A Personalized Approach to Rosacea management

The National Rosacea Society (NRS) has unveiled updated treatment algorithms that prioritize a patient’s unique symptoms over rigid subtype classifications. This approach reflects a deeper understanding of rosacea as a condition with diverse manifestations stemming from systemic inflammation.The algorithms,[published] on March 25,aim to refine diagnosis and tailor treatments for optimal patient outcomes [3].

Rethinking Rosacea Diagnosis

The new algorithms mark a meaningful change in diagnostic strategy. Dr. Zoe D.Draelos, president of dermatology Consulting Services, emphasized that the algorithms fundamentally alter how rosacea is diagnosed.

While the NRS’s original morphologic classification system proved didactically prosperous, an update in the Journal of the American Academy of Dermatology in 2018 noted that subtypes like erythematotelangiectatic, papulopustular, phymatous, and ocular where often misinterpreted as separate diseases. Current research suggests that rosacea’s varied features arise from a common inflammatory process,detectable even when not clinically apparent.

The phenotypic approach prioritizes individual patient signs and symptoms.Persistent erythema or phymatous changes are now considered diagnostic hallmarks. In the absence of thes, the presence of at least two major phenotypes—papules and pustules, telangiectasia, flushing, and ocular manifestations—can also support a rosacea diagnosis.

Tailoring Therapy to the Individual

This new approach enables physicians to customize treatment based on a patient’s specific signs and symptoms,taking into account the severity of each symptom.

• Mild Redness: Dr.Draelos suggests nonirritating cosmetics and a sunscreen along with avoiding triggers such as alcoholic beverages, especially red wine, and extreme cold, heat, or rapid temperature changes.
• Moderate Redness: Topical vasoconstrictors like oxymetazoline or brimonidine may be necessary. Intense pulsed light, potassium-titanyl-phosphate laser, or pulsed-dye laser treatments can also reduce redness in skin types I-IV.
• Pronounced Erythema: Oral therapies such as low-dose or extended-release doxycycline or minocycline may be added if topical treatments are insufficient. Minocycline, [approved] in 2024 for inflammatory rosacea lesions, is a recent addition to the treatment algorithms [2].

Microencapsulated benzoyl peroxide cream is another recent topical addition. The microencapsulation prevents the benzoyl peroxide from releasing all at once onto the skin…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, Dr. Draelos explained.

The algorithms offer concise guidance for physicians in selecting the most appropriate treatment options for each patient’s symptoms. This allows the dermatologist to craft a treatment regimen specific for the signs and symptoms of that patient, Dr. Draelos stated. The algorithms also guide prescribers on transitioning to treatments with easier administration, fewer side effects, and improved long-term safety as the patient’s condition improves.

Alignment with Established Guidelines

Dr. Adam Friedman,professor and chair of Dermatology at the George Washington School of Medicine and Health Sciences,noted that the algorithms align with guidelines from the American Academy of Dermatology and international consensus panels, 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.
Dr. Adam Friedman, professor and chair of Dermatology at the George Washington School of Medicine and Health Sciences

Unanswered Questions and Ongoing Research

Despite advancements, significant research gaps remain. We don’t fully understand why some people get it and some don’t, Dr. Draelos admitted. The roles of heredity, Demodex mites, gut bacteria, Cutibacterium acnes, vasomotor dysregulation, skin dysbiosis, and immune system dysregulation are still under inquiry. All of those are purported causes…Maybe it’s several of those. But I don’t think we certainly know what causes rosacea yet.

Dr. Friedman highlighted the diagnostic challenges, particularly in differentiating rosacea from conditions like acne, seborrheic dermatitis, and Demodex dermatitis, especially in patients with darker skin tones. He also emphasized the importance of identifying ocular rosacea, as patients may not spontaneously report ophthalmologic symptoms.

managing refractory cases remains a challenge, even with an expanding range of therapies. 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, Dr. Friedman advised.