Rosacea: Dermatologic Evaluation and Treatment

What Is Rosacea?

Rosacea is a chronic inflammatory facial disease that predominantly affects fair-skinned adults, with peak incidence between 30-50 years. It is characterized by persistent centrofacial erythema, telangiectasias (dilated vessels), papules, pustules, and episodes of flushing (transient redness).

The disease affects roughly 5-10% of the adult population and is more prevalent in people of Northern European descent. Although it can superficially resemble acne, rosacea has distinct pathophysiology, triggers, and treatment. Unlike acne, it does not present with comedones.

Rosacea is underdiagnosed and frequently underestimated. The psychosocial impact is significant: patients report embarrassment, social anxiety, and reduced self-esteem. Facial burning and stinging can be as disabling as the visible appearance of lesions.

Pathophysiology

Rosacea results from an interaction among neurovascular dysfunction, dysregulation of innate immunity, and cutaneous barrier alteration. A central finding is the excess of cathelicidin LL-37, an antimicrobial peptide that, at high concentrations, becomes proinflammatory and angiogenic.

The kallikrein 5 (KLK5) enzyme cleaves cathelicidin into proinflammatory fragments. Patients with rosacea show significantly elevated KLK5 and LL-37 in facial skin. TLR-2 receptor activation (by microorganisms or thermal stress) amplifies KLK5 and cathelicidin production, perpetuating the inflammatory cycle.

Demodex folliculorum — a commensal mite of the facial follicles — is present at 5-10 times greater density in rosacea skin. Its proliferation activates TLR-2, contributing to inflammation. Treatment with topical ivermectin (antiparasitic) is highly effective, validating this mechanism. Neurovascular dysfunction involves hyperexcitable TRPV1 channels, which respond exaggeratedly to heat, capsaicin, and alcohol.

Symptoms

Rosacea is currently classified by phenotypes (individual manifestations) rather than fixed subtypes, recognizing that features overlap. Persistent centrofacial erythema and flushing are the most common and defining findings.

Diagnosis

Diagnosis is clinical, based on the phenotypes present. The main diagnostic criterion is fixed centrofacial erythema that worsens with known triggers. Phymatous changes are also diagnostic on their own.

Dermoscopy can help identify Demodex and differentiate rosacea from other conditions. Biopsy is rarely needed but may be useful to rule out cutaneous lupus and contact dermatitis. Ophthalmologic examination is recommended to screen for ocular rosacea.

Differential Diagnosis

Rosacea affects the central face and can be mistaken for several other conditions. Fixed erythema, flushing, and absence of comedones are the most important distinguishing features.

Lupus Erythematosus vs. Rosacea: Differences That Matter

The malar rash of systemic lupus erythematosus (SLE) is photosensitive, spares the nasolabial fold, and is often associated with other systemic disease criteria — arthralgia, serositis, cytopenias, proteinuria, and antinuclear antibodies (ANA positive in more than 95% of cases). Clinical overlap with rosacea can be misleading, especially in early stages.

Features that raise suspicion of SLE include marked photosensitivity, joint involvement, disproportionate fatigue, blood-count abnormalities, proteinuria, or positive ANA on screening. ANA is the screening test and, if positive, should be complemented with specific antibodies (anti-double-stranded DNA, anti-Sm). The acupuncture physician systematically investigates these signs to avoid delaying an SLE diagnosis.

Carcinoid and Paroxysmal Flushing: A Red Flag

Carcinoid tumor — a neuroendocrine neoplasm usually of the gastrointestinal tract — produces serotonin and other vasoactive amines that cause episodic facial flushing, diarrhea, and bronchospasm (carcinoid syndrome). Carcinoid flushing is typically dry (without sweating), lasts minutes to hours, may appear reddish or cyanotic, and often has specific triggers (alcohol, cheeses, exercise).

Urinary 5-HIAA (a serotonin metabolite) has 70-80% sensitivity for functioning carcinoid tumors. Serum chromogranin A is a more sensitive marker. Differential diagnosis with rosacea is mandatory in any patient with episodic flushing — especially when accompanied by gastrointestinal symptoms.

Ocular Rosacea: The Frequently Overlooked Subtype

Ocular rosacea occurs in 50 to 60% of patients with cutaneous rosacea and often precedes the cutaneous manifestations. It presents as chronic blepharitis, recurrent conjunctivitis, foreign-body sensation, photophobia, and, in severe cases, keratitis with risk of visual compromise. Diagnosis is frequently delayed because the physician does not link the ocular symptoms to rosacea.

Treatment of ocular rosacea includes meticulous lid hygiene (warm compresses, cleansing with neutral shampoo), ocular lubrication, oral doxycycline and, in severe cases, ophthalmologist follow-up. Every patient with rosacea should be asked about ocular symptoms, and any associated ocular complaint should prompt ophthalmologic evaluation.

Treatment

Treatment of rosacea is directed at the phenotypes present. Identification and avoidance of triggers is fundamental. Topical and/or oral treatment is chosen according to predominant phenotypes: erythema/flushing, papules/pustules, telangiectasias, or phymatous changes.

Acupuncture as Treatment

Acupuncture is studied in rosacea for its effects on vasomotor regulation, inflammatory modulation, and stress control — three pillars of the disease's pathophysiology. Modulation of the autonomic nervous system by acupuncture may influence the exacerbated facial vascular reactivity.

Hypothesized mechanisms include modulation of sympathetic vasomotor tone, effects on vasoactive neuropeptides (substance P, CGRP), and mast-cell activation — hypotheses extrapolated from other vascular and inflammatory conditions, with specific data for rosacea still scarce.

In clinical practice, acupuncture may be a complementary option for patients with rosacea in whom stress is a significant trigger, for frequent flushing, and for facial burning. It does not replace topical ivermectin, photoprotection, or treatment of telangiectasias.

Prognosis

Rosacea is chronic and requires long-term treatment. With trigger avoidance and adequate treatment, most patients achieve satisfactory control. Ivermectin and sub-dose doxycycline control papules and pustules in most cases.

Telangiectasias do not respond to topical treatment and require laser or IPL for removal, with good results. Once established, rhinophyma requires surgical or ablative laser treatment. Untreated ocular rosacea can rarely lead to keratitis and visual compromise.

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