Rosacea is a chronic skin condition driven primarily by inflammation. While its exact etiology remains unknown, several micro-organisms inhabiting human skin are implicated in its development, including Demodex mites (which tend to prefer rosacea-affected areas), bacterial species such as Helicobacter pylori and Staphylococcus aureus, and yeast species such as Malassezia. Common triggers include UV/sunlight, temperature extremes (hot/cold), physical exercise, stress, hot beverages/coffee, chocolate, caffeine, alcohol, spicy foods, and specific cosmetics or medications.
Clinical Concept: Patients with rosacea should avoid astringents, toners, menthols, camphor, exfoliants, waterproof cosmetics requiring solvents for removal, or products containing sodium lauryl sulfate. For patients with ocular rosacea, an oral antimicrobial is the preferred treatment option.
Rosacea is characterized by facial flushing, erythema, telangiectasia, and inflammatory papulopustular eruptions. Although intermittent initially, symptoms can progress to persistent flushing and permanent telangiectasia. Clinical presentation is categorized into four main subtypes:
The diagnosis of rosacea is made purely on a clinical basis through correlation of patient history and physical examination findings. No specific laboratory or diagnostic testing is required.
Treatment focuses on identifying triggers, adopting daily sunscreen use, and choosing appropriate procedural, topical, or systemic therapies based on the subtype:
| Treatment Class | Agents / Procedures | Clinical Notes & Indications |
|---|---|---|
| Procedural & Laser Interventions | Pulsed Dye Laser (1–3 sessions), mechanical dermabrasion, laser peel, surgical shave | Nonablative lasers remodel dermal connective tissue and reduce telangiectasia (does not reduce facial erythema). Surgical/shave methods are reserved for phymatous rosacea. |
| Topical Antimicrobials & Anti-inflammatories | Metronidazole gel (0.75% or 1%), Erythromycin, Clindamycin, Ivermectin (Soolantra®) cream | Metronidazole is first-line. Ivermectin cream exerts anti-inflammatory effects to treat inflammatory lesions. |
| Topical Alpha Agonists | Brimonidine (Mirvaso®), Oxymetazoline (Rhofade™) | FDA-approved for treating persistent erythema; yields noticeable reduction in facial redness within 1 month. |
| Topical Acne & Other Agents | Azelaic acid, Sulfacetamide, Benzoyl peroxide, Tretinoin, Dapsone, Tacrolimus (Protopic®) | Effective for papules/pustules. Dapsone is for severe/refractory cases. Tacrolimus reduces itching/inflammation after other treatments fail. Avoid medium/high-potency topical corticosteroids on the face. |
| Oral Systemic Therapies | Minocycline, Doxycycline, Tetracycline, Metronidazole, Erythromycin, Oral Isotretinoin | Oral antibiotics act primarily via anti-inflammatory pathways. Oral antimicrobials are preferred for ocular rosacea. Oral isotretinoin is used for refractory cases (monitor for serious adverse effects). |
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