Key Points

  • Rosacea has four different clinical presentations: erythemato-telangiectatic, papulo-pustular, phymatous, and ocular. It is essential to correctly identify the subtype of rosacea in order to select the appropriate medical or surgical therapy.
  • Rosacea treatment should be tailored to the clinical subtype and disease severity to optimize therapy.
  • Facial erythema is the primary feature of rosacea and presents ubiquitously in all subtypes. Persistent facial erythema has significant impact on quality of life.
  • Erythemato-telangiectatic rosacea must be differentiated from chronic sun damage.
  • Papulo-pustular rosacea must be distinguished from acne vulgaris, seborrheic dermatitis, perioral dermatitis, and Demodex folliculitis/demodicidosis. Rosacea can be distinguished from acne vulgaris by the lack of comedones, identification of triggers for flushing, absence of scarring, the presence of phymatous changes, and the predilection to affect older adults rather than teenage adults.
  • Rosacea patients often have sensitive skin and suffer from intolerance to skin products and cosmetics.
  • Patients with rosacea flush, have facial erythema, telangectasia, papules and pustules, sebaceous hyperplasia of the nose (rhinophyma), and/or ocular symptoms. Triggers for flushing include alcohol, sun exposure, hot weather, exercise, ingestion of hot or spicy foods/ drink or a medication, and emotional stress. Eliminating the triggers of flushing can alleviate rosacea symptoms.
  • Newer topical treatments provide effective options for treating rosacea subtypes. The alpha adrenergic agonist brimonidine (Mirvaso) effectively reduces erythema in erythemato-telangiectactic rosacea, as well as in other subtypes. Ivermectin cream (Soolantra) is highly effective in reducing inflammatory lesions of papulo-pustular rosacea.
  • Ocular rosacea requires systemic antibiotics.
  • Phymatous rosacea may require laser treatment or other surgical intervention.