Reflecting the growing understanding of rosacea as a continuum of systemic inflammation, new National Rosacea Society (NRS) Treatment Algorithms suggest therapies based not on the rosacea subtype but on the individual patients’ clinical signs and symptoms. The algorithms were published on the NRS website’s physician section on March 25.
New Diagnostic Approach
The algorithms change how rosacea is diagnosed, Zoe D. Draelos, MD, president of Dermatology Consulting Services in High Point, North Carolina, said in an interview. Draelos reviewed and edited the algorithms.
Although the Society’s original morphologic classification system proved “didactically successful,” wrote authors of an update published in the Journal of the American Academy of Dermatology in 2018, the erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes were largely misconstrued as distinct disorders. However, newer evidence suggested that rosacea’s diverse, often fluctuating features might stem from a shared inflammatory process that is histologically and biochemically detectable even when not clinically visible.
Rather than categorizing cases by subtype, the phenotypic approach focuses first on individual patient signs and symptoms. Specifically, persistent erythema, phymatous changes, or both are considered diagnostic for rosacea. Absent the foregoing phenotypes, the presence of at least two of what the algorithms call major phenotypes — papules and pustules, telangiectasia, flushing, and ocular manifestations — also can support a rosacea diagnosis.
Individualized Therapy
The approach allows physicians to recommend a treatment for each of the signs and symptoms that a patient may have while also considering symptom severity, Draelos said. For mild facial redness, “you might advise that those people use nonirritating cosmetics and a sunscreen and avoid triggers that cause flushing and blushing — things like alcoholic beverages, especially red wine, and extreme cold, heat, or rapid temperature changes.”
Patients with moderate redness might require a topical vasoconstrictor such as oxymetazoline or brimonidine. Treatment with intense pulsed light, potassium-titanyl-phosphate laser, or pulsed-dye laser also may reduce redness in skin types I-IV.
Patients with pronounced, persistent erythema that is incompletely treated by topical vasoconstrictors might need to add an oral therapy such as low-dose or extended-release doxycycline or minocycline. The latter, approved in 2024 for inflammatory rosacea lesions in adults, is the newest oral treatment incorporated into the algorithms, said Draelos.
The newest topical treatment included is microencapsulated benzoyl peroxide cream. “The microencapsulation prevents the benzoyl peroxide from releasing all at once onto the skin. And that makes it more tolerable because the skin of people with rosacea is somewhat sensitive, especially to low- or moderate-grade irritants such as benzoyl peroxide,” she said.
For physicians, Draelos said, the algorithms provide succinct guidance regarding which options might be most appropriate for each patient’s symptoms. “This allows the dermatologist to craft a treatment regimen specific for the signs and symptoms of that patient.” As patients’ rosacea improves, she added, the algorithms show prescribers how to switch to treatments with easier administration, fewer side effects, and greater long-term safety.
Adam Friedman, MD, professor and chair of Dermatology at the George Washington School of Medicine and Health Sciences in Washington, DC, said that the algorithms align with other established guidelines, such as those from the American Academy of Dermatology and international consensus panels, in emphasizing a phenotype-driven approach. “This consistency underscores a broader movement within dermatology toward individualized patient care, ensuring that treatment strategies are both evidence-based and adaptable to the specifics of each case,” added Friedman, who was not involved with the algorithms.
Ongoing Challenges
Yet much work in rosacea research remains. Draelos said, “We don’t fully understand why some people get it and some don’t.” As with a potential hereditary component, the culpability of Demodex mites, their gut bacteria, Cutibacterium acnes, vasomotor dysregulation, skin dysbiosis, and immune system dysregulation remains unclear. “All of those are purported causes,” she said. “Maybe it’s several of those. But I don’t think we know what causes rosacea yet.”
Friedman added, “The diagnostic struggle is still very real, particularly in distinguishing rosacea from other dermatologic conditions with overlapping features, such as acne, seborrheic dermatitis, and Demodex dermatitis, especially in patients with darker skin tones. Further, ocular rosacea is often missed as patients don’t often volunteer ophthalmologic complaints to a dermatologist, so it’s on us to ask and address.”
Although the therapeutic armamentarium for rosacea continues to expand, he said, managing refractory cases that do not respond to standard, on-label therapies also remains challenging. “Being comfortable utilizing combination therapy and off-label vessel-targeting therapies such as clonidine and propranolol and low-dose isotretinoin (off-label) builds on this growing on-label list. Ongoing education and familiarity with evolving guidelines are essential to navigate these complexities effectively.”
The algorithm webpage is funded by Journey Medical Corporation, the manufacturer of extended-release minocycline. Draelos is a NRS board member and was an investigator on studies of subantimicrobial minocycline (before Journey acquired the product). Friedman reported no relevant financial relationships.
John Jesitus is a Denver-based freelance medical writer and editor.