Acne or Rosacea? Tips for Diagnosis, Treatment and Crossover

Acne vulgaris and acne rosacea are two common skin conditions that affect adolescents and adults. They’re both inflammatory conditions that can be frustrating to treat for both patients and providers. At times, their presentations can be difficult to differentiate; however, teasing out the differences is important since treatments for acne can be very irritating for rosacea, and treatments for rosacea may not be helpful for acne. Here, we’ll discuss ways to diagnose, treat and educate patients about how to care for their skin. 

Acne vs Rosacea

As many people are aware, acne affects adolescents and young adults of all skin types. Rosacea tends to affect patients over 30 with lighter skin types, the majority being women. However, phymatous rosacea, a less common but more severe subset, occurs almost exclusively in men. Both conditions are usually a clinical diagnosis based on history and physical exam. Rosacea typically presents with different diagnostic phenotypes: 

  • Fixed centrofacial erythema that may periodically intensify with triggers
  • Phymatous changes – thickening of the skin due to dilated follicles and hyperplasia of sebaceous glands
  • Papules and pustules
  • Flushing and telangiectasias 
  • Ocular rosacea*: This is important not to miss as ocular rosacea must be evaluated by an ophthalmologist. It can occur with or without the above cutaneous manifestations. 

Secondary phenotypes of rosacea include burning and stinging of the skin, edema or dryness. 

Acne, in contrast, typically presents on the face, neck, chest, back and upper arms, as these areas have more hormonally responsive sebaceous glands. The following are classic features: 

  • Closed comedones: non-inflammatory smooth, skin- or grayish colored papules <5 mm in size. 
  • Open comedones: non-inflammatory papule with a dilated area containing gray, brown or black keratotic material. Typically <5 mm in size. 
  • Papulopustular acne: inflammatory papules and pustules typically <5 mm in diameter
  • Nodular acne: Inflammatory lesions that are typically larger papules ( >0.5 cm) or nodules (>1cm). These are often painful and tender.  

Treating Acne and Rosacea

So, say you’ve diagnosed someone with acne or acne rosacea. How do you treat them? This is influenced by the clinical history, features on exam, and any patient-identified triggers. For acne, treatment ranges from topical retinoids to oral isotretinoin, which is the only medication that’s considered a “cure” for acne. For acne rosacea, treatment includes avoiding known triggers, topical medications, oral antibiotics, and/or laser

Rosacea Treatment

Starting with acne rosacea, it’s important to educate your patients on mild skincare, sun protection and to avoid common triggers: alcohol, spicy food, temperature extremes, sun/wind, and anything else that exacerbates symptoms.

For mild to moderate rosacea, we can choose from topical vasoconstrictors (Mirvaso, Rhofade), topical azelaic acid (Finacea), topical Metronidazole (in 0.75% or 1%), and topical ivermectin (Soolantra). All of these have different mechanisms of action but mainly share antimicrobial, anti-inflammatory, and/or antiparasitic properties. Topical sulfacetamide-sulfur (various brands) is thought to be helpful due to its anti-inflammatory properties. However, in practice, you’ll find that some can’t handle the smell. Topical minocycline 1.5% foam (Amzeeq) is a newer topical that’s effective for papulopustular rosacea, which can be used as an option for patients who have failed other topical therapies but prefer to avoid oral medications. 

If you’re looking for cost-effectiveness, metronidazole is your go-to. Topicals such as Mirvaso and Rhofade may be more desirable in patients who have more concerns about flushing.

For patients with more severe disease or who don’t respond to topical therapies, oral antibiotics are the next line of therapy. Tetracyclines, such as doxycycline and minocycline, are the most studied agents. We often start these at antimicrobial doses to quickly reduce inflammation; however, due to concerns over antibiotic resistance, there are maintenance therapies in lower doses (20-40 mg) that utilize only the anti-inflammatory properties. These can also be used in conjunction with topical therapies or for as-needed “break-through” therapy in patients who are usually well-controlled with topicals. 

For refractory acne rosacea, oral isotretinoin is an option. The weight-based dosing is lower than what is given for nodular acne, but the treatment lasts until the inflammation is under control for one to two months. This totals to almost five to six months of treatment. However, it’s important to note that there aren’t good long-term data on isotretinoin’s efficacy in acne rosacea. Additionally, there are many side effects associated with isotretinoin use, and strict monitoring is required due to its teratogenicity. 

Another option is laser, which helps target telangiectasias and erythema. The major drawback with laser is that it’s not covered by insurance, and the data supporting it as a treatment for inflammatory papules and pustules is mixed, so we can’t recommend it as a treatment that will yield long-lasting results. You can always recommend a consult with your local dermatologist for patients with questions about laser or intense pulsed light (IPL) therapies. 

Acne Treatment

Now, on to acne. With tons of companies that make products marketed for acne, “clear skin”, “reducing pore size”, clearing breakouts, there are a lot of options to choose from. Also, as an FYI, you can’t reduce your pore size, you can only make them appear less prominent! The main topical therapies will fall into the following categories:

Topical exfoliants/retinoids: Think salicylic acid, alpha- and beta-hydroxy acids (LHAs/BHAs), glycolic acid, retinol, tretinoin, adapalene. I may have missed some here, but you get the point. All of these work by increasing the skin’s turnover rate and keeping pores from getting clogged with dead skin and acne-causing bacteria. They’re great to use in combination with other therapies or as maintenance medications. Be sure patients know that they can cause irritation and peeling at any concentration and to use sun protection during treatment. 

Topical antimicrobials: Think benzoyl peroxide (BPO), clindamycin, erythromycin, and minocycline. These treat any acne-causing bacteria and often have mild anti-inflammatory properties. BPO has been around for years and is great for the face, chest and back since it comes in various concentrations and is available without a prescription. You can recommend stronger concentrations for chest and back, but make sure to warn patients that BPO bleaches clothing! When using clindamycin, erythromycin, and minocycline products, make sure they aren’t being used alone long-term; they need to be combined with topical BPO to prevent antimicrobial resistance. 

Combination products: There are so many combination products out there that I can’t fit all of them here. Essentially, you’re using products with different mechanisms of action that have been studied to be synergistic together or help prevent antimicrobial resistance in topical antimicrobials when used alone. They come in different strengths and can be great for maintenance or as-needed spot treatment. Examples include Benzaclin (BPO + Clindamycin), Epiduo (Adapalene + BPO), Ziana (Clindamycin + tretinoin).

Oral antibiotics: Think tetracyclines (doxycycline, minocycline), which have both antimicrobial and anti-inflammatory effects. These are typically used short-term – no longer than 1-3 months at a time and when patients have failed topical therapies and/or have papulopustular acne. These work best when combined with topical maintenance therapies. 

Oral Contraceptive Pills (OCPs) and Spironolactone: These are the dark horses of oral acne products in my clinical opinion. They are great when you’re treating acne that is more hormonal in nature – it occurs cyclically with menstrual cycles and/or is in a hormonal distribution such around the jawline or chin and in patients with PCOS. Both options have antiandrogen effects and can treat moderate to severe acne that has failed topical therapies. These work best when combined with topical maintenance therapies. 

Oral isotretinoin: Also known as Accutane, isotretinoin is an option for patients with severe nodular acne or for those with moderate to severe acne who have failed the other therapies mentioned above. This will be managed by dermatology as patients are registered in the iPledge program for monitoring due to teratogenicity and the need for occasional lab monitoring. However, don’t let this deter you from recommending this to your patients. It’s a very effective treatment and many patients see amazing results after a full course.

Crossover for Acne Vulgaris and Acne Rosacea: This is so important for both patient populations! Make sure your patients avoid harsh scrubs, medicated washes (unless you’re the one recommending it as part of their treatment plan), toners, etc. Mild cleansers without fragrance are best: Cetaphil, Cerave, Neutrogena, LaRoche Posay, etc. Sun protection is an integral, but often forgotten component of treatment. Sun can flare rosacea and contribute to ongoing post-inflammatory erythema or hyperpigmentation in resolving acne lesions. Daily use of a broad-spectrum zinc oxide or titanium dioxide sunscreen with at least 30 SPF is ideal – this is the least irritating to skin and offers non-chemical protection. 

The Differential

Now that you have all of this acne and acne rosacea medication to share with your colleagues, make sure you don’t forget to include differential diagnoses in your clinical decision-making. Centrofacial erythema or telangiectasias could be due to sun damage over time or flushing disorders induced by hormonal changes or a malignant process. Other inflammatory conditions can mimic acne rosacea, such as seborrheic dermatitis, cutaneous lupus erythematosus or dermatomyositis. Conditions such as perioral dermatitis or corticosteroid-induced acne can mimic comedonal and papulopustular acne presentations, but require a different approach to treatment. Nodular acne can be mimicked by hidradenitis suppurativa, especially lesions that occur on the trunk, axillae, and/or groin. If symptoms do not improve with treatment or patients report other systemic symptoms, consider further workup to rule out other, potentially more serious disease processes.

Now, go out and show the medical world your newfound knowledge on how to tackle acne and rosacea in your patients!

Rachael Whittemore, MPAS, PA-C
Rachael Whittemore, MPAS, PA-C

Rachael currently works in family medicine and has experience in medical and surgical dermatology along with chronic illness advocacy for young adults. She has also served in free medical clinics and in local hospitals in Belize and Peru, respectively, prior to finishing PA school. She enjoys the ability to care for a variety of patients in her community and serve Spanish-speaking patients through her practice.

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