Being told you have rosacea is only half a diagnosis. Rosacea is a common, long-term inflammatory skin condition that mainly affects the centre of the face. However, it is not one condition. In fact, there are four recognised patterns and they do not all respond to the same treatment. The type you have decides whether a cream will settle it, whether the redness needs laser or if you need a specialist. So if you’re worried about having rosacea, you should also ask “which type of rosacea is this”. In this post, we review the four types of rosacea, how to tell them apart and what treats each one.
What Are the Four Types of Rosacea?
The four types of rosacea are erythematotelangiectatic (redness and flushing), papulopustular (acne-like bumps), phymatous (skin thickening) and ocular (eye involvement). The National Rosacea Society first set out these four subtypes in 2002, grouping the condition by its most common patterns of signs. The names are a bit of a mouthful, so it helps to break them down by what they actually do to you:
- Erythematotelangiectatic rosacea is the redness type. Easy flushing, persistent redness across the central face and visible thread veins.
- Papulopustular rosacea is the acne-like type. Red bumps and pus-filled spots on a background of redness.
- Phymatous rosacea is the skin-thickening type. Firm, bumpy skin and, classically, a slowly enlarging nose.
- Ocular rosacea is the eye type. It gives dry, gritty, irritated or bloodshot eyes.
Whichever type you have, the underlying process is similar. Rosacea is driven by over-reactive blood vessels and an over-alert immune response in the skin. In some people, Demodex mites (microscopic mites that live in the hair follicles of the face) can amplify the inflammation. The patterns differ because that inflammation can express itself through the vessels, the pores, the structure of the skin or the eyes. Most people will recognise their main pattern in one of the four, and the rest of this post takes each in turn.
What Is Erythematotelangiectatic Rosacea (Redness Type)?
Erythematotelangiectatic rosacea is the redness type, where the main problem is colour and reactivity rather than spots. The main features are easy flushing, a persistent flush across the central face and small visible blood vessels, or telangiectasia, on the cheeks and around the nose. The skin often feels sensitive too, stinging or burning with triggers such as heat, cold, alcohol or spicy food.
This type is worth separating from the others because its two features need different tools. The background redness and flushing can often be calmed with trigger control, gentle barrier-supporting skincare, daily sun protection and, where a doctor judges it suitable, a calming prescription cream. The visible thread veins are a different matter. Once a vessel is fixed and dilated, no cream can close it. This is because the vessel wall itself has remodelled, so established telangiectasia is usually treated with vascular laser or intense pulsed light, which is an in-person procedure. Knowing that split from the start saves you months of expecting a cream to do a laser’s job.
What Is Papulopustular Rosacea (Acne-Like Type)?
Papulopustular rosacea, sometimes called acneiform rosacea, is the type that looks like acne, and it is the one people most often mistake for it. It shows up as small red papules and pus-filled pustules on the central face, on top of a background of persistent redness. It usually appears in adults, more often in women, and it comes and goes in flares.
This is also the type that responds best to topical prescription rosacea treatment, which is why getting the diagnosis right matters so much. The standard topical options are azelaic acid, metronidazole and ivermectin. A doctor may use one or more of these depending on your skin. Azelaic acid calms inflammation and helps both the bumps and any marks they leave behind. Metronidazole was the first topical treatment approved specifically for rosacea, back in 1988, and it remains a first-line option nearly four decades on. Ivermectin is the newer arrival and works on two fronts at once. It reduces the Demodex mites linked to rosacea and calms the inflammation they provoke. More severe or stubborn cases are sometimes treated with a course of oral antibiotics, which is prescribed and monitored in person by a GP or dermatologist.
How Do You Tell Papulopustular Rosacea From Acne?
The single most useful sign is comedones, which are the blackheads and whiteheads that define acne. Papulopustular rosacea produces papules and pustules but never comedones. Rosacea never makes blackheads. So if the bumps come with blackheads, that points to acne. If however they are purely papules or pustules with persistent redness and visible vessels, that points to rosacea. A few other features help separate them:
- Location: Rosacea concentrates on the central face, meaning the cheeks, nose, chin and forehead. Acne can affect anywhere on the face including the jawline. It can also affect the neck, chest, back and limbs.
- When it started: Acne usually begins in the teens although adult-onset acne is also common. Rosacea usually starts after 30.
- How the skin feels: Rosacea-prone skin is often dry, sensitive or stinging. Acne skin may be oily or greasy.
- How it behaves: Rosacea flares within minutes of a trigger like heat, alcohol or spicy food. Acne breakouts usually develop over days.
You can also have both conditions at once, which is part of why the mix-up is so common. Our rosacea vs acne article walks through every distinguishing sign side by side. If the two co-exist, you will need an acne treatment alongside rosacea management. Lastly, if the bumps cluster tightly around your mouth and spare the rim of skin right at the lip line, it might be neither and perioral dermatitis instead.
What Is Phymatous Rosacea (Skin-Thickening Type)?
Phymatous rosacea is the skin-thickening type, where tissue slowly builds up instead of just reddening. Over time the skin becomes firmer and bumpier, and on the nose this can build into a swollen, enlarged shape called rhinophyma. Phymatous rosacea is far less common than the redness and acne-like types. It tends to appear later and most commonly affects the nose, mainly in men. It can also affect the chin, forehead and ears.
We do not treat this at City Skin Clinic as it is not something a prescription cream can reverse once it is underway. Thickened, fibrous tissue is treatable with physical methods such as ablative laser or surgery to reshape the area. These are in-person procedures that require a specialist provider. If your nose or skin is progressively thickening, the right next step is an in-person dermatologist or surgeon, not an online skin clinic.
What Is Ocular Rosacea (Eye Type)?
Ocular rosacea is the type that affects the eyes, and it is both common and easy to miss. The features include dry, gritty or burning eyes, the something-in-the-eye feeling that is easy to blame on tiredness or screens, red or swollen eyelids, recurrent styes and sensitivity to light. More than half of people with rosacea have some eye involvement, and in around 1 in 5 the eye symptoms appear before any skin signs.
Left alone, ocular rosacea can progress to keratitis, a rare but serious complication that can threaten eyesight. This is why eye involvement needs urgent assessment by an eye specialist. If you have persistent eye irritation alongside facial redness, see your GP, an optometrist or an ophthalmologist. We do not manage eye disease at City Skin Clinic as we do not believe this is something that an online service can manage appropriately.
Do You Have to Fit Neatly Into One Type?
No. Many people have features of more than one type at the same time, and the pattern can shift over the years. The original classification acknowledged from the start that patients may have characteristics of more than one subtype at once. This overlap is why, in 2017, experts moved to a phenotype-based approach that diagnoses rosacea by its individual features rather than forcing each person into one box. In practice, either persistent central redness or skin thickening is enough to diagnose rosacea on its own. However, flushing, bumps, visible vessels and eye involvement usually need weighing together to exclude other similar conditions. Each feature points to a different treatment.
How Does Knowing Your Rosacea Type Affect Treatment?
Each type of rosacea requires specific treatment and using the wrong one can waste months or make things worse. There is also no cure for rosacea so the best rosacea treatments aim to control the condition and prevent flare-ups.
| Type | Main features | Typical approach | Can an online clinic help? |
|---|---|---|---|
| Erythematotelangiectatic (redness) | Flushing, persistent central redness, visible thread veins | Trigger control, gentle skincare, sun protection and calming prescription creams. Fixed vessels usually need laser or IPL | Background redness can be treated topically. Visible vessels need in-person laser |
| Papulopustular (acne-like) | Red bumps and pustules, no comedones | Prescription topicals such as azelaic acid, metronidazole or ivermectin. Oral medication for severe cases | Yes, for topical treatments. Oral or severe cases need an in-person clinic |
| Phymatous (skin-thickening) | Firm, thickened skin, enlarging nose | Physical treatment such as ablative laser or surgery once established | No. Needs an in-person dermatologist or surgeon |
| Ocular (eyes) | Dry, gritty or burning eyes, lid problems, styes | Lid care and treatment directed by an eye specialist | No. Needs a GP, optometrist and possibly an ophthalmologist |
Background redness and acne-like bumps are the features that are usually treatable by online rosacea treatment services or in-person clinics. However, visible vessels, the thickening and the eyes need in-person specialist care.
Understanding which type of rosacea you have is the first step towards treating it effectively. It is possible to manage the redness and acne-like types with prescription creams. However, thickened skin and eye involvement need in-person specialist care. Most people have features of more than one type, so treatment should target the combination you actually have. They may also have other skin concerns like acne alongside rosacea which also affects treatment. Also, there is no cure for rosacea so a combination of treatment and life-style modifications is normally necessary to control it and prevent flare-ups. Finally, remember that patience matters. Most treatments need at least several weeks of consistent use before you see the difference.
At City Skin Clinic, we are passionate about personalised skincare. If your rosacea is mostly redness or acne-like spots, our doctors can assess your skin online and design a custom prescription rosacea treatment for you using ingredients like azelaic acid, metronidazole and ivermectin where appropriate. Your doctor can also address other skin concerns you have and will adjust your protocol as your skin responds. To start your plan, book a virtual video consultation or use our online consultation form. 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 health concerns or questions you might have.
