How is rosacea in adults (30‑50 years, fair skin, slightly more common in women) diagnosed and managed, including skin and ocular manifestations?

Rosacea: Diagnosis and Management

Diagnosis

Rosacea is diagnosed clinically when persistent centrofacial erythema with periodic intensification by trigger factors is present—this alone meets minimum diagnostic criteria. 1

Essential Diagnostic Features

• Persistent centrofacial erythema is the essential component and minimum requirement for diagnosis, with centrofacial distribution being mandatory 1, 2
• Telangiectasia and ectasia on cheeks, nose, and ears represent major features (though not independently diagnostic) 1
• Papules and pustules develop on the erythematous background in inflammatory disease 2
• Flushing episodes (paroxysmal facial erythema) triggered by meals, temperature changes, alcohol, or hot drinks are characteristic 2

Clinical Presentation in Target Population

• Typically presents between ages 30-50 years 2
• More common in women, though men develop more severe disease 3, 2
• Fair-skinned individuals, especially Northern European descent, are most affected 3, 2

Diagnostic Pitfalls

• Rosacea is difficult to diagnose in darker skin tones because telangiectasia and facial flushing are not visible—look for hyperpigmentation and symptoms of burning/stinging instead 4
• Diagnosis is often overlooked when only mild signs like telangiectasia and easy facial flushing are present 3
• Stinging sensation is a recognized minor feature that supports diagnosis 1

Ocular Manifestations

Evaluate for ocular rosacea immediately in all patients, as it commonly accompanies cutaneous disease and can lead to sight-threatening complications if untreated. 1

Ocular Assessment

• Ask about: burning, stinging, dryness, foreign body sensation, or recurrent styes 1
• Examine for: blepharitis, meibomian gland dysfunction (MGD), conjunctival injection, or corneal involvement 1
• 37-52% of patients with ocular rosacea have aqueous tear deficiency 3
• Document lid margin telangiectasia, meibomian gland orifice narrowing, and any corneal changes 4

Serious Ocular Complications

• Ocular rosacea is associated with epithelial basement membrane abnormalities and recurrent corneal epithelial erosions 3
• Potential for corneal melting/perforation exists, particularly in severe cases 3, 4

Documentation Requirements

Document the following features using a 5-point categorical scale (Clear/none, Almost clear/minimal, Mild, Moderate, Severe) for each feature independently: 1

• Number and extent of inflammatory papules and pustules 1
• Intensity and extent of background erythema 1
• Specific facial areas affected and percentage of centrofacial distribution 1
• Presence and extent of telangiectasia (vessel size and area) 1
• Flushing episodes: frequency, duration, intensity, area involved, and triggering factors 1
• Associated symptoms: burning, stinging, dry sensation, or edema 1
• Ocular findings: blepharitis, MGD, conjunctival injection 1
• Quality of life impact on daily activities and emotional well-being 1
• Photographic documentation for tracking changes over time 1

Management

First-Line Topical Therapy

For mild to moderate rosacea, initiate topical therapy with metronidazole, azelaic acid, or ivermectin as first-line agents. 5

• Metronidazole (topical) is a first-line option 6, 5
• Azelaic acid (topical) is a first-line option 6, 5
• Ivermectin (topical) is a first-line option for inflammatory lesions 6, 5
• Topical minocycline can be used for mild to moderate disease 6

Symptomatic Treatment of Erythema

• Brimonidine or oxymetazoline (topical vasoconstrictors) can be used for symptomatic treatment of persistent centrofacial erythema 5

Systemic Therapy

For therapy-resistant and severe forms of papulopustular rosacea, low-dose doxycycline is the drug of choice for systemic therapy. 5

• Low-dose doxycycline is the systemic drug of choice 5
• Low-dose isotretinoin is an alternative systemic option 5
• Oral medications can be prescribed in combination with topical therapy 6
• Minocycline (oral) is efficacious for mild to moderate forms 6

Ocular Rosacea Treatment

Treat ocular rosacea with lid margin hygiene as the foundation, supplemented with topical agents. 5

• Lid margin hygiene is the primary intervention 5
• Topical options: ciclosporin eye drops, azithromycin, ivermectin, or metronidazole 5

Procedural Interventions

• Pulse dye lasers and intense pulsed light are best used for erythematotelangiectatic type 7, 6
• Electrosurgery, dermabrasion, and surgical resurfacing may be necessary for severe phymatous changes (rhinophyma) 6

Essential Lifestyle Modifications

Photoprotection using broad-spectrum sunscreen and wide-brimmed hats is essential, as UV radiation activates inflammatory pathways. 1

• Avoid known triggers: alcohol, stress, spicy foods, extremes of temperature 8
• Implement sun protection consistently 1, 6

Treatment Goals and Monitoring

Treatment goals include reducing erythema intensity, decreasing flush frequency, improving patient-reported symptoms, and enhancing quality of life. 1

• Assess treatment response at 4-6 week intervals 1
• Evaluate each phenotypic feature independently rather than using subtype classification 1
• Record: reduction in lesion count, decrease in erythema severity, frequency of flare episodes, patient-reported improvement, and quality of life impact 1