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Rashes On the Face: Is It Acne, Rosacea, or Demodex?

Rashes On the Face: Is It Acne, Rosacea, or Demodex?

Nearly all of us at some point wake up in the morning to find several unsightly red bumps on the face. One of the most important principles for treating pimples (or to be more technically accurate, pustules) on the face is to correctly identify the cause. Here, we discuss how to distinguish between acne, rosacea, and a lesser known, but very common condition called demodex folliculitis.

Acne is one of the most common causes of pustules on the face in teenagers and young adults. It is the result of multiple factors, including: increased oil production associated with hormonal changes common in puberty, bacterial infection, and subsequent inflammation of the pores on the skin. Interestingly, acne could also be caused by medical conditions, medications, overuse of cosmetic products, and even workplace exposures to certain chemicals. Blackheads (or open comedones) are one of the characteristic findings that help distinguish acne from other conditions on the face such as rosacea. Multiple effective acne treatments ranging from topical cleansers to antibiotics can reduce outbreaks, shrink pores, and prevent scarring.

Rosacea can also result in pustules on the face, but tends to occur in individuals between the ages of 30 and 60. Flushing is a common feature of rosacea, with tiny blood vessels on the cheeks and nose often being seen—especially after exposure to rapid changes in temperature (e.g. after a hot shower), spicy foods, or alcohol. Sometimes rosacea can cause irritation of not only the skin, but also the eyes. Treatments for rosacea include anti-inflammatory creams, low-dose antibiotics, and lasers.

While most people have heard about or even had acne or rosacea, there is another very common cause of red bumps on the face that many patients (and even doctors) are not familiar with: demodex folliculitis. Demodex is a tiny mite that lives in the hair follicles in nearly all humans. Although demodex mites are considered a normal part of our skin microbiome, overgrowth can result in small red pustules on the nose or cheeks. Occlusive skin products and ointments can worsen a demodex infestation. Demodex folliculitis should be considered when misdiagnosed “acne” does not respond to standard treatments. A gentle scraping of the skin and evaluation under the microscope can reveal multiple live Demodex mites (see photo), which would confirm the diagnosis. Treatment for demodex folliculitis includes antiparasitic creams and cleansers.

Distinguishing between acne, rosacea, and demodex folliculitis is an important first step in creating a successful treatment plan for those pesky red bumps on the face. To avoid frustration and misdiagnoses, it is imperative to see a dermatologist who can identify these subtle, yet important differences.

– Dmitriy Timerman, M.D.

Dr. Timerman is a board-certified dermatologist who sees adult & pediatric patients in Norwalk and Danbury, CT.


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Advanced Specialty Care’s Dermatology practice is welcoming and patient-centered, specializing in all of your family’s skincare needs from head-to-toe. Our board-certified Dermatologists excel in general medical, surgical and cosmetic dermatology for patients of all ages, with expertise which allows them to not only diagnose and treat complex skin conditions, but also improve the appearance and condition of the skin.

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