9 April 2022
Rosacea – a rosy outlook?
Rosacea can significantly affect patients' quality of life, so optimising diagnosis and management is important.
Rosacea, estimated to affect up to 5.5% of the global population, is a common, chronic, inflammatory facial dermatitis.
It can present with a range of morphological signs and is associated with exacerbations and remissions.
The exact pathophysiology remains an enigma. However, there appears to be a complex interplay between genetics, and immune and neurovascular dysregulation with environmental triggers. Rosacea can have a significant impact on quality of life, so optimising diagnosis and management is important.
Could it be rosacea?
While it is most common in Celtic or fair-skinned populations, rosacea can occur in all nationalities and phototypes.
Women are two to three times as likely as men to suffer rosacea. Rhinophyma, however, is more likely to occur in men. Rosacea is now recognised to be associated with a range of comorbidities. In particular, there is an increased risk of rosacea with migraine in women, inflammatory diseases of the gastrointestinal tract, metabolic syndrome and neurodegenerative disorders. The exact nature of these associations is not completely understood.
Rosacea has a range of clinical features yet has two diagnostic signs: persistent facial centrofacial erythema and phymatous changes (skin thickening). Additional features include facial telangiectasia, papules and pustules, facial flushing, and ocular inflammation. Ocular signs and symptoms should be sought in all rosacea patients.
Rosacea is a clinical diagnosis. Currently there are no serological or histological tests that can confirm the diagnosis. Serology, histology and even patch testing may be required, however, if diagnostic uncertainty exists to exclude other conditions such as lupus erythematosus or contact dermatitis. If flushing is severe and/or prolonged, with or without sweating, then a detailed history with appropriate investigations is necessary to exclude underlying pathology such as neuroendocrine malignancies.
The first standard classification system was developed by the American National Rosacea Society in 2002.
Rosacea was previously classified into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular.
In 2017, new recommendations were put forward by the international ROSacea COnsensus (ROSCO) group, recognising that patients often present with a range of features that cross over various subtypes. The new classification system is now based on diagnostic criteria (Table 1).
Table 1: NRS rosacea diagnostic criteria*
|Diagnostic signs||Clinical features|
|Fixed centrofacial erythema||Erythema in a characteristic centrofacial pattern that may periodically intensify (flushing)|
|Phymatous changes||Patulous follicles, skin thickening or fibrosis, glandular hyperplasia, and bulbous appearance of the nose (rhinophyma is the most common form)|
|Major features||Without a diagnostic phenotype, the presence of two or more of the following major features may be considered diagnostic:Papules and pustulesFlushing: frequent and typically prolongedTelangiectasia: predominantly centrofacial in phenotypes I-IV, rarely seen in darker phenotypesOcular manifestations|
|Secondary features||The following secondary signs and symptoms may appear with one or more diagnostic or major phenotypes:Burning and stingingOedema: facial oedemaDry appearance: central facial skin may be rough and scaly|
Complicating diagnosis, there is a broad range of possible differential diagnoses for rosacea (Table 2). It is also common for rosacea to overlap with other dermatoses.
Table 2: Rosacea Differential Diagnoses*
|– Extrinsic photoageing / Actinic damage|
– Periorofacial dermatitis
– Seborrhoeic dermatitis
– Irritant contact dermatitis
– Allergic contact dermatitis
– Facial psoriasis
– Steroid-induced facial dermatitis / telangiectasia
|– Keratosis pilaris|
– Yeast folliculitis
– Systemic lupus erythematosus
– Cutaneous lymphoma
– Cutaneous sarcoidosis (lupus pernio)
– Perniosis of the nose (chilblains)
– Flushing (due to other causes)
Management – Getting it right
Treating rosacea requires a broad skill set, encompassing knowledge of skincare, topical and oral medical therapies and lasers, and energy-based devices. Management success depends on teasing out each element of the presenting features and addressing each without inadvertently worsening the other.
Patient education plays a key role in optimising management.
Education should highlight that rosacea is not curable but, rather, controllable. Patients should also be advised as to common rosacea trigger factors, which may include sun exposure, heat and noxious cold, spicy food, smoking, exercise and alcohol.
Treatment plans should encompass acute management, long-term management and planning for when flares may occur. Photography, prior to commencing treatment and through the treatment journey, can be a valuable tool to assess progress.
Patients will frequently present having trialled numerous skincare regimens, often aggravating highly sensitive inflamed skin. Patients should be advised to choose a simple and quality skincare regimen.
A soap-free cleanser is ideal. Products should be selected that are free from fragrance, colours and essential oils.
Choice of skincare regimens should consider ingredients that protect and repair the epidermal barrier function, including cosmeceutical ingredients with anti-inflammatory properties, and antioxidants. These include niacinamide (vitamin B3), hydroxypropyl chitosan, colloidal oatmeal and panthenol. Other anti-inflammatory cosmeceutical ingredients that may benefit patients with rosacea include feverfew, glycyrrhiza inflata, gingko biloba, aloe vera and bisabolol. Antioxidant cosmeceutical ingredients include vitamin C and green tea (Camellia sinensis).
Advice regarding sun protection is paramount and broad-spectrum SPF 50 sunscreen should be applied daily if possible.
Topical agents are first-line therapy in the treatment of mild-to-moderate rosacea. Table 3 shows common topical therapies, their application and indication for use. Patient presentation and preferences should be factored into the choice of therapy.
Table 3: Topical Therapies in Rosacea
|Topical metronidazole||Twice a day for up to 3-4 months||Targets inflammatory papulopustules.|
Can be found in 1% and 0.75% formulations.
Long history of safety and moderate efficacy.
Mild stinging and burning can occur on application.
Pregnancy category B2
|Azelaic acid||Daily application||Targets inflammatory papulopustules.|
Can be found in 15% acid gel & foam, or 20% azelaic acid cream.
Similar efficacy to metronidazole. Pregnancy category B
|Ivermectin cream (1%)||Daily application for up to 12 weeks||Targets inflammatory papulopustules.|
One study reported it to be more efficacious than 0.75% metronidazole cream.
Pregnancy category B3
|Brimonidine tartrate||Daily application, exhibiting a response within 30 minutes, lasting up to 12 hours.||Used to manage moderate-to-severe facial erythema. |
It is available in a 0.33% gel.
May be associated with a rebound erythema.
Pregnancy category B3
|Oxymetazoline hydrochloride||Daily application||Targets facial erythema.|
A primary alpha-1a agonist that creates vasoconstriction of cutaneous microvasculature.
Not commercially available in Australia but may be compounded as a 1% cream
The two main groups of systemic therapies for rosacea are antibiotics, namely tetracyclines, and isotretinoin.
Tetracyclines, in particular doxycycline and minocycline, have been a long-term mainstay of rosacea papulopustules. Their anti-inflammatory effects aid in the overall reduction of inflammation associated with rosacea. They have the most effective action on ocular and periorificial subtypes.
A standard regimen is 50-100mg doxycycline daily for 6-8 weeks. If the patient is responding to therapy after this period, then these can be continued. They also have efficacy in ocular rosacea. Adverse reactions of doxycycline may include photosensitivity, candida vaginitis and oesophagitis. Macrolides, such as erythromycin, are not always as effective as the tetracyclines. Erythromycin has the benefit of being pregnancy category A and safe in breastfeeding.
If patients are not responding to oral antibiotics, then a dermatologist referral is appropriate. Isotretinoin may be considered as it has demonstrated efficacy in the treatment of papulopustular rosacea. There is also some evidence indicating efficacy in managing early rhinophyma.
Laser and light devices
Laser and light devices are an important and valuable adjunct to rosacea management and are typically used for erythema and telangiectasia. They can also remodel and rebuild dermal collagen, improving overall skin quality. Choice of laser or light therapy should be tailored to the individual patient (Table 3).
Table 4: Laser and light therapies in rosacea
|Pulsed dye laser (585/595nm)||All telangiectatic vessels and diffuse erythema|
|Potassium titanyl phosphate laser (532nm KTP laser)||Superficial small calibre telangiectatic vessels|
|Long- pulsed neodymium-yttrium-aluminium garnet laser (1064 nm LP Nd:YAG)||Large and deep telangiectatic vessels, diffuse erythema|
|Intense pulsed light (IPL 515-1200nm)||Superficial and small telangiectatic vessels, mild diffuse erythema|
|Non-ablative and ablative lasers||Phymatous tissue remodelling and dermal repair|
Historically, several different therapies have been used to try to optimise rhinophyma. Currently the consensus favours fully ablative laser re-surfacing as the treatment of choice.
Don’t forget the eyes!
Ocular involvement occurs in 60-70% of patients with rosacea and may be easily overlooked. Ocular symptoms may be broad and include burning, itching, watering, grittiness, photosensitivity, lid margin or conjunctival erythema with or without recurrent stye and chalazion formation.
If blepharitis or chalazia are present, conservative measures include warm compresses for the eyelid, eyelid massage (targeting the meibomian glands to both upper and lower eyelids) and hygiene measures. Eyelid hygiene can be performed with baby shampoo or a formulated cleanser.
More severe ocular rosacea may benefit from systemic antibiotics. If ocular surface inflammation has occurred then a limited course of topical steroids such as fluorometholone 0.1% 2-4 times per day may be appropriate, often through consultation with an ophthalmologist. These should be used with caution as they can have adverse side effects including raised intraocular pressure, cataract formation and microbial keratitis.
Systemic agents for flushing
When topical therapies alone are not enough to manage symptoms of flushing, occasionally systemic agents are required. Beta-adrenergic blockers, such as propranolol or carvedilol, may be utilised but may be limited by side effects such as bradycardia, bronchospasm and hypotension. Clonidine, as an alpha-adrenergic receptor agonist, may be also used to reduce flushing. Caution is required to avoid systemic side effects.
Engaging with patients and targeting their particular presentation of rosacea are vital in optimising treatment outcomes.
Although it is a chronic and relapsing condition, it is possible to manage rosacea successfully.
Dr Belinda Welsh MBBS MMed FACD, is a director of Complete Skin Specialists in Sunbury, Victoria. She is a past Chair of the Victorian Faculty of the Australasian College of Dermatologists and is the current VP of the Australasian Society of Cosmetic Dermatologists.
Dr Anneliese Willems is a Melbourne-based general practitioner, medical educator and research fellow at the Skin Health Institute.
- Gallo RL, Granstein RD, Kang S, Mannis M, Steinhoff M, Tan J, 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):148-55.
- B Welsh. Rosacea – Classification, Differential Diagnoses and Overlap Diagnoses: Part 1. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- B Welsh. Rosacea – Classification, Differential Diagnoses and Overlap Diagnoses: Part 2. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- HH Oon CL Goh. Rosacea Diagnosis and Management with a Focus on Laser and Light Devices – the Asian Perspective. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- Chen Y. Ocular Rosacea Update. Opinions and Progress in Cosmetic Dermatology. May 2021;01.
- C Sun, D Lim, P Bekhor. Management of Rhinophyma: A Review of Current Literature. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- Armour K. Cosmeceuticals in the Treatment of Rosacea. Opinions and Progress in Cosmetic Dermatology. 2021;01(02).
- Greive K. Basics of Skin Care in Rosacea. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- N Wines PA, S Andric, L Dawes-Higgs, S Donohue, A Harris, S Ng, C McKay, M Polcz, A O’Connor, A Tomizawa. An Update on Rosacea Medical Management. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).
- Vieira ACC, Höfling-Lima AL, Mannis MJ. Ocular rosacea-a review. Arq Bras Oftalmol 2012;75(5):363–9.
*Tables 1 & 2 have been reproduced with consent from publications by Dr Belinda Welsh in Rosacea – Classification, Differential Diagnoses and Overlap Diagnoses: Part 1. Opinions and Progress in Cosmetic Dermatology. May 2021;01(02).