Rosacea is a chronic inflammatory facial dermatosis with four main phenotypes: erythematotelangiectatic (ETR), papulopustular (PPR), phymatous (including rhinophyma), and ocular rosacea. Pathophysiology includes dysregulated innate immunity, Demodex proliferation, neurovascular hyperreactivity, and barrier dysfunction. Management is phenotype-based: vascular lasers and topical vasoconstrictors for erythema; topical metronidazole, azelaic acid, ivermectin for PPR; oral tetracyclines for moderate–severe inflammation; procedural therapies for phymatous changes; and lid hygiene plus ophthalmology care for ocular disease. Trigger avoidance and photoprotection are fundamental.
Epidemiology
- Common in fair-skinned populations but occurs in all skin types; often underrecognized in skin of color (presents as warmth, edema, roughness, and PIH rather than obvious erythema).
- Onset typically adulthood; female predominance except phymatous changes more common in men.
Pathophysiology
- Innate immunity (cathelicidin, KLK5), neurovascular dysregulation (TRP channels), microbiome/Demodex mites, barrier compromise.
- Triggers: heat, spicy foods, alcohol (especially red wine), UV, stress, hot beverages, topical irritants/corticosteroids.
Clinical Phenotypes
- ETR: persistent central facial erythema, flushing, telangiectasias, burning/stinging.
- PPR: inflammatory papules/pustules on erythematous background; comedones absent (helps distinguish from acne).
- Phymatous: tissue hypertrophy, nodular irregularity, most commonly nose (rhinophyma), also chin, forehead, ears.
- Ocular: blepharitis, conjunctival hyperemia, dryness, foreign body sensation, chalazia; can precede skin disease.
Differential Diagnosis
- Acne vulgaris, seborrheic dermatitis, periorificial dermatitis, lupus, dermatomyositis, steroid-induced rosacea, carcinoid/menopause flushing.
Management
- General measures
- Trigger diary and avoidance; gentle cleansers, barrier-repair moisturizers; daily broad-spectrum SPF 30–50+; avoid topical steroids on face.
- Topical therapies
- PPR: ivermectin 1% cream (anti-Demodex/anti-inflammatory), azelaic acid 15–20%, metronidazole 0.75–1%.
- Erythema/flushing: topical vasoconstrictors—brimonidine 0.33% gel, oxymetazoline 1% cream; caution for rebound erythema with overuse.
- Combination approaches common (e.g., ivermectin + vasoconstrictor AM; azelaic/retinoid analogs PM when tolerated).
- Systemic therapies
- Subantimicrobial-dose doxycycline (40 mg modified-release) or doxycycline 50–100 mg/day for inflammatory lesions; short courses preferred; combine with topicals.
- Isotretinoin low-dose for refractory PPR or phymatous disease under specialist care.
- Beta-blockers (propranolol, carvedilol) or clonidine can help severe flushing under medical supervision.
- Procedural treatments
- ETR/telangiectasias: pulsed dye laser (PDL), KTP, Nd:YAG, intense pulsed light (IPL); multiple sessions often needed.
- Phymatous: CO2 laser, electrosurgery, tangential excision, dermabrasion; recurrence possible—maintenance may be needed.
- Ocular rosacea
- Lid hygiene (warm compresses, lid scrubs), preservative-free tears; oral doxycycline/azithromycin for meibomian gland dysfunction; coordinate with ophthalmology to prevent keratitis.
- Skin of color considerations
- Erythema harder to detect; rely on symptoms and texture; PIH risk with inflammation and procedures—test spots, conservative energy settings, strict photoprotection; azelaic acid beneficial for PIH.
References (recent guidelines and key reviews)
- ROSCO/AAD consensus updates on phenotype-based rosacea management, 2022–2024.
- Evidence for ivermectin, vasoconstrictors, and low-dose doxycycline, 2021–2024.
- Reviews on Demodex and neurovascular pathophysiology, 2022–2024.