Recognizing Rosacea: Tips on Differential Diagnosis

September 2019 | Volume 18 | Issue 9 | Original Article | 888 | Copyright © September 2019

Sandra Marchese Johnson MD FAAD,a Andrew Berg PA,b Chelsea Barr MPAS PA-Cc

ªJohnson Dermatology, Fort Smith, AR

BBerg Consulting and Investments, Inc, Lee’s Summit, MO

cHouston Skin Associates, Houston, TX

(IGA) score of 1 (almost clear) or 0 (clear) in four randomized clinical trials of treatment with ivermectin 1% cream, metronidazole 0.75% cream, or vehicle. Evaluations included time to relapse, the Dermatology Life Quality Index (DLQI) and subject assessment of improvement in rosacea. Patients with complete clearing had almost half a year longer relapse-free period compared to those rated ‘almost clear’ (>8 months vs 3 months, P<.0001). In addition, quality of life was significantly better in the ‘clear’ group. A clinically relevant improvement in DLQI score was statistically significantly more likely in those who achieved ‘clear’ compared to ‘almost clear’ (59% vs 44%, P<.001). Further, a large majority of those rated ‘clear’ (84%) had a final DLQI score of 0-1, indicating rosacea no longer adversely affected their quality of life (P<.001 vs ‘almost clear’ at 66%). The authors noted that improving treatment with “earlier effective treatment and longer remission times might not only control symptoms, but also delay progression of disease.” Notably, a comparative study of ivermectin 1% cream QD versus metronidazole 0.75% cream BID in subjects with moderate to severe rosacea showed that more subjects were judged “clear” with ivermectin (34.9% vs 21.7% with metronidazole).32 The difference in treatment efficacy was even more marked in the subgroup of individuals with severe rosacea, where clearing was 27.5% with ivermectin vs 12.3% with metronidazole.32

Topical treatments for rosacea target papules/pustules and include metronidazole 0.75% cream, ivermectin 1% cream, azelaic acid 15% gel and foam, and sodium sulfacetamide 10% with or without sulfur 5%. Topical treatments for erythema include brimonidine 0.33% gel and oxymetazoline 1% cream. These treatments can be combined for best results, and the recent MOSAIC study showed that initiation of therapy with a combination regimen of ivermectin 1% cream plus brimonidine 0.33% gel was associated with superior efficacy and good patient acceptance.33 In addition, medical and physical therapies may be used together for good results.34,35 Commonly used oral therapies for rosacea include tetracycline-type agents in an antibiotic dose and in a sub-antimicrobial dose. Clinician-directed skin care (cleanser, moisturizer, sun protection) should be a part of the rosacea regimen to improve therapeutic outcomes and decrease the likelihood of skin irritation.11 Treatment can now be individualized to the patient’s presentation, taking into account the specific signs and symptoms present, trigger factors, and patient preferences.


Rosacea is a complex disease that is often under-diagnosed, particularly in dark-skinned individuals. For best outcomes, it is important for clinicians to be able to recognize rosacea and differentiate it from other diseases with similar presentations. Patients with rosacea typically have multiple signs and symptoms that require different therapies, which may include medical and physical approaches as shown in the MOSAIC Study. In addition, clinicians may need to have different discussions with patients, depending on what manifestations are present at the given time. Optimally, all signs/symptoms should be addressed at the same time to increase patient satisfaction with outcomes. Today there are different drugs with targeted mechanisms of action and complete clearance is a realistic, achievable clinical goal.


Editorial services for this publication were provided by Galderma Laboratories. All authors have served as consultants for Galderma. The authors wish to acknowledge Valerie Sanders, Sanders Medical Writing, for assistance with preparation of this publication.


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