In 2017, the National Rosacea Society updated the guidelines based on current knowledge of the disease process.9 The 2017 guidelines move away from the subtypes, taking cutaneous signs, symptoms, and phenotypes into account. It is now recommended that a diagnosis of rosacea be considered if the patient displays 1 diagnostic sign or 2 major phenotypes, with allowance for the addition of secondary phenotypes (Table).9 

Table. Summary of 2017 National Rosacea Society Guideline for Rosacea9

Cutaneous Signs Major PhenotypesSecondary Phenotypes
• Fixed centrofacial erythema with/without intermittent fluctuations in intensity
• Phymatous changes
• Papules and pustules
• Occasional nodules
• General absence of comedones
• Flushing with/without blushing
• Telangiectasia
• Ocular manifestations
• Burning, stinging, or itching (less frequent)
• Edema
• Dryness

The 2017 guidelines recognize that as ocular rosacea can occur with or without other cutaneous signs or symptoms, clinical presentation may include lid margin telangiectasia, interpalpebral conjunctival injection, meibomian gland inspissation, spade-shaped infiltrates in the cornea, and scleritis/sclerokeratitis, and chalazia.9 Patients may present with complaints of dryness or grittiness of the eye, itchiness, burning, photosensitivity, foreign body sensation, and eye pain.

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It is important to rule out other etiologies, and referral to an ophthalmologist is recommended. Upon diagnosis, ocular rosacea is graded as mild (blepharitis), mild-moderate (blepharitis plus conjunctival injection), moderate-severe (involvement of the cornea with punctate keratitis, infiltrates, and vascularization), or severe (scleritis or sclerokeratitis).9

A number of methods are available for assessing disease severity of rosacea and subsequent treatment response. Assessment can be approached through a clinician-based assessment, a patient-based perspective, or quality-of-life studies. Options include the Flushing ASsessment Tool (FAST), the Global Flushing Severity Score (GFSS), the Clinician’s Erythema Assessment, and the Patient’s Self-Assessment Grading Scale for persistent erythema.9

It is imperative for clinicians to gather a thorough history and listen carefully to the patient. Combining history with clinical presentation will lead to a more accurate diagnosis. Additionally, it is important to consider a comprehensive differential diagnosis that includes seborrheic dermatitis, keratosis pilaris, lupus, as well as flushing secondary to nonrosacea etiology, such as anxiety, menopause, pheochromocytoma, acne, and follicular mucinosis.

Treatment Options

It is important to customize and direct treatment plans toward a patient’s specific presentation. Numerous treatment options for rosacea are available, many of which can be used in tandem to optimize treatment success. When broaching the discussion of treatment with a patient with rosacea, it is important to stress appropriate skin care techniques. Use of gentle, soap-free cleansers, employing good sun protection measures, avoiding environmental triggers, and avoiding abrasive products are essential for optimizing treatment success.

Options for topical prescription medications include metronidazole 0.75% cream, gel, or lotion twice daily or 1% cream once daily. This medication has been shown to have significant anti-inflammatory effects and has been a cornerstone of therapy for rosacea.10 Additionally, a twice-daily application of azelaic acid (15% gel or foam) has been shown to be efficacious;  although treatment-related adverse events such as burning, stinging, and/or tingling and pruritus may make it less tolerable than other topical treatments.10 Topical brimonidine 0.33% gel, an alpha2-adrenergic agonist, has shown efficacy in the symptomatic treatment of persistent facial erythema, although it can result in rebound redness10 Oxymetazoline 1%, an alpha1-adrenergic agonist, is also used to treat erythema, and rebound redness is less frequently associated with this medication.10  Topical ivermectin 1% has been proven to work well against PPR, decreasing the demodex population and acting as an anti-inflammatory agent.10 

In addition to topical treatment, there is significant evidence demonstrating the efficacy of numerous oral medications. Doxycycline and minocycline offer anti-inflammatory properties in dosages of 50 to 100 mg once or twice daily for approximately 4 to 8 weeks.2 Additionally, doxycycline formulated in a 30-mg immediate release/10-mg delayed release product offers anti-inflammatory properties while maintaining a low risk of microbial resistance.10 Other antibiotics such as tetracycline, erythromycin, azithromycin, and metronidazole have been used clinically with some evidence of success. Isotretinoin 0.3 mg/kg can be used for severe or refractory cases. For patients with severe episodic flushing, carvedilol (up to 12.5 mg twice daily for a period of 6 months) has been used successfully.11

It is important to consider the appropriate use of antibiotics and the associated risks of antimicrobial resistance when prescribing long-term antibiotic therapy for a chronic condition such as rosacea. A review of data from 2003 through 2013 showed that dermatologists in the United States write 8 to 9 million antibiotic prescriptions annually; this represents approximately 20% of all prescriptions written by dermatologists.12

The push for good antibiotic stewardship and evaluation of the necessity of these prescriptions is imperative as we consider the risks vs benefits of treatment. Opting for antibiotics with anti-inflammatory properties dosed at submicrobial levels can help minimize these concerns. Doxycycline 40 mg (30-mg immediate release/10-mg delayed release) provides a steady state below the microbial threshold. Alternatively, doxycycline 20 mg twice a day theoretically offers a similar benefit.10,12  

Although behavior modification and prescription therapeutic management have been the mainstay of therapy for rosacea, cosmetic treatment modalities are gaining in popularity and efficacy. Intense pulse light laser therapy and lasers designed to treat vascular disorders are used frequently and can improve the appearance of the telangiectasias associated with chronic, progressive rosacea.13 Additionally, CO2 lasers or excisional therapy can be considered for patients with severe phymatous changes.13

Other Considerations

As primary care providers become better versed in the intricacies of rosacea, they may become more acutely aware of the frequency of this disease. Clinicians often notice the signs and presentations before a patient brings up the condition. As evidenced by multiple quality-of-life studies among rosacea patients, there is a significant psychological burden associated with rosacea that must be considered.9 Embarrassment about symptoms may have an impact on activities of daily living and symptoms such as depression and anxiety can negatively affect quality of life.9 The RosaQoL, the Dermatology Quality of Life Index, and the Depression Anxiety and Stress scale are tools to assess the severity of these feelings.9 As clinicians, we have a responsibility to do everything that we can to identify patients with rosacea so they can receive appropriate therapeutic intervention and improve their quality of life.

Amber Blair, MMS, PA-C, is the Director at Large for the Florida Society of Dermatology Physician Assistants (FDSPA) and is an adjunct professor at Nova Southeastern University in the Physician Assistant program. She is a preceptor for physician assistant students interested in dermatology and holds a seat on the MAUI Derm NP/PA conference scientific advisory board. Blair practices in Winter Park, FL alongside a fellowship as a trained MOHS surgeon.


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