What is Rosacea
Rosacea is a chronic inflammatory skin disease primarily affecting the central face, characterized by persistent centrofacial erythema with periodic intensification by trigger factors, which alone meets minimum diagnostic criteria. 1, 2, 3
Core Diagnostic Features
The presence of persistent centrofacial erythema with telangiectasia and ectasia, exacerbated by exercise and outdoor exposure, accompanied by a stinging sensation, is diagnostic of rosacea. 2 The centrofacial distribution is essential for diagnosis—this is not negotiable. 2, 3
Independently Diagnostic Features
- Phymatous changes (thickening of skin due to hyperplasia of sebaceous glands) are independently diagnostic of rosacea without requiring other features. 3
- Persistent centrofacial erythema with periodic intensification by trigger factors meets minimum diagnostic criteria. 2, 3
Major Features (Not Independently Diagnostic)
- Flushing/transient erythema: Characterized by intensity, frequency, duration, area involved, and associated symptoms. 3
- Persistent erythema: Assessed by intensity and extent. 3
- Inflammatory papules and pustules: Evaluated by number of lesions and extent of facial involvement. 3
- Telangiectasia: Assessed by vessel size and extent of involvement on cheeks, nose, and ears. 2, 3
- Ocular manifestations: Including blepharitis, conjunctivitis, and keratitis. 3
Minor Features
Epidemiology and Demographics
Rosacea is observed more frequently in fair-skinned individuals but occurs in people of all races and both sexes. 4, 1 The disease typically presents in middle age, peaking between ages 30-60, and occurs more often in women, though it can be more severe when it occurs in men. 4, 1
Critical Diagnostic Pitfall
Rosacea may be difficult to diagnose in patients with darker skin tones (phototypes V and VI) because telangiectasia and facial flushing are difficult to visualize. 4, 1, 3 In these patients, emphasize hyperpigmentation and burning/stinging symptoms rather than relying on visible erythema. 1, 3
Ocular Involvement (Commonly Overlooked)
Evaluate for ocular rosacea immediately in all patients with rosacea, as it can lead to sight-threatening complications if untreated. 2 Between 37-52% of patients with ocular rosacea also have aqueous tear deficiency. 4
Ocular Manifestations to Document
- Blepharitis and meibomian gland dysfunction. 4, 2
- Conjunctival injection or blepharoconjunctivitis. 2
- Lid margin telangiectasia. 2
- Corneal involvement, epithelial basement membrane abnormalities, and recurrent corneal epithelial erosions. 4
Special Consideration in Children
Do not dismiss recurrent styes as benign in children—they may represent early ocular rosacea before facial manifestations appear. 1 Children with ocular rosacea often present with corneal involvement, asymmetry of ocular disease, and potential for visual impairment including corneal melting/perforation. 4, 2 Facial rosacea is less frequent in children, and associated atopy is common. 4
Pathophysiology
Rosacea involves dysregulation of both innate and adaptive immune systems, with increased levels of antimicrobial peptides, neuropeptides, and nitric oxide radical species. 3 The Demodex mite load is increased in individuals with rosacea and may play a role in pathogenesis. 4
Clinical Course
Rosacea is a chronic condition with periods of exacerbation and remission. 4 The patient can enter the disease at any stage—it does not necessarily progress through sequential stages. 5 Without treatment, severe cases may lead to eyelash loss, eyelid scarring with trichiasis, and corneal scarring and neovascularization. 4, 3
Modern Classification Approach
The current approach has shifted from subtype-based to phenotype-based classification, which addresses rosacea in a manner more consistent with the patient's individual experience. 3 This allows for more personalized assessment and treatment based on the specific manifestations present in each patient, rather than forcing patients into rigid subtypes. 3