How to Tell if Your Acne Is Actually Rosacea

When our skin is acting up, it’s only natural to want to get to the root of the situation. And while most of us are pretty adept at identifying an unwelcome pimple, sometimes our skin concerns can be a little harder to figure out. For example, if you’re struggling with what seems like pimples across the center of your face, turns out, they might not be pimples—or at least, not in the way we typically think of them. "Acne rosacea is a common skin condition that is often characterized by background redness on the face, papules, pustules and often swelling," explains Florida-based board-certified dermatologist Stacy Chimento. While rosacea can’t be cured, per se, fortunately, there are a lot of treatment avenues to explore, and the range of options are consistently growing, too. In treating rosacea, "Our goal is to try to slow down the progression, and that often includes a combination of topical creams, oral antibiotics, and pills," explains New York City-based board-certified dermatologist Shari Marchbein explains, all of which work in different ways to target different elements of the condition. Below, dermatologists explain the difference between acne rosacea and acne vulgaris—and how to handle both. 

What Is Acne Rosacea?

When we think of rosacea, we typically think of redness—and that’s accurate, but the condition can involve present itself in different ways. In addition to red facial skin, rosacea can also sometimes entail "bumps and broken blood vessels on nose, chin, cheeks, and foreheads," says Redondo Beach, CA-based board-certified dermatologist Annie Chiu. When rosacea is not treated, Chiu explains, it can cause small red bumps that sometimes contain pus, cysts, dilated blood vessels, and eye irritation. 

What Is Acne Vulgaris?

Acne vulgaris is the technical term for the condition we picture when we hear "acne." Simply put, it’s a skin condition in which the pores (hair follicles) of the skin clog up and become inflamed. "Depending on the degree of severity, this can lead to blackheads (comedones), pimples, cysts, and scars occurring in groups," Chiu notes. 

How Does Acne Rosacea Compare to Acne Vulgaris?

While acne rosacea is typically concentrated on the face, acne vulgaris can also affect areas like the back and chest. It is the most common skin disease in adolescence and young adulthood. 

"While the two are often confused by patients given their looks, both conditions are distinct," says Chiu. "Rosacea typically can resemble a combination of pimples, rashy skin, and redness. While acne also causes redness, it appears as whiteheads, blackheads, and hard lumps in severe cases. Unlike rosacea, the redness is isolated to the pimple."

According to Miami-based board-certified dermatologist Jeremy Green, one way to tell whether you may have acne or rosacea is to note the distribution. "If the redness and bumps involve primarily cheeks and nose, it could be rosacea. Also, patients who only have rosacea (not acne) tend to have minimal or few comedones in these areas," he says.

What Causes Acne Rosacea?

Rosacea can be genetic (which usually means multiple family members have it). One theory, Green explains, is that patients with rosacea have a "hypersensitivity to a particular mite (demodex folliculorum) that lives on all of our skin." Finally, having rosacea also means paying attention to the various triggers that can lead to flare-ups, from the inevitable (emotional stress, heat) to the ones that you can at least try to avoid (alcohol, spicy foods, caffeine, and sun exposure). 

What Causes Acne Vulgaris?

Acne vulgaris results from the overproduction of sebum from the oil glands in the skin. The oil glands are attached to your hair follicles and release oil into your pores. "Excess sebum clogs the pores along with dead skin, leading to buildup in the pores and hair follicles," explains New York City-based board-certified dermatologist, Morgan Rabach. “This buildup can lead to materials rupturing under the skin, and along with bacteria that comes from the skin, causes more inflammation under your skin as inflammatory cells come to the area to clear the debris.”

Anything that increases the sebum can lead to acne vulgaris—this can include a genetic predisposition for acne and hormonal variants. "Male hormones called androgens lead to increased sebum, and fluctuations of hormones lead to oil buildup,” Rabach says. Cortisol, the hormone released in stress, also leads to increased sebum. Finally, certain medications can lead to breakouts including lithium, hormones, iodine, and steroids.

How Is Acne Rosacea Treated?

• Azelaic Acid 15% gel: Azelaic acid is a well-liked ingredient over the counter, too, but for more serious cases of rosacea, dermatologists will prescribe a medicated dose of this antibacterial. "It is overall well tolerated and doesn’t cause the dryness or irritation that other acne topicals, including retinoids, do (so it’s great for sensitive and rosacea-prone skin)," Marchbein explains, noting that it is is FDA-approved for daily use. 
• Soolantra (aka Ivermectin): If your dermatologist thinks those aforementioned mites could be at the root of your rosacea, they might prescribe Soolantra (the brand name for Ivermectin). "This is an anti-inflammatory and anti-parasitic cream that works against the Demodex mite found in the oil glands and hair follicles in those with rosacea," Marchbein says, adding that it’s usually well-tolerated, and may help more with acne rosacea breakouts (papules and pustules) than with redness. It is FDA approved for once daily use. 
• Low Dose Doxycycline: In Marchberin’s opinion, a low dose (40 mg daily) of doxycycline can help with both inflammatory breakouts and redness, and is the "gold standard for treating ocular rosacea." (Yes, you can get rosacea on your eyes, too). At this dose, it works as an anti-inflammatory rather than an antibacterial, and also reduces new blood vessel formation.
• Brimonidine and Oxymetazoline: Both Brimonidine and Oxymetazoline are topical treatments that work to constrict blood vessels and are used specifically to temporarily reduce the redness from rosacea. "They need to be applied daily and last for up to 12 hours," Marchbein says. However, she notes, "Extremely rarely, these topicals may cause a phenomenon known as rebound erythema, where the redness is worse than it was to begin with, and this can be both distressing to patients and last for months."
• Lasers: Though certainly an expensive method, Laser treatments can be effective in fighting rosacea. These treatments often require multiple sessions at monthly intervals, and then need to be repeated every 1-2 years for maintenance. Green is a proponent of “green light Excel V by Cutera KTP laser to reduce the unsightly redness of rosacea or post-acne redness.”

How Is Acne Vulgaris Treated?

• Retinol: The gold standard in skincare for a reason, "Retinols are the most effective topical medication to reduce sebum, unclog pores, slough away dead skin, and help to reduce blackheads and whiteheads," Rabach says. Retinol can also be ingested in the form of isotretinoin, also known as Accutane.
• Topical Antibiotics: Topical antibiotics like clindamycin help reduce inflammatory papules and pustules (the red bumps and pus-filled bumps in acne.)
• Spironolactone: Spironolactone is an oral medication for women with hormonal acne and may be especially helpful for acne on the lower face, jawline and neck. "Sprinolactone blocks androgen receptors leading to less sebum production and, as a result, fewer clogged pores," Rabach explains. Depending on the dose, a patient should expect fewer breakouts.
• Oral Birth Control: Like Spironolactone, oral birth control is used to target the hormonal elements of acne. "Oral birth control for women works by reducing the balance of androgens in the body, and also reduces the cyclic surges of hormones, including androgens," Rabach tells us. “Androgens cause sebum production which leads to clogged pores and acne, so when taking birth control for acne, patients can expect a reduction in breakouts—especially ones that are correlated to the monthly menstrual cycle." It's important to note, however, that not all birth control is effective at treating acne (certain forms of birth control can actually worsen acne). So it's important to talk to your OBGYN or dermatologist about the best birth control for you.
• Benzoyl Peroxide and Salicylic Acid: Benzoyl peroxide and salicylic acid are pivotal ingredients when it comes to over-the-counter acne treatments. Benzoyl peroxide works to destroy bacteria in the pores that lead to acne. It also helps dry up pus, and "eases inflammation," according to Rabach. Salicylic acid is a beta-hydroxy acid (BHA) that helps exfoliate away dead skin cells that can lead to clogged pores.
• Oral Isotretinoin (aka Accutane): Oral isotretinoin, also commonly known as Accutane, is a high dose of vitamin A. "The indication," Rabach explains, “is for people with nodulocystic acne that has scarring and also for people with scarring for whom antibiotics did not work." It works by, in some cases, permanently inhibiting the sebaceous glands (aka the oil glands) that cause acne. The permanent nature of this change is why some people consider Accutane to be a cure for acne. But it’s not a simple drug to be on, though: "Patients are required to get monthly lab work, cannot get pregnant on the medication, and cannot donate blood while on the medication," Rabach explains. There are also some side effects associated with the medication, so be sure to thoroughly go through all aspects of the drug with your physician.