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

Rosacea is a common chronic inflammatory dermatosis with a variety of clinical manifestations. Rosacea primarily affects the central face, and includes papules, pustules, erythema, telangiectasias, perilesional redness, phymatous changes, and even ocular involvement. Symptoms may vary among different patients and even vary over time in an individual patient. Central facial redness affects many adults and can be an indicator of the chronic inflammatory disease rosacea. Rosacea is a clinical diagnosis based on the patient’s history, physical examination, and exclusion of other disorders. It is under-diagnosed, particularly in individuals with skin of color. The goal of this article is to provide clinicians with the tools and understanding needed to correctly identify rosacea and differentiate it from other conditions that have overlapping signs and symptoms.

J Drugs Dermatol. 2019;18(9):888-894.


Rosacea is a chronic inflammatory skin disease with a complex, multifactorial pathophysiology that remains to be fully understood. An enhanced immune response and neuroimmune/neurovascular alterations are thought to have a central role.1 The disease is characterized by a waxing and waning natural history. Different symptoms may manifest at different time periods.2 Rosacea is underdiagnosed, and the exact prevalence of rosacea is unknown. However, it is estimated to occur in 2% to 10% of the adult population.2,3 The goal of this article is to help clinicians recognize rosacea and distinguish it from other dermatologic conditions that may have similar signs and symptoms.

Step 1 in Recognizing Rosacea: Understanding the “Typical” Rosacea Patient
Central facial redness and erythema have been recognized as the hallmarks of rosacea and may occur alone or in combination with a constellation of symptoms (Figure 1).4,5 The diagnosis of rosacea is often first made in individuals aged 30-60 years. Women are two to three times more likely to be affected than men.6,7 However, men may be more likely to have severe symptoms and phymatous overgrowth of skin (especially rhinophyma).2 Rosacea is most common in fair-skinned individuals with Northern European heritage, but can affect all ethnicities and skin types.6,8-10

Signs and symptoms of rosacea include marked involvement of the central face with telangiectasias, papules, pustules, and intermittent or chronic facial edema.8,11 Patients may experience an uncomfortable flushing (transient erythema), which can be accompanied by stinging, burning, or itching and extend down the neck to the chest.10 Rosacea manifestations are often transient, and occur independently; thus, it is prudent to use a symptom-oriented approach in management.12 Ocular problems occur in up to 50% of patients with rosacea, and are seen equally in men and women. Clinical features usually manifest as inflammatory conjunctivitis with or without blepharitis.6 Patients may complain of a gritty sensation, and itchy, burning, or dry eyes may occur; erythema or lid swelling may also be present. With chronic ocular involvement, corneal neovascularization and keratitis can occur, ultimately leading to corneal scarring and perforation.13 The severity of skin and ocular symptoms are not correlated. Ocular rosacea can be present in the absence of skin symptoms.8,10 Dermatologists who treat many patients with skin of color recognize that rosacea is uncommon but not rare among this demographic (Figure 2).14 Factors that may contribute to a