Acne and rosacea are two of the most prevalent skin conditions that can significantly impact an individual's confidence and quality of life. Although they may appear similar at first glance, they are distinct disorders requiring different approaches to diagnosis and treatment. Misidentifying one for the other can lead to ineffective treatments and prolonged discomfort.
This is common; according to one national survey, nearly half of people with rosacea believed they had acne before they were correctly diagnosed. This article aims to clarify the critical differences between acne and rosacea, providing readers with the knowledge needed to identify and manage these conditions accurately.
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What Is Acne?
Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells, forming lesions known as pimples or zits.
Sebum is an oily substance produced by sebaceous glands within the skin. When excess sebum combines with dead skin cells, it can clog pores, creating an environment where bacteria, particularly Cutibacterium acnes (formerly Propionibacterium acnes), thrive. In some cases, the immune system's response to this bacterial buildup may cause inflammatory acne, characterized by red, swollen, and painful blemishes. (13)
On a deeper level, the development of acne is influenced by the following factors:
- Hormones: Androgenic hormones DHEA, testosterone, and dihydrotestosterone (DHT) stimulate sebaceous glands to produce more oil, which is why acne is prevalent during puberty and conditions like polycystic ovary syndrome (PCOS). Fluctuations in estrogen and progesterone during the menstrual cycle, pregnancy, or menopause can also increase the risk of acne. (48)
- Studies that have demonstrated a three-times greater risk of developing acne in people with a first-degree family member with acne support the notion that genetics are involved in acne development, progression, and severity.
- Lifestyle factors, such as diet, stress, use of certain skin and hair care products, and taking certain medications, can make acne worse.
Acne can appear on the skin as different types of lesions, including:
- Comedones: blackheads and whiteheads
- Papules: small, red bumps
- Pustules: pus-filled papules
- Nodules: large, painful lumps beneath the skin
- Cysts: deep, pus-filled lumps
Acne most commonly affects areas with a high concentration of oil glands, including the face, chest, shoulders, and back (4).
What Is Rosacea?
Rosacea is a chronic inflammatory skin condition characterized by persistent redness, visible blood vessels, and often small, red, pus-filled bumps on the face. The exact cause of rosacea is not fully understood but involves neurovascular dysregulation and exaggerated immune responses that cause excessive inflammation (20).
The following have been identified as possible factors contributing to the development of rosacea:
- Increased expression of a protein called cathelicidin
- Low vitamin D serum levels
- Extreme temperatures
- Exposure to ultraviolet (UV) radiation
- Consumption of alcohol, spicy foods, and hot beverages
- Dysbiosis, including an overgrowth of Demodex mites on the skin, Helicobacter pylori infection in the gastrointestinal tract, or small intestinal bacterial overgrowth (SIBO)
Rosacea often follows a course of relapse and remission. During flares, patients will experience the following symptoms:
- Facial redness, especially on the cheeks and nose
- Visible blood vessels (telangiectasia)
- Red, swollen bumps or pustules that resemble acne
- Burning or stinging sensations on the skin
- Thickening and scaling of the skin, especially around the nose
- Eye irritation
Key Differences Between Acne and Rosacea
While both conditions may present with similar symptoms, various distinguishing factors help differentiate acne from rosacea. The table below highlights these differences.
Diagnosis: How to Tell the Difference
Given the complexities of distinguishing between acne and rosacea, professional evaluation by a dermatologist is the most reliable way to achieve an accurate diagnosis. Dermatologists are healthcare professionals with the expertise to differentiate between the two based on clinical examination, patient history, and, sometimes, additional tests.
Acne can be diagnosed based on patient history and physical examination. Open ("blackheads") and closed ("whiteheads") comedones should be visualized on the skin, most often in areas with the highest concentration of sebaceous glands. Inflammatory papules, pustules, nodules, and cysts may also be present in more severe cases. (17)
The American Academy of Dermatology developed a grading scale to classify acne based on severity:
- Mild Acne: A few to several papules and pustules, but no nodules
- Moderate Acne: Many papules and pustules, with a few to several nodules
- Severe Acne: Numerous papules and pustules and many nodules
Rosacea is also diagnosed based on history and physical examination. Clinical guidelines for diagnosing rosacea state that one of the following is present on the central face:
- Flushing (transient erythema)
- Persistent redness (nontransient erythema)
- Papules and pustules
- Telangiectasia
Treatment Options for Acne
Acne treatment typically begins with conventional therapies that reduce oil production, combat bacterial infection, and promote skin cell turnover.
- Topical retinoids, such as tretinoin, adapalene, and tazarotene, are considered first-line treatments for mild acne. In addition to having anti-inflammatory properties, these vitamin A derivatives promote cell turnover and prevent the clogging of pores. Visible improvements in acne can be observed after 8-12 weeks of treatment.
- Benzoyl peroxide is a widely used topical agent that treats acne through its antibacterial properties and clearing pores. It is used in concentrations ranging from 2.5-10% and is most effective when combined with topical retinoids or antibiotics. (29)
- Salicylic acid is an anti-inflammatory, antibacterial, and exfoliative beta-hydroxy acid. The American Academy of Dermatology recommends using skin care products containing salicylic acid to treat pustules, papules, and comedones. (43)
- Topical and oral antibiotics are commonly prescribed for moderate to severe acne, particularly when there are inflammatory lesions. Antibiotics, such as clindamycin and erythromycin, reduce Cutibacterium acnes bacteria and inflammation.
- Oral contraceptive pills (OCPs) may be prescribed to female patients with acne to regulate hormones and reduce androgen levels. The U.S. Food and Drug Administration (FDA) has approved the following OCPs for treating acne: Ortho Tri-Cyclen, Estrostep, and Yaz (49).
- Isotretinoin (Accutane) is a potent oral retinoid reserved for acne that is severe or resistant to other treatments. It works by shrinking sebaceous glands, reducing oil production, and normalizing skin cell shedding. Although isotretinoin is highly effective – clinical studies show it can cure acne in about half of the people who take it – it comes with potentially serious side effects, including teratogenicity, dry skin, and elevated lipid levels. Therefore, it requires careful monitoring by a healthcare professional.
In addition to conventional treatments, complementary and integrative approaches can support acne management, particularly for patients seeking a holistic approach.
- A low-glycemic diet can reduce acne severity within 10 to 12 weeks.
- A gentle skincare routine that avoids harsh scrubs and non-comedogenic products can help manage acne. Cleansing the skin twice daily and after sweating with a mild cleanser and using oil-free moisturizers can prevent further irritation and breakouts.
- Supplementing 2,000 mg of omega-3 fatty acids (combined EPA and DHA) daily for ten weeks can decrease the severity of non-inflammatory and inflammatory acne lesions.
- Probiotics may help balance gut microbiota, which can influence skin health. Evidence suggests that probiotics can improve acne by supporting the immune system, reducing oxidative stress, and supporting a healthy microbiome.
Treatment Options for Rosacea
Topical agents are first-line therapy in the treatment of mild-to-moderate rosacea. The following agents are FDA-approved for treating rosacea and act by reducing its associated inflammation and redness:
- Metronidazole
- Azelaic acid
- Sulfacetamide/Sulfur
- Brimonidine
- Ivermectin
Trigger avoidance, using mild cleansing and moisturizing agents on the skin, and sun protection (using hats and sunscreen) are also recommended as foundational therapies for rosacea (31).
For more severe or persistent cases of rosacea, pulsed dye laser, intense pulsed light, and near-infrared lasers are effective in treating redness and telangiectasia. These modalities are expensive and may not be covered by insurance. (31)
Additional approaches to rosacea emphasize treating underlying causes and supporting overall health:
- Treating SIBO: According to one study, treating SIBO with a 10-day course of rifaximin (an oral antibiotic) resulted in rosacea remission in 58.3% of patients, 64.5% of whom were still in remission after three years.
- Dietary Modifications: Surveys have identified alcohol, spices, fried foods, chocolate, coffee, refined sugar, and milk as the primary triggers of rosacea. These should be eliminated from the diet. Some patients also benefit from avoiding foods high in histamines, which can trigger vasodilation and flushing. Conversely, vegetables, nuts, whole grains, tea, and fish are foods that can reduce the severity of the disease. (19)
- Nutritional Supplements: Supplements like omega-3 fatty acids, zinc, and probiotics have been suggested to support skin health and reduce inflammation.
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Key Takeaways
- While acne and rosacea share some similarities, they are distinct conditions with different underlying causes, triggers, and treatment options.
- Acne is more common in younger individuals and is characterized by blackheads and whiteheads, whereas rosacea typically affects adults over 30 and presents with persistent redness, visible blood vessels, and acne-like bumps without blackheads.
- Proper diagnosis is important, as treatments effective for acne may worsen rosacea, and vice versa. Consult a healthcare professional if you're unsure of your condition.
- Both acne and rosacea can be managed with the right treatment. Understanding these differences and implementing the appropriate care can help individuals achieve healthier skin.
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