Rosacea: Subtypes, Triggers & Evidence-Based Management

Rosacea is a chronic inflammatory facial dermatosis with vascular, papulopustular, phymatous, and ocular manifestations.

Four Subtypes (Often Overlap)

• Erythematotelangiectatic (ETR): Flushing, persistent centrofacial erythema, telangiectasia.
• Papulopustular (PPR): Acne-like papules/pustules on erythematous base (no comedones).
• Phymatous: Thickening, irregular nodularity — rhinophyma (nose), gnathophyma (chin), metophyma (forehead).
• Ocular: Blepharitis, conjunctivitis, keratitis, dry eye, photophobia — can precede cutaneous signs.

Pathophysiology

• Dysregulated innate immunity (cathelicidin/LL-37 ↑, TLR2 ↑)
• Neurovascular dysregulation (TRPV1, TRPA1 sensitivity)
• Demodex mite overpopulation (controversial role)
• Genetic predisposition (HLA, glutathione pathways)

Common Triggers

• UV radiation, heat, spicy food, alcohol (especially red wine), stress, exercise, hot beverages, wind, irritating topicals.

Treatment by Subtype

Subtype	First-Line	Second-Line / Procedural
ETR	Topical α-agonist (brimonidine, oxymetazoline) for transient erythema; broad-spectrum SPF	Vascular laser (PDL, Nd:YAG, IPL) for telangiectasia
PPR	Topical ivermectin 1%, azelaic acid 15%, metronidazole 0.75%	Oral doxycycline 40 mg modified-release (anti-inflammatory dose)
Phymatous	Early: oral isotretinoin (low-dose)	Ablative laser (CO₂, Er:YAG), electrosurgery, scalpel sculpting
Ocular	Lid hygiene, artificial tears, topical cyclosporine, oral doxycycline	Ophthalmology co-management

General Skin Care

• Gentle cleanser, fragrance-free moisturizer, mineral sunscreen (ZnO/TiO₂).
• Avoid: alcohol, witch hazel, menthol, eucalyptus, abrasive scrubs.

Rosacea is chronic but controllable. Long-term adherence to trigger avoidance and maintenance therapy prevents progression.