As a dermatologist in Miami who has rosacea myself, I understand firsthand the challenges that come with this chronic skin condition. I've seen countless patients in my practice who struggle with various symptoms of rosacea, including the often-misunderstood and frustrating rosacea acne, characterized by bumps such as pimples, papules, and pustules. This article will talk about the differences in acne and the type of rosacea that get pimples known as papulopustular rosacea.

Rosacea acne lesions are dome-shaped red papules with or without accompanying pustules, often appearing in crops and predominantly in the centrofacial area. These rosacea bumps and rosacea pimples are frustrating and embarrassing to deal with, can feel itchy or stinging, and require targeted treatment with acne spot treatments.

According to the updated standard classification of rosacea by the National Rosacea Society Expert Committee in 2017, rosacea can be categorized based on diagnostic features that include:

• centrofacial erythema 
• flushing
• telangiectasia
•  papules and pustules (papulopustular rosacea)
•  ocular manifestations
• phymatous changes

This blog will discuss the papules and pustules seen in the type of rosacea known as papulopustular rosacea.

This form of rosacea is very distressing because the pimples and papules are embarrassing but they ca also sting and itch and be distracting, making it hard to get you mind oof of your skin.

Characteristics of papulopustular rosacea:

• Constant redness in the middle of the face that doesn't go away
• Pimple-like bumps or pus-filled bumps that come and go, mostly in the middle of the face
• These bumps can also show up around the mouth, nose, or eyes
• Looks similar to regular acne, but there are no blackheads or whiteheads
• Can happen along with regular acne, so blackheads and whiteheads might be seen together with rosacea bumps
• People with this type of rosacea may feel burning or stinging on their skin
• Often happens after or at the same time as another type of rosacea that causes redness and visible blood vessels
• Tiny blood vessels in the skin may be there but hard to see because of the constant redness and bumps
• These tiny blood vessels become easier to see after the redness and bumps are treated and go away

Acne and rosacea both cause pimples and bumps on the skin, but there are some important differences between them. A study by Yang et al. (2021) used bioinformatics analysis to find these differences in the immune cells present in acne and rosacea pimples:

1. Acne pimples have more neutrophils, monocytes, and activated mast cells compared to rosacea pimples. This means that acne pimples have a stronger inflammatory response.
2. Rosacea pimples have more naive CD4+ T cells, plasma cells, memory B cells, and resting mast cells compared to acne pimples. This suggests that rosacea pimples have a more adaptive immune response.
3. Acne pimples have fewer regulatory T cells (Tregs) compared to the skin around the pimples and the skin of healthy people. Tregs help maintain balance in the immune system, so having fewer Tregs in acne pimples may lead to more inflammation.
4. Both acne and rosacea involve Th1 and Th17 cells, but acne pimples have more Th1 and Th17 activity compared to rosacea pimples.
5. Among the three types of rosacea (erythematotelangiectatic, papulopustular, and phymatous), papulopustular rosacea pimples are most similar to acne pimples in terms of immune cell activity.

While both acne and rosacea pimples involve inflammation, acne pimples have a more intense innate immune response, while rosacea pimples have a more adaptive immune response. Rosacea pimples also tend to go away faster than acne pimples and are usually found in the central part of the face, while acne can also appear on the forehead and jawline. 

Demodex mites reside in the pilosebaceous units of the skin and are found in higher densities in rosacea patients compared to healthy individuals. When present in excessive numbers, Demodex mites can contribute to the formation of papules and pustules characteristic of papulopustular rosacea through several mechanisms.

1.  The mites can cause direct damage to the follicular epithelium, leading to inflammation and the development of papules. 
2. Demodex mites have been shown to carry bacteria on their surface, such as Bacillus oleronius, which can stimulate an immune response and exacerbate inflammation.
3. The mites' digestive enzymes and waste products can irritate the skin and trigger an inflammatory reaction. 

This inflammation, combined with the altered skin microbiome and potential immune system dysregulation, can lead to the formation of the papules and pustules seen in papulopustular rosacea. Treatments targeting Demodex mites, such as topical ivermectin or oral antibiotics, have been shown to reduce mite density and improve the symptoms of papulopustular rosacea, further supporting the role of these mites in the pathogenesis of the condition.

The study by McAleer, Fitzpatrick, and Powell (2010) found no significant relationship between papulopustular rosacea prevalence and UV exposure, suggesting that UV radiation may not be a significant factor in the pathogenesis of rosacea acne. However, sun exposure is believed to contribute to the first stage of rosacea called  erythematotelangiectatic rosacea.

For this reason, and to prevent skin aging and skin cancer, incorporating rosacea-friendly sunscreens into your daily skincare regimen is still important for overall skin health. Sunscreens specifically designed for sensitive, rosacea-prone skin can provide protection against UV damage while minimizing irritation. Look for gentle, non-comedogenic SPF formulas containing mineral-based UV filters like zinc oxide or titanium dioxide, as these are less likely to aggravate rosacea symptoms compared to chemical sunscreens. Consistently using a rosacea-friendly sunscreen with anti-inflammatory ingredients can help reduce inflammation, and prevent further photodamage, all of which are beneficial for managing papulopustular rosacea.

When it comes to treating rosacea papules, a different approach is often needed compared to managing acne pimples. While retinoids, benzoyl peroxide, and salicylic acid are commonly used for acne, rosacea-prone skin is often too sensitive and reactive to tolerate these strong ingredients. 

Instead, choose gentler spot treatments containing sulfur or lower concentrations of salicylic acid. Additionally, use soothing rosacea creams and serums to help calm inflammation and reduce redness associated with papulopustular rosacea. These products often contain ingredients like niacinamide, argan oil, green tea, and centella asiatica, which work to reduce irritation.

In my patients, i sometimes use prescription medications like Soolantra (ivermectin) cream to  reduce Demodex mites on the skin which are thought to contribute to the inflammation and development of papules, Soolantra can help improve the appearance of rosacea acne. Even if you are using prescription rosacea medications, for best results, you need to use them with a rosacea skin care routine customized to your Baumann Skin Type.

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1. Zeichner J, Mitchell K. Rosacea Ch. 17 of Baumann's Cosmetic Dermatology Ed 3. (McGraw Hill 2022)
2. Baumann, L. Ch.64- 74 in Cosmeceuticals and Cosmetic Ingredients (McGraw Hill 2015)
3. Saurat, J. H., Halioua, B., Baissac, C., Cullell, N. P., Hayoun, Y. B., Saint Aroman, M., ... & Skayem, C. (2024). Epidemiology of acne and rosacea: a worldwide global study. Journal of the American Academy of Dermatology.
4. Rajalingam, K., Levin, N., Marques, O., Grichnik, J., Lin, A., & Chen, W. S. (2023). Treatment options and emotional well-being in patients with rosacea: An unsupervised machine learning analysis of over 200,000 posts. JAAD international, 13, 172-178.
5. Yang, L., Shou, Y. H., Yang, Y. S., & Xu, J. H. (2021). Elucidating the immune infiltration in acne and its comparison with rosacea by integrated bioinformatics analysis. PloS one, 16(3), e0248650.
6. McAleer, M. A., Fitzpatrick, P., & Powell, F. C. (2010). Papulopustular rosacea: prevalence and relationship to photodamage. Journal of the American Academy of Dermatology, 63(1), 33-39.
7. McGregor, S. P., Alinia, H., Snyder, A., Tuchayi, S. M., Fleischer, A., & Feldman, S. R. (2018). A review of the current modalities for the treatment of papulopustular rosacea. Dermatologic Clinics, 36(2), 135-150.
8. Husein‐ElAhmed, H., & Steinhoff, M. (2020). Efficacy of topical ivermectin and impact on quality of life in patients with papulopustular rosacea: a systematic review and meta‐analysis. Dermatologic Therapy, 33(1), e13203.
9. Trave, I., Micalizzi, C., Cozzani, E., Gasparini, G., & Parodi, A. (2022). Papulopustular rosacea treated with ivermectin 1% cream: remission of the demodex mite infestation over time and evaluation of clinical relapses. Dermatology Practical & Conceptual, 12(4).