What is rosacea?

What is Rosacea

Rosacea is a chronic inflammatory skin disease primarily affecting the central face, characterized by two diagnostic features: persistent centrofacial erythema with periodic intensification by trigger factors, and/or phymatous changes. 1

Diagnostic Features

Primary Diagnostic Features

• Persistent centrofacial erythema with periodic intensification by trigger factors is independently diagnostic 1, 2
• Phymatous changes (thickening of skin with enlarged sebaceous glands, commonly affecting the nose) are independently diagnostic 1, 3

Major Features (Not Independently Diagnostic)

• Flushing/transient erythema - paroxysmal episodes of facial redness 1, 2
• Telangiectasia - visible small dilated blood vessels 1, 3, 2
• Inflammatory papules and pustules - red bumps and pus-filled lesions 1, 2
• Ocular manifestations - including blepharitis, conjunctival hyperemia, and other eye symptoms 1, 2

Minor Features

• Burning or stinging sensations 1, 3, 2
• Facial edema 1, 2
• Dry sensation and scaling 1, 2

Epidemiology

• Affects approximately 16 million people in the United States 2
• More common in fair-skinned individuals, particularly those of Northern European descent 4
• Typically develops between ages 30-50 4, 5
• More prevalent in women than men 4, 5
• Often underdiagnosed, particularly in people with darker skin tones 3, 2

Pathophysiology

• Involves dysregulation of both innate and adaptive immune systems 1, 2
• Increased levels of antimicrobial peptides, neuropeptides, nitric oxide radical species, proteases, cytokines, and chemokines 1, 2
• Trigger factors including Demodex mites and ultraviolet radiation exposure may activate inflammatory pathways 1, 3, 2
• Complete pathophysiology remains not fully understood 1, 6, 7

Classification

• Modern approach has shifted from subtype-based to phenotype-based classification 1, 2
• Traditional subtypes included:
  • Erythematotelangiectatic rosacea (flushing and persistent erythema) 1, 4, 8
  • Papulopustular rosacea (papules, pustules on erythematous background) 1, 4, 8
  • Phymatous rosacea (skin thickening, irregular surface nodularities) 1, 4, 8
  • Ocular rosacea (eye involvement) 1, 4, 8

Clinical Presentation

• Centrofacial distribution - primarily affects cheeks, nose, chin, and central forehead 1, 3, 2
• Flushing episodes - triggered by specific factors such as heat, spicy food, alcohol, or emotional stress 3, 4
• Persistent erythema - background redness that doesn't completely resolve 1, 2
• Inflammatory lesions - papules and pustules that may resemble acne but without comedones 1, 8
• Ocular symptoms - may include blepharitis, foreign body sensation, dryness, and irritation 3, 2, 8

Diagnostic Challenges

• Can be difficult to diagnose in darker skin tones as erythema and telangiectasia are less visible 3, 2
• May be confused with other facial dermatoses, particularly lupus erythematosus 3
• Ocular rosacea may precede cutaneous manifestations, especially in children 3

Quality of Life Impact

• Can cause significant psychosocial burden 1
• Associated with embarrassment, anxiety, low self-esteem, and social isolation 1, 2
• Assessment of patient burden is important in management decisions 1

Management Approach

• Treatment is guided by phenotype rather than subtype 2, 7
• Targets specific signs and symptoms observed by the clinician and those most bothersome to the patient 2, 8
• Includes trigger avoidance, gentle skincare, photoprotection, and pharmacologic therapies 2, 8
• Multiple features may require combination therapy 2, 8