Rosacea vs Acne, Here’s How to Tell Which One You Have

Rosacea and acne are two of the most common inflammatory skin conditions in the UK. They can both cause texture, redness and breakouts on the face and are often mistaken for one another. Although rosacea is more likely in adults, acne is still common and to complicate matters further, it’s possible to have both at the same time. Being able to tell these conditions apart is important because they have different causes, triggers and treatments. Getting the diagnosis wrong can lead to sub-optimal or inappropriate treatment which can make either condition worse. In this article, we explore the differences between rosacea vs adult acne, how to figure out which one you have and choose the best treatment for you.

What is Acne?

Acne is a chronic inflammatory skin condition that affects the hair follicles and their oil glands also know as pilosebaceous unit. These open onto the skin and appear as pores. It typically starts in adolescence but can persist into or appear for the first time in adulthood. Acne is a complex skin condition and usually develops when several factors combine together to clog pores causing breakouts and inflammation. The main features of acne include:

• Excess sebum production: Androgen hormones stimulate the sebaceous glands to produce more oil which helps clog pores. This effect of androgen hormones is particularly likely during puberty, menopause and at certain points in the menstrual cycle.
• Clogged pores: The skin cells lining the hair follicle have a tendency to stick together rather than shedding normally. The name of this process is follicular hyperkeratinisation and can block the pore leading to microcomedone formation.
• Bacterial overgrowth: Cutibacterium acnes is a bacteria that normally grows on the skin. It thrives in the oily, blocked follicle to trigger further inflammation.
• Inflammation: The immune system responds to the trapped bacteria and sebum, producing the red, sore spots we recognise as acne.

There are several different types of acne lesions. It commonly shows up as comedones (blackheads and whiteheads), inflammatory papules and pustules. In more severe cases, it can also present to nodules and cysts. It tends to appear on areas with the most oil glands which includes the face, chest, shoulders and back. Although it’s most common in teenagers, acne can persist or start well in to adulthood especially in women.

What is Rosacea?

Rosacea is also a chronic inflammatory skin condition which presents with redness and can also involve pimples and texture. Unlike acne which can present anywhere across the body, rosacea mainly affects the central face. It tends to develop after the age of 30 and is more common in women and those with lighter skin. However, it can affect all skin tones and is frequently under diagnosed in skin of colour. We don’t fully understand the exact cause of rosacea but research suggests it involves a combination of factors including:

• Vascular dysregulation: Blood vessels in the face become more reactive and dilate easily. This causes flushing and persistent redness.
• Immune system dysfunction: An overactive immune response leads to chronic inflammation. Rosacea prone sufferers tend to have a high level of proteins called cathelicidins. Research suggests that these proteins may play a part in triggering this excessive immune activation.
• Demodex mites: Higher numbers of these naturally occurring skin mites and the bacteria they harbour appear to drive inflammation in rosacea-prone skin. This is also likely a key driver of acne-like rosacea pimples.
• Skin barrier dysfunction: A weakened barrier makes rosacea-prone skin more sensitive and reactive to triggers like heat, sun and skincare.

Generally speaking, rosacea is usually split into four main subtypes that can occur alone or together. These are erythematotelangiectatic rosacea (flushing, redness and visible vessels), papulopustular rosacea (which causes acne-like spots), phymatous rosacea (skin thickening, particularly of the nose) and ocular rosacea which affects the eyes. Papulopustular (also called acneiform-rosacea) is the form most people commonly mistake for acne and vice versa.

What Are the Key Differences Between Rosacea vs Acne?

Although they can look similar at first glance, rosacea and acne are very different conditions. The overlap is biggest with papulopustular rosacea which causes acne-like spots. However, there are several features that help tell them apart. Here’s a head to head comparison of rosacea vs acne:

• Who it affects: Acne typically starts in the teens and can affect any skin type or tone. Rosacea usually starts after 30 and is more common in those with fairer skin. Although, it does occur in all skin tones but often gets missed in skin of colour.
• Where it appears: Acne can affect the face, neck, chest, back and shoulders. Rosacea is almost always only affects the central face, including the cheeks, nose, forehead and chin.
• Type of spots: Acne includes comedones (blackheads and whiteheads) alongside papules, pustules and sometimes deeper nodules. Rosacea causes papules and pustules but never comedones and there’s usually also persistent redness and visible blood vessels.
• Skin type: Acne tends to occur on oily or combination skin. Rosacea-prone skin is usually dry, sensitive and easily irritated.
• Sensation: Acne spots are typically sore or tender. Rosacea also often produces flushing, warmth, stinging or burning rather than pain.
• Triggers: The main drivers of acne are hormones, oil and pore clogging. Rosacea tends to flare due to heat, sun exposure, alcohol, spicy food, stress and harsh skincare.
• Eye involvement: Rosacea can affect the eyes (ocular rosacea), causing dryness, grittiness and redness. Acne does not generally affect the eyes.
• Long term changes: Acne can leave atrophic scars and post-inflammatory hyperpigmentation. Rosacea rarely scars but can lead to permanent redness, broken capillaries, rough texture, hyperpigmentation and in severe cases skin thickening (rhinophyma).

Can You Have Both Acne and Rosacea at the Same Time?

It’s possible to genuinely have acne and rosacea at the same time.This is particularly likely in adults with persistent acne who also go on to develop rosacea in their 30s or 40s. However, it’s more common to just have one or the other but confuse them as below:

• Papulopustular rosacea mistaken for acne: This is the most common reason rosacea is missed. The papules and pustules look like adult acne. However, treatment with aggressive acne products that then trigger rosacea flares.
• Adult acne mistaken for rosacea: Equally, adult hormonal acne on the cheeks and jawline can look like rosacea. The presence of comedones is the clue that points to acne.
• Steroid-induced rosacea: Long-term use of topical steroids on the face can trigger a rosacea-like eruption with papules and pustules, which is then often mismanaged as either condition.

In the case where acne and rosacea genuinely coexist, treatment needs to be carefully balanced to manage both without flaring either. This often means choosing ingredients that work for both such as azelaic acid, avoiding harsh acne treatments that aggravate rosacea and using gentler formulas and lower frequencies than you would for acne alone.

How to Treat Rosacea vs Acne?

The treatments for acne and rosacea can look similar on the surface but the goals and ingredients are quite different. Acne treatment focuses on unclogging pores, reducing oil and targeting C. acnes bacteria. Rosacea treatment focuses on calming inflammation, targeting demodex and reducing vascular reactivity. Both conditions need long term, personalised management and the right approach depends on the severity, subtype and your skin type. Here’s how the main treatments compare:

• Topical treatments: Acne is typically treated with topical retinoids like tretinoin and adapalene, benzoyl peroxide, clindamycin and azelaic acid. Spironolactone or Winlevi can also help with hormones. Rosacea responds better to metronidazole, ivermectin and azelaic acid. Brimonidine or oxymetazoline added for persistent redness. Low strength tretinoin can also be used for rosacea to help with texture and photo-ageing.
• Oral treatments: Oral antibiotics like lymecycline and doxycycline are used for both, although rosacea responds particularly well to sub-antimicrobial dose doxycycline. Acne also benefits from hormonal treatments such as spironolactone or the combined oral contraceptive pill. Isotretinoin is reserved for severe or scarring acne and may be used at lower doses in treatment-resistant rosacea.
• In-clinic treatments: Chemical peels, microneedling and LED therapy can support acne treatment and improve acne and associated dark marks or scars. IPL and vascular laser are the gold standard in-clinic procedures for treating persistent redness and broken capillaries in rosacea.
• Basic skincare: Acne-prone skin benefits from gentle cleansers, oil balancing ingredients and light hydrating moisturisers. Try to avoid harsh cleansers or toners that strip the skin of oil. Rosacea-prone skin needs barrier repair with fragrance-free cleansers and ceramide-rich moisturisers. Avoid alcohol-based toners, aggressive exfoliants and anything that stings on application as these can aggravate rosacea.

The one active ingredient that bridges both conditions is azelaic acid. It’s effective for inflammatory acne, rosacea papules and post-inflammatory hyperpigmentation. This makes it particularly useful when acne and rosacea coexist or when there is diagnostic uncertainty. Mineral sunscreens, particularly zinc oxide ones, are best of sensitive rosacea and acne-prone skin.

Although they can look very similar and even co-exist, it’s possible to differentiate between rosacea vs acne. The key is to focus on the specific features that distinguish them. These include the presence of comedones, the distribution of spots and the background of the skin all give important clues. One thing to appreciate is that both conditions are chronic. This means they need consistent treatment to manage them effectively and prevent relapse.

At City Skin Clinic, we are super passionate about personalised skincare. Through our virtual skin clinic, our doctors offer safe and effective custom acne and rosacea online treatments. Where appropriate, our doctors use prescription ingredients including Tretinoin, Clindamycin, Azelaic acid, Metronidazole and Ivermectin. Start your online consultation today. The journey towards great skin starts here.

This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any medical concerns or questions you might have.