This stage is characterized by large inflammatory nodules, furunculoid infiltrations, thickening of the skin, edematous skin, large pores, irregular surface nodularities and enlargement. This may lead to phymatous rosacea with the most common location of the nose (rhinophyma). Other less frequent locations are chin, forehead, cheeks and ears. It may be accompanied by prominent follicles, persistent erythema, telangiectases, induration and coarsening of the skin in these areas.
Differential diagnoses comprise in dependency of the individual clinical picture acne vulgaris, leonine facies of leprosy or leukemia, familial nevoid sebaceous gland hyperplasia, Melkersson-Rosenthal syndrome, acromegaly.