Initial Evaluation

Initial evaluation should include a thorough patient history, including any triggers of the skin findings and any associated signs or symptoms (including ocular manifestations). Careful physical exam should seek to identify individual phenotypes in order to establish a clinical diagnosis of rosacea. Biopsy or laboratory testing is not necessary for diagnosis. A diagnosis of rosacea can be made by fulfilling:

One (or more) of the Diagnostic Phenotypes   or   Two (or more) of the Major Phenotypes

Diagnostic Phenotypes

Major Phenotypes

Persistent erythema, defined as fixed centrofacial erythema in a characteristic pattern that may periodically intensify

Inflammatory papules and pustules
Phyma Transient erythema / flushing
Ocular manifestations

Secondary phenotypes may appear in conjunction with one or more diagnostic or major phenotypes:

  • Burning or stinging
  • Edema
  • Dryness

Diagnostic Phenotypes

Fixed centrofacial erythema in a characteristic pattern that may periodically intensify: Persistent erythema of the central face (chin, cheeks, nose and nasolabial folds) with periodic intensification secondary to triggers such as heat, sunlight, emotional or physical stress and consumption of spicy foods and alcohol is characteristic.

Phyma: Phymatous changes typically reflect long-term disease and are not seen in children. Phyma is marked by thickening of the skin, irregular skin texture, edema, and hypertrophy and hyperplasia of sebaceous glands, connective tissue, and vascular bed of the nose (rhinophyma). These changes can also be seen on the chin (gnathophyma), ears (otophyma), forehead (metophyma), and eyelids (blepharophyma); they are almost exclusively seen in men.

Major Phenotypes

Inflammatory papules and pustules: Papules and pustules are present often on a blush of erythema that primarily affects the nose, cheeks, and forehead. There is a predilection for lesions on the central aspect of the face, sometimes with central facial edema. Nodules may occur.

Transient erythema / flushing: Prolonged frequent intermittent facial erythema and warmth due to neurovascular stimulation is characteristic. Common triggers include heat, sunlight, emotional or physical stress, and the consumption of spicy foods or alcohol.

Telangiectasia: The presence of small vessels in a centrofacial distribution is characteristic. Ocular manifestations: Interpalpebral conjunctival erythema and injection, lid margin telangiectasias, sometimes accompanied by eyelid edema (blepharitis), foreign body sensation, and/or glandular inflammation (chalazion) along the eyelid margin are characteristic. Patients report subjective symptoms such as foreign body sensations, dry eyes, itching and burning, and photosensitivity. Vision is rarely affected. The ocular manifestations of rosacea can be seen in the presence or absence of skin manifestations of rosacea. In children, ocular rosacea may precede the onset of cutaneous symptoms and can lead to a delay in diagnosis.