotic-associated colitis. For more information, see the CKS topic on Diarrhoea - antibiotic associated. 
  • Cardiovascular  
    • Uncommon: QTc interval prolongation, torsades de pointes, and palpitations and cardiac rhythm disorders, including ventricular tachyarrhythmias.
  • Hepatobiliary
    • Uncommon: cholestatic hepatitis, jaundice, hepatic dysfunction, hepatomegaly, hepatic failure, and hepatocellular hepatitis.
  • Skin and subcutaneous tissues 
    • Common or very common: skin reactions.
    • Uncommon: Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme (uncommon), and acute generalised exanthematous pustulosis (AGEP).
  • Other adverse effects include:
    • Dizziness.
    • Eosinophilia, leucopenia, and neutropenia.
    • Hallucinations.
    • Headache.
    • Hearing impairment, tinnitus.
    • Interstitial nephritis.
    • Myasthenia gravis.
    • Seizures, confusion, vertigo.
    • Vasodilation.
    • Vision disorders.
  • Infantile hypertrophic pyloric stenosis has been reported.
    • The risk is highest in the first 14 days after birth.
    • Assess the benefit-risk balance of erythromycin treatment in infants.
    • Advise parents and carers to seek medical attention if vomiting or irritability with feeding occurs in infants during treatment with erythromycin.
    • Rare or very rare — hearing loss (can occur after large doses).

Drug interactions

  • Drug interactions of erythromycin include:
    • Calcium channel blockers — erythromycin possibly inhibits the metabolism of calcium channel blockers, such as verapamil and amlodipine, increasing the risk of hypotension and other adverse effects.
      • Monitor for hypotension and other adverse effects, and adjust the dose of the calcium channel blocker if necessary.
    • Ciclosporin — erythromycin significantly increases ciclosporin concentrations, and cases of toxicity have been reported. Erythromycin-related ototoxicity has also been reported.
      • Monitor the concentration and effects (for example, on renal function) of ciclosporin more frequently if erythromycin is started or stopped.
      • Adjust the ciclosporin dose as necessary.
    • Cimetidine — cimetidine may inhibit the metabolism of erythromycin, leading to an increased plasma concentration. Monitor concurrent use for erythromycin adverse effects.
    • Coumarin anticoagulants (for example, warfarin) — few patients have a clinically significant interaction. Consider increased monitoring of INR, especially in the first 3 days of starting erythromycin.
    • Digoxin — erythromycin may increase the plasma concentration of digoxin. Monitor for signs of digoxin adverse effects (bradycardia), measure digoxin concentrations, and adjust the dose if necessary.
    • Direct oral anticoagulants (DOACs) — erythromycin is predicted to increase the exposure to DOACs, resulting in an increased risk of bleeding. Monitor for signs and symptoms of bleeding or anaemia, especially in older people and people with renal impairment.
      • Edoxaban — decrease the edoxaban dose to 30 mg once daily. 
    • Drugs that prolong the QT interval — erythromycin can prolong the QT interval. Concurrent use with other drugs that prolong QT intervals can increase the risk of QT prolongation and cardiac arrhythmias, including ventricular tachycardia, ventricular fibrillation, and torsades de pointes.
      • Concurrent use with domperidone, tolterodine, mizolastine, or amisulpride is contraindicated.
      • Most manufacturers advise avoiding the use of two or more drugs that are associated with QT prolongation.
      • Increasing age, female sex, cardiac disease, and some metabolic disturbances (notably hypokalaemia) predispose to QT prolongation.
    • Drugs that cause hypokalaemia (such as diuretics) — concurrent use with erythromycin can predispose to QT prolongation.
      • Monitor potassium concentrations closely.
    • Drugs that induce cytochrome P450 (CYP3A4) enzyme — concurrent use with drugs such as rifampicin, phenytoin, carbamazepine, phenobarbital, and St John's Wort may induce the metabolism of erythromycin, leading to sub-therapeutic levels of erythromycin and a decreased effect. The induction decreases gradually two weeks after discontinued treatment with the CYP3A4 inducers.
      • Avoid erythromycin during (and for 2 weeks after) treatment with a CYP3A4 inducer. If concurrent use is unavoidable, be alert for decreased erythromycin efficacy.
      • It may also be necessary to monitor the plasma levels of the CYP3A4 inducer, which could be increased due to the inhibition of CYP3A4 by erythromycin. For example, concurrent treatment with rifabutin and erythromycin increases rifabutin levels and decreases erythromycin levels. 
    • Statins — erythromycin is a CYP3A4 enzyme inhibitor. Concurrent use with a statin metabolized by CYP3A4 will increase the plasma concentration of the statin, leading to an increased risk of myopathy (including rhabdomyolysis).
      • Simvastatin — concurrent use is contraindicated. If erythromycin treatment cannot be avoided, withhold simvastatin for the duration of the erythromycin course.
      • Atorvastatin — avoid concurrent use. If concurrent use cannot be avoided, withhold statin, or give the lowest dose possible, and advise the person to report any muscle pain, tenderness, or weakness.
      • Pravastatin  — advise the person to report any muscle pain, tenderness, or weakness.
    • Other drugs metabolized by CYP3A4 — concurrent use with erythromycin may increase plasma concentrations of the concurrent drug, leading to increased or prolonged therapeutic and adverse effects of the concurrent drug.
      • Concurrent use with pimozide or terfenadine is contraindicated. Erythromycin significantly alters the metabolism of these drugs, and rare cases of serious, potentially fatal cardiovascular events, including cardiac arrest, torsade de pointes, and other ventricular arrhythmias, have been observed.
      • Concurrent use with ergot alkaloids is contraindicated.
      • For other medications, appropriate monitoring should be undertaken and dosages adjusted as necessary. 
    • Theophylline — erythromycin can reduce theophylline clearance, leading to raised theophylline levels and potential theophylline toxicity. Oral erythromycin exposure may be reduced by theophylline. Theophylline can cause hypokalaemia, increasing the risk of torsade de pointes, which might be additive with the effects of erythromycin.
      • Monitor theophylline levels, and adjust the dose accordingly.
      • Monitor the effects of erythromycin to ensure they are adequate.
      • Monitor potassium concentrations closely.
    •  Live cholera vaccine — efficacy of the vaccine may be reduced.
      • Avoid antibiotics from 14 days before to 10 days after receiving live cholera vaccine.
    • Live typhoid vaccine — immune response to the vaccine may be reduced.
      • Avoid antibiotics from 3 days before to 3 days after receiving live typhoid vaccine.

[MHRA, 2020; BNF, 2025; EMC, 2025b; Preston, 2025]

Supporting evidence

This CKS topic is largely based on the ROSacea COnsensus (ROSCO) international consensus publications Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel [Schaller, 2017], Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel [Tan, 2017], and Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel [Schaller, 2020], the US National Rosacea Society (NRS) publications Standard classification and pathophysiology of rosacea [Gallo, 2018], and Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee [Thiboutot, 2020], the American Acne and Rosacea Society (AARS) publication Update on the management of rosacea from the American Acne and Rosacea Society (AARS) [Del Rosso, 2019], the British Association of Dermatologists (BAD) guidelines for the management of people with rosacea 2021 [Hampton, 2021], a systematic review Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments [van Zuuren, 2019], and expert opinion in review articles Rosacea: diagnosis and treatment [Oge, 2015], Rosacea [van Zuuren, 2017], Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and practical clinical experience [Alexis, 2019], and Applying the phenotype approach for rosacea to practice and research [Tan, 2018].  The rationale for individual recommendations is discussed in the relevant basis for recommendation sections of this topic. 

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of rosacea.

Search dates

May 2020 - June 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 19th May 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2 
S2    AB rosacea OR rosacea 
S1    (MH "Rosacea+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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