Current Rosacea Treatment Algorithms: Guide to Subtypes and Existing Therapies

Rosacea is a common condition occurring on the convexities of the face and affecting middle-aged persons. It may be caused or worsened by a variety of different factors, including genetics; problems with the blood vessels in the face, the nervous system, and/or the immune system; the presence of Demodex mites; and environmental factors. It is a chronic condition that is not contagious.

Cases of rosacea are traditionally classified into three different subtypes. Each of these subtypes can also be broken down into smaller categories based on their severity, with grade 1 being the least severe and higher grades being more severe.[1] The recommended treatment for rosacea depends on the subtype and the grade of the individual’s condition, as well as on the phenotype, which will be presented separately.

Determining the Subtype

Subtype 1, which is also known as “erythematotelangiectatic rosacea,” is characterized by skin that is easily irritated, as well as flushing and persistent redness (erythema) on central areas of the face, such as the nose, the cheeks, the forehead, the chin, and dilated, superficial blood vessels (telangiectasia). Patients with this subtype may also experience scaling, roughness of the skin, swelling, burning and/or stinging.

Subtype 2, which is also known as “papulopustular rosacea,” is characterized by persistent redness of the face, along with acne-like breakouts of pustules or papules that may come and go over time. Contrary to acne, there are no blackheads. Patients with this subtype of rosacea may also notice burning and stinging.

Rosacea subtype 3, which is also known as “phymatous rosacea,” is characterized by enlargement of parts of the face, the development of bumps and irregularities on the surface of the skin (nodularities and patulous follicles), and significant skin thickening. Locations commonly affected include the nose, forehead, cheeks, chin, and ears. Some patients may also develop telangiectasia

Rosacea subtype 4, which is also known as “ocular rosacea,” affects the eyes. This subtype of rosacea is characterized by watery or bloodshot eyes, itching, dryness, blurred vision, and sensitivity to light. Patients may also develop widened blood vessels (telangiectases) and styes on the lid margins, burning, stinging, feeling of a foreign body in the eye, inflammation of the conjunctiva, keratitis, and reduced or blurred vision.

Current Treatments for Rosacea Subtype 1

Rosacea subtype 1 can be divided into three grades based on severity.  Grade 1 is a mild form of the disorder, which usually causes faint redness and occasional flushing with little to no appearances of telangiectasia. This form of the disorder is usually treated conservatively. Doctors help patients to identify the lifestyle factors and environmental triggers that make their condition worse, such as the sun, high and low temperatures, hot or alcoholic drinks, spicy foods, exercise, and stress. The doctor may also help the patient develop an appropriate skincare regimen to restore the skin barrier and minimize symptoms, recommend the use of sun protection and broad-spectrum sunscreens to prevent flare-ups, and use cosmetics to conceal any defects that remain.

Grade 2 is a moderate form of this disorder characterized by more frequent flushing, moderate redness on the face, and the appearance of multiple telangiectases. In addition to the treatments recommended for grade 1, the doctor may also recommend prescription therapy to reduce the redness on the face. For telangiectasia, electrosurgery or light- or laser-based treatments may be recommended. These treatments may reduce redness and flushing as well.

Grade 3 is a more severe form of rosacea type 1 in which patients experience extreme redness of the skin, frequent flushing, many noticeable telangiectases, scaling, roughness, and stinging. Patients may also notice burning and swelling. In addition to the treatments for grade 1 and grade 2, doctors treating a patient with a grade 3 form of this disorder may recommend topical alpha-adrenergic receptor agonists or hormone replacement therapy for menopausal flushing.

The type of medication recommended will depend on the patient’s triggers. Some patients who experience flushing related to their emotions may notice an improvement after treatment with biofeedback and/or psychological counseling.

Treatment for Rosacea Subtype 2

Rosacea subtype 2 can also be divided into three grades based on severity. Patients with a grade 1 disorder have may notice a few acne-like pustules and papules. These patients may also have some mild redness.  In most cases, this mild form of the disorder is treated with topical therapy. However, patients may benefit from an oral antibiotic, especially at the beginning of the treatment process. Once the condition is in remission, doctors may use topical therapy alone, or they may recommend topical therapy in conjunction with a very low dose of an oral antibiotic (sub-antimicrobial) to keep inflammation down.

Patients with a grade 2 form of this disorder usually have several pustules and/or papules as well as moderate redness. Doctors treating patients with a grade 2 form of this condition may recommend stronger topical or oral therapies, including oral antibiotics, first until remission is achieved, then on the long term to maintain remission.

Patients with a grade 3 form of this disorder usually experience severe, persistent redness and numerous papules and/or pustules. Red plaques, burning, and stinging are also possible. In addition to the treatments recommended for grade 1 and grade 2, doctors treating the grade 3 form of this subtype of rosacea may recommend a skin care regimen to help deal with any stinging and burning. In cases where the patient’s condition isn’t responding to traditional therapies, alternative topical and/or oral medications may be recommended.

Treatment for Rosacea Subtype 3

The third subtype of rosacea is divided into three grades as well. Patients with a grade 1 form of the disorder experience prominent follicles in the affected area with no changes to the contours of the face. Depending on the individual case, doctors may recommend oral isotretinoin to prevent the condition from worsening and to shrink the follicles. If these patients have any inflammatory lesions or redness, doctors may recommend oral or topical medications used to treat rosacea subtypes 1 and 2.

The grade 2 form of this disorder is characterized by changes in contours of the face such as nose enlargement and skin thickening. The grade 3 form of the disorder consists of changes in the contours of the face and the presence of lumps and bumps (surface nodularities). Patients with either of the more severe forms of this condition can benefit from several different procedures to repair the contours of their face and remove excess tissue through plastic surgery or other ablative methods such as laser therapy or dermabrasion. Skin grafting may sometimes be necessary.

Treatment for Rosacea Subtype 4

Like the other forms of rosacea, rosacea subtype 4 can be divided into three grades based on severity. Grade 1 is characterized by more mild symptoms that affect only the Meibomian glands and the eyelid margin. In most cases, doctors can treat this form of the disorder by instructing patients to cleanse their eyelashes and use artificial tears.

Patients with the grade 2 form of this type of rosacea may experience symptoms on the inner eyelid and/or ocular surface. Secretion of tears may be reduced. In addition to cleansing the eyelashes and using artificial tears, doctors treating this form of the disorder may recommend an antibiotic ointment applied to the eyelashes or also an oral antibiotic.

Grade 3 ocular rosacea leads to more severe symptoms and complications, such as inflammation of the white of the eye (episcleritis), the iris (iritis), or the eye cornea (keratitis); there is a danger of corneal damage and vision loss. Patients with this form of the disorder may not respond to standard treatments and should be under the care of an ophthalmologist. Alternative therapies such as topical steroids, oral medications, and surgery may be required.

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[1] Rosacea Treatment Algorithms. Published June 19, 2015. Accessed December 4, 2018.