Rosacea is a prevalent chronic inflammatory skin condition characterized by a complex and not fully understood pathophysiology. It is believed that an amplified immune response along with neuroimmune and neurovascular changes play a pivotal role in its development.1 The disease follows a relapsing and remitting course, with varying symptoms emerging at different stages.2 Rosacea often goes undiagnosed, and while its precise prevalence remains unknown, estimates suggest it affects between 2% and 10% of adults.2,3 This article aims to assist clinicians in effectively identifying rosacea and differentiating it from other dermatological conditions that present with similar signs and symptoms, focusing on the crucial aspect of Rosacea Differential Diagnosis.
Understanding the Archetypal Rosacea Patient
Central facial redness and erythema are recognized as the cardinal signs of rosacea. These may appear in isolation or accompanied by a cluster of other symptoms (Figure 1).4,5 Rosacea is frequently initially diagnosed in individuals between 30 and 60 years of age. Women are reportedly two to three times more likely to be affected compared to men.6,7 However, men may exhibit more severe symptoms, including the phymatous overgrowth of skin, particularly rhinophyma.2 Rosacea is most commonly observed in fair-skinned individuals of Northern European descent but can affect individuals of all ethnicities and skin types.6,8-10
Signs and symptoms of rosacea typically involve the central face prominently and include telangiectasias, papules, pustules, and intermittent or persistent facial edema.8,11 Patients may experience uncomfortable flushing, characterized by transient erythema, which can be associated with stinging, burning, or itching sensations and may extend from the neck down to the chest.10 Rosacea manifestations are often transient and occur independently, highlighting the importance of a symptom-focused approach in management.12
Ocular involvement is observed in up to 50% of rosacea patients and affects men and women equally. Clinical features commonly present as inflammatory conjunctivitis, with or without blepharitis.6 Patients may report a gritty sensation, itchy, burning, or dry eyes, and erythema or lid swelling may also be present. Chronic ocular involvement can lead to corneal neovascularization and keratitis, potentially resulting in corneal scarring and perforation.13 It’s important to note that the severity of skin and ocular symptoms is not correlated, and ocular rosacea can occur even in the absence of skin symptoms.8,10
Dermatologists with experience treating diverse patient populations acknowledge that while rosacea may be less common in individuals with skin of color, it is certainly not rare (Figure 2).14 Factors that may contribute to a differential diagnosis in these patients are crucial to consider.
