Because rosacea’s signs and symptoms can vary so widely, the chronic facial skin disorder was initially classified into four subtypes. However, with the explosion of research in the last 20 years, it has become clear that rosacea’s often fluctuating and seemingly unrelated signs and symptoms are part of a single underlying inflammatory continuum.1 Rosacea is now identified according to its individual characteristics, or phenotypes, which may appear in different combinations and at different times. This new targeted approach encourages consideration of the full range of potential signs and symptoms, better assessment of their severity, and selection of treatment that is more precisely tailored for each individual case.
The following treatment algorithms are based on the 2019 update to the standard management options for rosacea,2 as well as the original 2009 publication3 and studies of more recently developed therapies. The algorithms are intended to provide a comprehensive summary of treatment options for the respective phenotypes, allowing physicians to tailor therapy for each individual case to achieve optimal patient outcomes.
Management Options for Rosacea Phenotypes
Diagnostic Phenotypes
A diagnosis of rosacea may be considered in the presence of one or more of the following diagnostic cutaneous signs.
Persistent Erythema
(Formerly part of Subtype 1)
Clinical Features: Persistent erythema of the central face in a characteristic pattern that may periodically intensify. This is the most common sign of rosacea in Fitzpatrick phototypes I to IV; in darker phototypes (V and VI) erythema may appear more brown or purple. A history of flushing or blushing is common in phototypes I to IV, and may be expressed as a burning or stinging sensation in phototypes V and VI.
A personal history, drug history, and complete physical examination are helpful to clinicians in excluding other entities in the possible differential diagnoses, such as lupus erythematosus, steroid-induced rosacea, or seborrheic dermatitis.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
1 | Faint persistent erythema | Identification and avoidance of environmental and lifestyle triggers to minimize flushing and irritation may be especially important in addition to an appropriate skin care regimen (including mild moisturizers and cleansers, and broad-spectrum sun protection); nonirritating cosmetics may conceal the appearance of erythema. |
2 | Moderate persistent erythema | In addition to above: daily application of topical oxymetazoline hydrochloride or brimonidine. Intense pulsed light (IPL), KTP laser or pulsed-dye laser may diminish erythema in patients with Fitzpatrick skin types I-IV. |
3 | Pronounced persistent erythema | In addition to above: oral therapies including minocycline or doxycycline (at sub-antimicrobial doses or full strength), or carvedilol. |
Phymatous Changes
(Formerly Subtype 3)
Clinical Features: Persistent erythema of the central face in a characteristic pattern that may periodically intensify. This is the most common sign of rosacea in Fitzpatrick phototypes I to IV; in darker phototypes (V and VI) erythema may appear more brown or purple. A history of flushing or blushing is common in phototypes I to IV, and may be expressed as a burning or stinging sensation in phototypes V and VI.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
1 | Active inflammation leading to patulous follicles, skin thickening with minimal contour changes | Topical retinoid or oral antibiotics, in combination with surgical intervention for rhinophyma, as described below. Carefully monitored oral isotretinoin may reduce incipient rhinophyma. |
2 | Change in contour without nodular component | In addition to above: may require surgical therapy, including cryosurgery, radiofrequency ablation, electrosurgery, heated scalpel, electrocautery, tangential excision combined with scissor sculpturing, skin grafting and dermabrasion; CO2 or erbium lasers may be used as a bloodless scalpel to remove excess tissue and recontour the nose. |
3 | Change in contour with nodular component | See above. |
Major Phenotypes
Major cutaneous signs often appear with one or more of the diagnostic features, although some can occur independently. Without a diagnostic phenotype, the presence of two or more major phenotypes may be considered diagnostic.
Papules and Pustules
(Formerly Subtype 2)
Clinical Features: Dome-shaped red papules with or without accompanying pustules, often in crops and dominant in the central face. Nodules may also occur. Although patients with concomitant acne may experience comedones, they should be considered part of the acne process unrelated to rosacea.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
1 | Few to several papules or pustules without plaques; mild persistent erythema | Topical microencapsulated benzoyl peroxide4, ivermectin, azelaic acid, minocycline5 or metronidazole, possibly with an initial course of oral antibiotic, to bring symptoms under control, and use of topical medication alone to maintain remission. A controlled- or extended-release, sub-antimicrobial dose of oral minocycline6 or doxycycline may be used. Topical sulfacetamide sodium/sulfa may also be effective. |
2 | Several to many papules or pustules without plaques; moderate persistent erythema | In addition to above: sub-antimicrobial minocycline or doxycycline until remission is achieved, along with or followed by long-term topical or oral therapy. Topical oxymetazoline or brimonidine may be used in combination to reduce perilesional erythema. |
3 | Numerous and/or extensive papules or pustules with or without plaques; severe persistent erythema; possible burning and stinging | In addition to above: in refractory cases, alternative therapies may be used, such as topical clindamycin, topical retinoids or oral antibiotics, oral isotretinoin, or trimethoprim/sulfamethoxazole. |
Telangiectasia
(Formerly part of Subtype 1)
Clinical Features: Fine blood vessels visible through the skin on the central face. Use of a dermatoscope may allow for detection of telangiectasias in patients with darker skin types.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
all | Telangiectasia on the nose, cheeks, forehead or chin | Long-pulsed dye or KTP lasers or IPL device or electrosurgery can remove telangiectases and reduce vascular erythema. Topical retinoids may also reduce telangiectasia. |
Flushing
(Formerly part of Subtype 1)
Clinical Features: Frequent and typically prolonged flushing or blushing is common except in darker skin tones, in which case flushing may be experienced as burning and stinging. In contrast to other erythematous changes, flushing may occur within seconds to minutes in response to neurovascular stimulation by trigger factors.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
1 | Occasional mild flushing | Cool compress. IPL treatment may diminish flushing. |
2 | Frequent and troublesome flushing accompanied by burning and stinging sensation | In addition to above: topical therapies such as oxymetazoline, brimonidine or ivermectin, or oral therapies such as carvedilol, clonidine or propranolol may reduce flushing response. |
3 | Frequent severe flushing that extends to the neck and chest, accompanied by severe burning and stinging | In addition to above: KTP laser treatment may reduce flushing. Flushing may be modulated by drugs specific to individual causes, such as NSAIDs for dry flushing, alpha-agonists or beta-blockers for neurally induced flushing (off-label) and HRT for menopausal flushing. Thermoregulatory flushing can be reduced by cooling the neck and mouth; emotionally induced flushing may benefit from psychological counseling or biofeedback. |
In addition to prescription therapies and light devices, gentle skin care may be beneficial to rosacea patients with flushing. Because sun exposure may be a leading influence on the development of flushing and erythema, advise patients to always use sunscreens, preferably mineral inorganic products that contain zinc oxide or titanium dioxide, because they do not produce heat as a byproduct. Skin-care products that contain anti-inflammatory ingredients, such as allantoin, licorice root extract, sulfur or aloe vera may also be helpful.
Ocular Rosacea
(Formerly part of Subtype 4)
Clinical Features: Ocular rosacea may appear as a spectrum of disease, from dry eye to blepharitis to meibomian gland dysfunction, all of which may be related to underlying inflammation. Signs and symptoms associated with ocular rosacea include lid margin telangiectasia, interpalpebral conjunctival injection, spade-shaped infiltrates in the cornea, and scleritis and sclerokaratitis. Ocular signs and symptoms that commonly appear with rosacea but are not specific to the disorder include watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, light sensitivity, lid and periocular erythema, meibomian gland dysfunction and blepharitis, “honey crust” and collarette accumulation at the base of eyelashes, styes (chalazion, hordeolum), chronic conjunctivitis, irregularity of the lid margin and evaporative tear dysfunction. Approximately 20% of patients have ocular findings before dermatologic evidence of rosacea, and the diagnosis may not be clear in those who never progress to the cutaneous form of the disorder.
| Grade | Typical Features by Grade | Therapeutic Approach |
|---|---|---|
1 | Signs and symptoms affecting the eyelid margin and meibomian glands | Apply a warm compress and cleanse eyelashes twice daily with baby shampoo. Artificial tears for patients with dry eye or meibomian gland dysfunction. |
2 | Signs and symptoms affecting the inner eyelid, tear secretion and/or ocular surface | In addition to above: ophthalmic azithromycin or tacrolimus ointment may be applied to eyelashes; topical cyclosporin drops may also be effective to reduce inflammation. A course of oral cyclosporine for 2-3 months may reduce inflammation; oral antibiotics such as sub-antimicrobial minocycline or doxycycline, azithromycin, or trimethoprim/sulfamethoxazole may also be used. IPL may improve the health of the ocular surface and meibomian gland function. If severity increases, consultation with an ophthalmologist may be needed. |
3 | Advanced or nonresponsive disease of the eyelid margin or ocular surface; episcleritis, iritis, or keratitis in addition to corneal damage and potential vision loss | In addition to above: care by an ophthalmologist is required and may include a topical steroid, alternative oral medications and potential surgery. |
Abbreviations: IPL, intense pulsed light; KTP, potassium-titanyl phosphate; NSAIDs, nonsteroidal anti-inflammatory drugs; HRT, hormone replacement therapy.
References
1. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018;78(1):148-155. Doi:10.1016/j.jaad.2017.08.037.
2. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: the 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2020;82(6):1501–1510. doi:10.1016/j.jaad.2020.01.077.
3. Odom R, Dahl M, Dover J, et al. Standard management options for rosacea, part 2: Options according to subtype. Cutis 2009;84:97-104.
4. Bhatia ND, Werschler WP, Baldwin H, et al. Efficacy and safety of microencapsulated benzoyl peroxide cream, 5%, in rosacea: results from two phase III, randomized, vehicle-controlled trials. J Clin Aesthet Dermatol 2023 Aug;16(8):34-40. PMID: 37636253; PMCID: PMC10452484.
5. Gold LS, Del Rosso JQ, Kircik L, et al. Minocycline 1.5% foam for the topical treatment of moderate to severe papulopustular rosacea: results of 2 phase 3, randomized, clinical trials. J Am Acad Dermatol 2020 May;82(5):1166-1173. doi: 10.1016/j.jaad.2020.01.043. Epub 2020 Jan 28. PMID: 32004648.
6. Tsianakas A, Pieber T, Baldwin H, et al. Minocycline extended-release comparison with doxycycline for the treatment of rosacea: a randomized, head-to-head, clinical trial. J Clin Aesthet Dermatol 2021 Dec;14(12):16-23. PMID: 35096250; PMCID: PMC8794488.
Treatment Brand Name Index
• Oral minocycline: Emrosi
• Topical microencapsulated benzoyl peroxide: Epsolay
• Azelaic acid: Finacea
• Topical metronidazole: Metrogel, Noritate, Rosadan, others
• Topical brimonidine: Mirvaso
• Oral doxycycline: Oracea
• Topical sulfacetamide sodium/sulfa: Plexion,Avar, Sulfacleanse, others
• Topical oxymetazoline: Rhofade
• Topical ivermectin: Soolantra
• Topical minocycline: Zilxi
Acknowledgment: This section was reviewed and edited by Dr. Zoe Diana Draelos, FAAD.
This page is made possible by funding from Journey Medical Corporation.