What is rosacea?

Rosacea: A Comprehensive Overview

Rosacea is a chronic inflammatory skin disease predominantly affecting the centrofacial region, characterized by specific diagnostic features and multiple phenotypic presentations that can significantly impact quality of life. 1

Diagnostic Features

• Rosacea has two independently diagnostic features:

  • Persistent centrofacial erythema associated with periodic intensification 1
  • Phymatous changes (tissue hyperplasia and nodules) 1

• Other common features that are not independently diagnostic but often present in combination include:

  • Flushing (transient erythema) 1
  • Telangiectasia (visible blood vessels) 1
  • Inflammatory lesions (papules and pustules) 1
  • Ocular manifestations 1

• Secondary features may include:

  • Burning or stinging sensations 1
  • Erythematous plaques 1
  • Facial dryness and scaling 1
  • Edema 1

Epidemiology

• Affects approximately 16 million people in the United States 1
• More commonly diagnosed in fair-skinned individuals 2
• Typically affects adults aged 35-50 years 2
• Women are affected more frequently than men, though men often have more severe phymatous changes 2
• Many cases remain undiagnosed, particularly in people with skin of color 1

Pathophysiology

• The exact pathophysiology remains incompletely understood 1
• Involves dysregulation of both innate and adaptive immune systems 1
• Key pathophysiological mechanisms include:
  • Increased levels of antimicrobial peptides, neuropeptides, and nitric oxide radical species 1
  • Elevated proteases, cytokines, chemokines, and vascular growth factors 1
  • Neurovascular dysregulation 3
• Trigger factors such as Demodex mites and ultraviolet radiation exposure may activate inflammatory pathways 1

Classification

• The current approach has shifted from subtype-based to phenotype-based classification 1

• Traditional subtypes included:

  • Erythematotelangiectatic rosacea (persistent erythema, flushing, telangiectasia) 1
  • Papulopustular rosacea (inflammatory papules and pustules) 1
  • Phymatous rosacea (tissue hyperplasia, most commonly affecting the nose as rhinophyma) 1
  • Ocular rosacea (eye involvement) 1

• The phenotype-based approach focuses on individual presenting features rather than subtypes, allowing for more personalized treatment targeting specific manifestations 1

Clinical Impact

• Rosacea significantly impacts quality of life, self-esteem, and well-being 3
• Social and professional stigmatization is common 1
• A global perception survey showed individuals with central facial redness were judged more negatively than those without 1

Management Approach

• Treatment is now guided by phenotype rather than subtype 1

• The approach targets the specific signs and symptoms observed by the clinician and those most bothersome to the patient 1

• General management principles include:

  • Long-term avoidance of triggers 1
  • Gentle skincare 1
  • Adherence to pharmacologic treatment 1
  • Photoprotection 4

• Multiple features in an individual patient can be simultaneously treated with multiple agents 1

• If first-line treatment fails, physicians should either consider an alternative first-line option or add an additional first-line agent 1

Ocular Rosacea

• Ocular manifestations include blepharitis, blurred vision, foreign body sensation, hyperemia, photophobia, redness, tearing, and telangiectasia 1
• Management includes:
  • Lid hygiene 1
  • Artificial tears for mild burning/stinging 1
  • Ophthalmological referral for all but the mildest ocular features 1

Treatment Considerations

• Maintenance therapy depends on treatment modality and patient preferences 1
• The minimum treatment necessary to maintain control should be used 1
• Treatments should be given sufficient time before switching to alternatives 1
• Moderate and severe presentations of major features typically require combination therapy 1

Recent Advances

• Encapsulated benzoyl peroxide 5% (E-BPO 5%) is a newly FDA-approved topical treatment for rosacea 1
• E-BPO 5% uses microencapsulation technology to improve therapeutic effects while minimizing skin irritation 1
• Minocycline foam 1.5% offers treatment for inflammatory lesions with decreased risk of systemic adverse events compared to oral minocycline 5