How do I tell the difference between rosacea and acne?

The key distinguishing feature is the presence or absence of comedones — blackheads and whiteheads. Acne always produces comedones; rosacea never does. Rosacea typically presents in adults aged 30–60, predominantly in women, with centrofacial flushing, persistent redness, telangiectasia, and sometimes papules and pustules in the central face (cheeks, nose, chin). Acne tends to have a wider distribution including the chest and back, and often starts in adolescence. A history of flushing triggered by alcohol, spicy food, heat, or sun strongly supports rosacea.

What is the best treatment for scalp seborrhoeic dermatitis (dandruff)?

Ketoconazole 2% shampoo (Nizoral) is first-line and available over the counter. Apply twice weekly during a flare, then reduce to once weekly for maintenance. Alternative antifungal shampoos include selenium sulfide 2.5% (Selsun, Tersi), ciclopirox 1% (Sebiprox), and zinc pyrithione 1–2% (Head and Shoulders). For thick inflamed scalp plaques during a flare, a short course of a topical corticosteroid lotion or solution can be added. Avoid switching shampoos too frequently — give each product 4–6 weeks at consistent use before concluding it is not effective.

Does rosacea ever affect the eyes?

Yes — ocular rosacea affects approximately 50–58% of people with rosacea at some point and can occur even when skin features are subtle. It presents as blepharitis (eyelid inflammation and scaling), conjunctivitis, and in severe cases keratitis (corneal inflammation), which is vision-threatening if untreated. Lid hygiene with warm compresses and lid scrubs is the first step; oral doxycycline 50–100 mg daily long-term is often required. Prompt ophthalmology referral is essential when there are visual symptoms, corneal involvement, or persistent ocular discomfort. Ocular rosacea must not be missed.

What triggers rosacea flares and can they be avoided?

Common triggers include alcohol (particularly red wine), spicy food, hot beverages, hot environments, saunas, intense exercise, emotional stress, UV sun exposure, and topical steroid use on the face. Keeping a trigger diary helps identify which factors are most relevant for an individual, since not everyone is sensitive to all triggers. SPF 50+ broad-spectrum mineral sunscreen (zinc oxide or titanium dioxide) is better tolerated than chemical sunscreens and should be used daily. Gentle, fragrance-free skincare without astringents, exfoliants, or alcohol-based products reduces baseline irritation.

Is extensive seborrhoeic dermatitis a sign of something more serious?

Seborrhoeic dermatitis in isolated scalp or facial areas is common and benign. However, when a new or suddenly extensive seborrhoeic dermatitis develops across the trunk, intertriginous areas, and face in an adult — particularly when it is resistant to standard antifungal treatment — HIV testing is warranted. Seborrhoeic dermatitis is the presenting skin problem in approximately 30–50% of people with HIV and is often the first visible sign of immunocompromise. Parkinson's disease, other neurological conditions, and certain immunosuppressive medications are also associated with more severe seborrhoeic dermatitis.

Rosacea and seborrhoeic dermatitis

Rosacea and seborrhoeic dermatitis: AU general practice guide

By Dr HB Lo, FACRRM Reviewed 2 June 2026 7 min read

Rosacea is a chronic facial inflammatory condition affecting around 5–10% of Australian adults, presenting with flushing, persistent centrofacial erythema, papules and pustules (without comedones), or sebaceous hypertrophy. Seborrhoeic dermatitis affects sebum-rich areas (scalp, face, chest), driven by Malassezia yeast overgrowth.

Rosacea management centres on trigger avoidance, mineral sunscreen, and topical ivermectin or metronidazole; oral doxycycline is added for papulopustular disease. Seborrhoeic dermatitis responds to ketoconazole shampoo for the scalp and ketoconazole cream for the face. Extensive or refractory adult-onset disease warrants HIV testing.

Rosacea and seborrhoeic dermatitis are two common, chronic facial skin conditions that general practitioners manage frequently, often together in the same patient. While distinct in pathophysiology, they share a tendency toward chronic relapsing courses, a significant impact on quality of life, and a need for long-term maintenance strategies rather than cure-focused thinking. Both are sometimes misdiagnosed — rosacea as acne, seborrhoeic dermatitis as eczema or psoriasis — and both carry risks when incorrectly managed with topical corticosteroids.

Therapeutic Guidelines (eTG) estimates rosacea affects approximately 5–10% of adults in Australia, predominantly women aged 30–60. Seborrhoeic dermatitis affects around 1–5% of the general population with a bimodal pattern: infants in the cradle-cap phase and adults from adolescence through older life. Both conditions are chronic and require patient education alongside treatment.

A. Core clinical — the AU general-practice framework

Rosacea: phenotype-based understanding

The Australasian College of Dermatologists uses a phenotype-based classification replacing older subtype nomenclature. Key features:

Erythematotelangiectatic — persistent centrofacial erythema with flushing and visible telangiectasia on the cheeks, nose, and chin.

Papulopustular — central-face papules and pustules without comedones. This is the subtype most commonly confused with acne; the absence of comedones is the discriminating feature.

Phymatous — sebaceous gland hypertrophy and fibrosis, most commonly as rhinophyma (bulbous nasal enlargement). Predominantly in men.

Ocular — blepharitis, conjunctival injection, and in severe cases keratitis (vision-threatening). Ocular features may appear before or without prominent skin disease.

A fifth descriptor, granulomatous rosacea, presents with firm papules on histology and may be harder to treat.

Rosacea pathophysiology

Rosacea results from vascular dysregulation, neurogenic inflammation, innate immune activation (particularly the cathelicidin LL-37 pathway), elevated Demodex folliculorum mite density, and environmental triggers. Triggers activate and amplify these pathways, producing the characteristic flares. Demodex — a commensal mite present on all human facial skin — is significantly more abundant in rosacea-affected skin and is the target of topical ivermectin.

Seborrhoeic dermatitis pathophysiology

Seborrhoeic dermatitis is not a primary fungal infection but an inflammatory response to Malassezia furfur / globosa yeasts, which colonise sebaceous skin and metabolise lipids into irritating fatty acids. The condition worsens in neurological conditions (Parkinson’s disease, stroke) and in HIV/immunocompromise — contexts where immune regulation is altered.

History

Rosacea: flushing pattern and identified triggers; age of onset (rosacea is adult-onset); centrofacial distribution; eye symptoms (redness, soreness, blurred vision); topical steroid history on face; family history; impact on quality of life.

Seborrhoeic dermatitis: scalp flaking and itch; facial and trunk involvement; course (chronic, flaring with stress or cold weather); HIV risk factors or immunosuppression; Parkinson’s history; prior antifungal shampoo use and response.

Examination

Rosacea: centrofacial distribution; persistent erythema; telangiectasia; papules/pustules without comedones (this is the key feature distinguishing it from acne); phymatous thickening; eyelid and conjunctival involvement.

Seborrhoeic dermatitis: greasy yellowish scales on erythematous base at sebum-rich sites — scalp, eyebrows, glabella, nasolabial folds, postauricular skin, beard area, presternal chest, axillae, groin.

Investigations

Both conditions are clinical diagnoses in most cases. Selective investigations:

KOH scraping: to exclude tinea faciei when an annular or scaling facial rash is suspected
Skin biopsy: atypical presentations, suspected discoid or subacute cutaneous lupus erythematosus, dermatomyositis, sarcoidosis
HIV serology (MBS item 69384): extensive or refractory adult-onset seborrhoeic dermatitis
ANA, anti-Ro/La: facial rash with photodistribution or systemic features suggesting lupus
Pre-isotretinoin baseline: FBC 65070, LFTs 66512, fasting lipids 66536, pregnancy test 66635 where isotretinoin is planned for severe rosacea

B. Evidence appraisal — what the trials support

Topical ivermectin versus metronidazole for papulopustular rosacea

Topical ivermectin 1% cream (Soolantra), applied once daily, has become established as a highly effective treatment for papulopustular rosacea through its Demodex-targeted mechanism. Head-to-head RCT data consistently shows ivermectin to be superior to metronidazole 0.75% for papule and pustule reduction. AMH and eTG both include ivermectin as a first-line topical option for papulopustular rosacea. Metronidazole 0.75–1% twice daily remains a well-supported and more cost-accessible option, particularly on the PBS general schedule.

Sub-antimicrobial doxycycline for chronic papulopustular rosacea

Modified-release doxycycline 40 mg daily (Oracea, Periostat, Effracea) works at sub-antimicrobial concentrations purely as an anti-inflammatory, reducing reliance on antibiotic activity and therefore carrying lower antimicrobial resistance risk. It is PBS Authority Required for rosacea. The evidence base supports its use for chronic papulopustular rosacea requiring ongoing oral anti-inflammatory therapy.

Ketoconazole 2% for seborrhoeic dermatitis

Ketoconazole 2% shampoo and cream are the most extensively studied antifungals for seborrhoeic dermatitis and are first-line per eTG. Multiple RCTs demonstrate superiority over placebo for both scalp and facial disease. Ciclopirox, selenium sulfide, and zinc pyrithione are alternatives with good evidence. Long-term topical corticosteroid use on the face is not evidence-supported and causes atrophy, perioral dermatitis, and steroid-induced rosacea.

C. Treatment guide — rosacea and seborrhoeic dermatitis

Rosacea: foundational approach

Trigger identification and avoidance is the most cost-effective intervention. A trigger diary (alcohol, red wine specifically, spicy food, hot beverages, heat, exercise, UV, stress) identifies individual patterns.

Skincare: fragrance-free, non-soap gentle cleanser; mineral SPF 50+ sunscreen (zinc oxide or titanium dioxide tolerate better than chemical filters on sensitive facial skin); avoid astringents, toners, exfoliants, and alcohol-based products.

Topical agents (per eTG and AMH):

Agent	Indication	Notes
Metronidazole 0.75–1% gel/cream BD	Papulopustular; ETR	PBS general schedule; anti-inflammatory
Ivermectin 1% cream (Soolantra) daily	Papulopustular; Demodex-targeted	Often superior to metronidazole; private cost
Azelaic acid 15% gel BD	Papulopustular; erythema	Pregnancy-safe; also reduces postinflammatory pigment
Brimonidine 0.33% gel (Mirvaso)	Transient erythema reduction	Rebound flushing possible — intermittent use

Oral antibiotic for moderate-to-severe papulopustular rosacea: doxycycline 50–100 mg daily for 8–12 weeks, or modified-release doxycycline 40 mg daily (Authority Required) for longer anti-inflammatory use.

Isotretinoin low-dose (10–20 mg daily): for severe, phymatous, or refractory rosacea. Authority Required; specialist or experienced GP; Pregnancy Category X — strict prevention.

Ocular rosacea: warm compress and lid hygiene; artificial tears; oral doxycycline long-term; ophthalmology referral where keratitis or persistent ocular symptoms are present.

Seborrhoeic dermatitis: scalp, face, and body

Scalp flares: ketoconazole 2% shampoo (Nizoral, OTC) twice weekly to daily during a flare; reduce to weekly for maintenance. Alternatives: selenium sulfide 2.5% (Selsun), ciclopirox 1% (Sebiprox), zinc pyrithione 1–2% (Head and Shoulders). Short topical corticosteroid scalp solution/lotion for acute flares only.

Face and body: ketoconazole 2% cream BD until clear, then as needed. Ciclopirox cream is an alternative. Topical hydrocortisone 1% for brief flare control — avoid potent corticosteroids on the face.

Topical calcineurin inhibitor (pimecrolimus cream): steroid-sparing maintenance for facial seborrhoeic dermatitis — Authority Required on PBS.

Cradle cap: olive or coconut oil massage, soft brush, gentle wash. Persistent cases: mild ketoconazole 2% cream or hydrocortisone 1% in appropriate paediatric formulations.

Eyelid seborrhoeic dermatitis and Demodex blepharitis: tea tree oil lid scrubs and warm compresses. Topical or oral ivermectin for refractory Demodex blepharitis.

D. Australian operations

PBS schedules for rosacea and seborrhoeic dermatitis (verified 2026):

Topical metronidazole, ivermectin cream, azelaic acid: general schedule
Doxycycline 50/100 mg: general schedule
Modified-release doxycycline 40 mg (Oracea/Periostat): Authority Required for rosacea
Isotretinoin (Roaccutane, generics): Authority Required for severe rosacea (low-dose, specialist)
Ketoconazole 2% shampoo and cream: OTC/general schedule
Topical calcineurin inhibitors: Authority Required

MBS billing: standard consults 23/36/44. Mental Health Care Plan 2715/2717 for rosacea with significant psychosocial impact — flushing and phymatous rosacea particularly carry high psychological burden. HIV item 69384 for refractory extensive adult seborrhoeic dermatitis workup.

IPL (intense pulsed light) and pulsed-dye laser for telangiectasia and persistent erythema in rosacea are highly effective but typically privately funded in Australia. Rhinophyma requires surgical or laser reduction by a specialist.

E. Special populations

Pregnancy

Rosacea in pregnancy: azelaic acid is first-line (Category B2); topical metronidazole is acceptable (Category B2); avoid isotretinoin (Category X) and tetracyclines (second and third trimester — teeth and bone development). Oral erythromycin is an acceptable antibiotic alternative.

Seborrhoeic dermatitis in pregnancy: topical ketoconazole and mild hydrocortisone 1% are generally considered acceptable. Avoid potent fluorinated corticosteroids on the face.

HIV-positive patients

Seborrhoeic dermatitis in HIV can be extensive, refractory, and a marker of immunosuppression severity. Standard antifungal treatment applies; systemic antifungals (oral fluconazole or itraconazole) may be needed for severe cases in this population. Antiretroviral therapy improving immune reconstitution often improves seborrhoeic dermatitis independently.

Older adults and Parkinson’s disease

Both rosacea and seborrhoeic dermatitis are more prevalent and often more severe in older adults and in Parkinson’s disease. The autonomic dysfunction and facial immobility of Parkinson’s amplifies sebaceous activity. Standard topical antifungal regimens apply; frequency of maintenance may need to increase.

When to escalate

Refer or escalate when:

Ocular rosacea with visual symptoms or keratitis: urgent ophthalmology
Isotretinoin initiation for severe rosacea: specialist or experienced GP; Pregnancy Category X counselling mandatory
Rhinophyma: laser, surgical, or dermabrasion specialist
Refractory atypical facial rash: consider lupus, dermatomyositis, sarcoidosis — biopsy + ANA/ENA
Extensive adult-onset refractory seborrhoeic dermatitis: HIV testing, consider dermatology input
Rosacea fulminans (rare acute severe form with pustular confluent lesions): emergency dermatology
Significant psychosocial impact from facial skin disease: Mental Health Care Plan referral

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — eTG: Dermatology, AMH, Australasian College of Dermatologists, and RACGP. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatments, including oral antibiotics, isotretinoin, and HIV testing, are made with your own GP and treating clinicians.

Consumer resources: HealthDirect — Rosacea, HealthDirect — Seborrhoeic dermatitis, Better Health Channel — Rosacea, Australasian College of Dermatologists.

Sources cited

Frequently asked questions

How do I tell the difference between rosacea and acne?

The key distinguishing feature is the presence or absence of comedones — blackheads and whiteheads. Acne always produces comedones; rosacea never does. Rosacea typically presents in adults aged 30–60, predominantly in women, with centrofacial flushing, persistent redness, telangiectasia, and sometimes papules and pustules in the central face (cheeks, nose, chin). Acne tends to have a wider distribution including the chest and back, and often starts in adolescence. A history of flushing triggered by alcohol, spicy food, heat, or sun strongly supports rosacea.
What is the best treatment for scalp seborrhoeic dermatitis (dandruff)?

Ketoconazole 2% shampoo (Nizoral) is first-line and available over the counter. Apply twice weekly during a flare, then reduce to once weekly for maintenance. Alternative antifungal shampoos include selenium sulfide 2.5% (Selsun, Tersi), ciclopirox 1% (Sebiprox), and zinc pyrithione 1–2% (Head and Shoulders). For thick inflamed scalp plaques during a flare, a short course of a topical corticosteroid lotion or solution can be added. Avoid switching shampoos too frequently — give each product 4–6 weeks at consistent use before concluding it is not effective.
Does rosacea ever affect the eyes?

Yes — ocular rosacea affects approximately 50–58% of people with rosacea at some point and can occur even when skin features are subtle. It presents as blepharitis (eyelid inflammation and scaling), conjunctivitis, and in severe cases keratitis (corneal inflammation), which is vision-threatening if untreated. Lid hygiene with warm compresses and lid scrubs is the first step; oral doxycycline 50–100 mg daily long-term is often required. Prompt ophthalmology referral is essential when there are visual symptoms, corneal involvement, or persistent ocular discomfort. Ocular rosacea must not be missed.
What triggers rosacea flares and can they be avoided?

Common triggers include alcohol (particularly red wine), spicy food, hot beverages, hot environments, saunas, intense exercise, emotional stress, UV sun exposure, and topical steroid use on the face. Keeping a trigger diary helps identify which factors are most relevant for an individual, since not everyone is sensitive to all triggers. SPF 50+ broad-spectrum mineral sunscreen (zinc oxide or titanium dioxide) is better tolerated than chemical sunscreens and should be used daily. Gentle, fragrance-free skincare without astringents, exfoliants, or alcohol-based products reduces baseline irritation.
Is extensive seborrhoeic dermatitis a sign of something more serious?

Seborrhoeic dermatitis in isolated scalp or facial areas is common and benign. However, when a new or suddenly extensive seborrhoeic dermatitis develops across the trunk, intertriginous areas, and face in an adult — particularly when it is resistant to standard antifungal treatment — HIV testing is warranted. Seborrhoeic dermatitis is the presenting skin problem in approximately 30–50% of people with HIV and is often the first visible sign of immunocompromise. Parkinson's disease, other neurological conditions, and certain immunosuppressive medications are also associated with more severe seborrhoeic dermatitis.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.

T1 AU primary 9 sources