Executive summary
- Recognise: persistent central facial erythema ± flushing, papules/pustules (no comedones), telangiectasia; ocular symptoms can occur.
- First-line foundation: gentle skincare + trigger management (heat, alcohol, spicy foods, hot drinks, topical steroids).
- Papulopustular rosacea: topical ivermectin or metronidazole or azelaic acid; add oral tetracycline if moderate–severe.
- Ocular red flags (pain/photophobia/visual change) → urgent eye assessment.
Topical therapy (common pathway)
- Topical ivermectin (often once daily) for mild–moderate papules/pustules where suitable.
- Alternatives: topical metronidazole or azelaic acid (especially if ivermectin unsuitable).
- Persistent erythema: consider topical vasoconstrictor options (e.g., brimonidine) where appropriate and available.
When to add oral antibiotics
- Consider oral tetracycline-class antibiotic (e.g., doxycycline) for moderate–severe inflammatory disease or inadequate response to topicals.
- Use time-limited courses with a plan to step down to topical maintenance once controlled.
- Avoid in pregnancy; counsel on photosensitivity and GI side effects.
Ocular rosacea red flags
Eye pain, photophobia, reduced vision, marked redness, or suspected keratitis requires urgent ophthalmology/eye service assessment. Simple “dry eye” symptoms can still be part of rosacea—ask proactively.
Frequently asked questions
How do I distinguish acne from rosacea?
Rosacea typically has flushing/erythema and papules/pustules but lacks comedones. Triggers (heat/alcohol) and ocular symptoms also point to rosacea.
What’s the best retention counselling?
Set expectations: improvement takes weeks; triggers matter; and many need maintenance topical therapy even after a good response.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.