The first thing most people think of when talking about rosacea is facial redness. However, rosacea can also present with inflamed pustules which can look like regular acne. The name of this type is acneiform rosacea (or papulopustular rosacea) and it is a distinct condition from acne. As such, it requires a different treatment approach. In this article, we’ll explore this condition in detail and how to spot acneiform pustules. We’ll also review the different types of acne rosacea and the best treatments, including for severe cases like acne rosacea fulminans.
What is Acneiform Rosacea?
This subtype of rosacea presents as recurring red bumps and pustules on the face that look like acne. Unlike conventional acne, acneiform rosacea does not involve closed comedones. It is essentially an inflammatory disease involving the facial vessels and the skin’s immune response. Acneiform rosacea also tends to affect the central part of the face. Acne vulgaris, by contrast, usually affects the T-zone and jawline but can present anywhere on the face and other parts of the body like the back or chest. The main features of acneiform rosacea include:
- No comedones (that is, blackheads or whiteheads).
- Lesions form in inflamed patches of rosy skin and often come with persistent redness, flushing or a burning sensation.
- Located on the central face including the cheeks, nose, forehead and chin.
- Typically affects adults aged 30 to 50. More common in women and people with lighter skin complexions.
- Often brought on by heat, spicy foods, alcohol or skincare products.
Acne rosacea fulminans (also referred to as rosacea fulminans or pyoderma faciale) represents a rare but extremely severe type of rosacea. It usually develops suddenly in people with a history of rosacea. However, unlike the more gradual onset of typical acneiform rosacea, fulminans involves a sudden outbreak of inflammation. This condition mainly affects young women and often presents during hormonal fluctuations such as pregnancy, which suggests a hormonal trigger. The key clinical features of acne rosacea fulminans include:
- Sudden appearance of grouped pustules, nodules and draining sinuses on the central face.
- Lesions are tender, painful and form ulcers or crusting.
- Absence of comedones (blackheads or whiteheads).
Immediate and aggressive treatment is crucial to halt progression of acne rosacea fulminans. It also reduces pain and the risk of long-term scarring. This condition is a dermatological emergency that needs specialist urgent care to manage inflammation and support skin healing.
What Causes Acneiform Rosacea?
Though the exact cause of acneiform rosacea isn’t fully clear, there are several likely drivers. The key contributing factors include:
- Genetics: This appears to play a significant role, especially in people with overactive facial blood vessels that are prone to dilation and increased visibility.
- Demodex Mite Proliferation: These are microscopic organisms that naturally inhabit human skin. They can trigger inflammation when present in excessive numbers.
- Immune System Overreaction: The innate immune response may be overactive, which leads to high levels of inflammatory markers and reactive oxygen species. These further aggravate the skin and continue the cycle of redness and pustule formation.
The above internal factors are often made worse by environmental triggers like temperature, diet, pollution and irritants.
How is Acneiform Rosacea Diagnosed?
Diagnosis of acneiform rosacea usually centres on a thorough medical history and examination of the skin. It’s best to seek help from a dermatologist or other healthcare provider if you have:
- Persistent central facial redness.
- Clusters of small acneiform pustules without comedones.
- Triggers like weather changes, skincare irritants or alcohol.
- History of rosacea or family predisposition.
If you develop facial nodules, rapidly appearing pustules, feel generally unwell or have eye involvement, then please get medical help straight away. This is vital to rule out more severe forms of rosacea such as acne rosacea fulminans or ocular rosacea. It also helps rule out other medical conditions with skin involvement like shingles or lupus.
What are the Treatments for Acneiform Rosacea?
Treating acneiform rosacea usually involves a multi-pronged approach that targets inflammation, treats pustules, reduces triggers and supports long-term skin health. The most effective medical treatments for acneiform rosacea include:
- Topical Treatments: First-line treatments typically include topical agents such as metronidazole, azelaic acid and ivermectin. These help calm inflammation and decrease the presence of Demodex mites. Doctors may also prescribe topical dapsone in more stubborn cases, particularly where pustules persist. However, it requires a G6PD deficiency check before prescribing.
- Oral Medications: Oral antibiotics like low-dose doxycycline or minocycline are commonly used for their anti-inflammatory effects. They suit moderate to severe acneiform rosacea, or cases where topical treatments are not enough. In treatment-resistant cases or in the presence of rosacea fulminans, a specialist may introduce oral isotretinoin under careful supervision. For patients who cannot tolerate tetracyclines, erythromycin or azithromycin may be used as alternatives.
- Professional Procedures: Laser therapy like pulsed dye laser (PDL) and intense pulsed light (IPL) can help with acneiform rosacea. They target the persistent redness and visible blood vessels often associated with it. PDL works by targeting the haemoglobin in dilated blood vessels, using concentrated bursts of light to collapse them without damaging surrounding skin. This helps reduce overall facial redness and clear broken capillaries over a series of sessions. IPL, though not technically a laser, uses broad-spectrum light to similarly target redness and pigmented lesions. This can be very useful for patients who also have uneven skin tone or sun damage. Both treatments are non-invasive and require minimal downtime, but they must be performed in a clinical setting. Multiple sessions are usually needed for the best results and maintenance treatments may be necessary.
It’s also important to stress that managing acne rosacea fulminans requires urgent, carefully planned treatment. The aim is to prevent long-term skin damage. The typical approach begins with a short course of oral steroids and/or antibiotics to swiftly reduce inflammation and calm the initial flare. Once the acute inflammation is under control, oral isotretinoin may be introduced to maintain remission and address any residual nodules or acneiform pustules. This protocol must be tailored and closely monitored by a dermatologist due to the potential side effects of isotretinoin.
How Do You Manage Acneiform Rosacea and Prevent Flares?
Maintenance is the key to long-term control of acneiform rosacea pustules. Even after initial symptoms subside, you are likely to need ongoing care. This means continuing topical treatments, maintaining a supportive skincare routine and avoiding triggers. This is the only way to sustain results and reduce the likelihood of relapse. Below are some of the key steps to reduce flare-ups:
- Treatments: Maintain consistent use of your prescription topical treatments.
- Adaptability: Adjust your skincare routine and treatments to adapt to weather changes, stress or hormone changes.
- Skincare: Use gentle fragrance-free cleansers and moisturisers to help soothe angry skin and support barrier repair. Consistent use of a high-SPF, broad-spectrum sunscreen is crucial in protecting the skin from UV-induced flares and cumulative damage.
- Lifestyle: It’s essential to avoid common rosacea triggers such as spicy foods, alcohol and exposure to extreme temperatures. These can all provoke inflammation and flares. To better understand your individual triggers, keep a detailed skincare journal.
- Cosmetics: Acneiform rosacea can take its toll on your self-esteem. So, whilst having treatment, do what you can to reduce its impact on you. Things like camouflage makeup can help improve the appearance of your skin and your confidence.
Acneiform rosacea and its more severe counterpart acne rosacea fulminans can be distressing. However, with fast accurate diagnosis and the right treatment, it’s entirely manageable. The key is to seek professional help early, as it’s sometimes hard to distinguish between acneiform pustules and other acne rosacea types. This will ensure you get appropriate treatment. Ultimately, this is a chronic condition. Any treatment needs to take into account a long-term management approach to maintain outcomes and limit flare-ups.
At City Skin Clinic, we believe that skincare is personal and should always centre around your needs. Our doctors offer custom topical skin treatments for rosacea using ingredients like ivermectin, metronidazole, azelaic acid and tretinoin where appropriate. If you are interested in a personalised skincare treatment please use our online skin consultation form or book a video consultation. Start your treatment journey today and take your first step towards great skin.
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 professional with any concerns about your skin or treatment options.
