Rating the level of evidence of topical and systemic prescription treatments for rosacea was outside the scope of this publication.23 In addition, the small number of clinical studies on skin barrier dysfunction and skincare using cleansers and moisturizers for rosacea as an adjunct to treatment and maintenance did not allow for grading.23
Algorithm for Cutaneous Rosacea Treatment and Maintenance Integrating Skincare
The USCRO algorithm for cutaneous rosacea treatment and maintenance used the mnemonic RECUR (Reliable, Efficient, Clear instructions, Understandable, Remember easily).24 A clinical algorithm's function is to standardize and support medical decision-making, such as regulating the selection and use of treatment regimens, thereby improving adherence to evidencebased guidelines.21-24 The algorithms have inputs and outputs, precisely defined specific steps, and uniquely defined results that depend on the preceding steps.24 The current algorithm for managing and maintaining rosacea focuses on promoting a healthy skin barrier reducing and managing the signs and symptoms of rosacea, and integrating OTC products and skincare (Figure 2). Detailed information on aspects of rosacea diagnosis, the main concern or rosacea subtype, is given in Box 1.
Foundational measures to be taken by all patients with rosacea and rosacea-prone skin are detailed in the algorithm. These measures include education, behavioral modifications, avoidance of triggers and skin irritants, preventative skincare, and sun avoidance and sunscreen use. Finally, the algorithm describes how assessment of skin condition and grading of cutaneous rosacea should take place during treatment and maintenance while the preventative measures continue. Each section is discussed in order as they appear in the algorithm.
Foundational Measures for All Rosacea Patients
Is rosacea a skin barrier disorder?
The discussion of "what comes first, the chicken or the egg" is relevant to many aspects of the pathogenesis of rosacea, including inflammation, skin microbiome dysbiosis, and loss of antimicrobial peptides.6,16-20 Studies in rosacea patients showing skin barrier deficiency such as increased TEWL, decreased hydration, and elevated skin surface pH point towards rosacea being a barrier defect disorder but are not conclusive.6,10-20
One study investigated the difference in skin barrier function and the cutaneous microbiome between lesional and non-lesional areas of papulopustular rosacea.16 The pilot study, including 25 patients, showed that rosacea's physiological features (lower water content and higher TEWL) are closely associated with changes in the skin microbiome.16 The main skin surface microorganisms include Propionibacterium, Staphylococcus, and low-abundant bacteria.18 There is a significant decrease in cutibacterium acnes (c. acnes) in rosacea-prone skin, which may be of pathological significance.25,26
Staphylococcus epidermidis tends to form biofilms when concentrations of c.acnes decrease.25,26 Demodex mites play a role in rosacea; however, it remains unknown whether rosaceaaffected skin favors Demodex, causing dysbiosis, or whether the mites themselves contribute to disease progression.27,28
There are important associations between skin barrier deficiency and microbiome dysbiosis in many skin diseases, including rosacea.19,20 However, it has not been clearly delineated whether the dysbiosis triggers rosacea or dysbiosis is a response to skin changes resulting from rosacea-induced inflammation.6,16
Some rosacea patients have overlapping conditions, such as seborrheic dermatitis, acne, or perioral dermatitis, complicating treatment and maintenance. Rosacea is a great imitator of other conditions, and it is, on occasion, challenging to diagnose.6
Diagnosis of cutaneous rosacea
In the last ten years, expert and consensus groups have called for the replacement of subtype classification with phenotype descriptors.1,3 Rosacea may be considered in the presence of at least one diagnostic sign.1,3,29-33 These signs include persistent redness of the central facial skin and thickened skin in the central face (phymatous changes).1,3,29-33 Major signs include papules, pustules, flushing, telangiectasias, and eye irritation.1,3,29-33 Secondary signs and symptoms, such as burning or stinging, edema, and dryness, may also develop but are not diagnostic.1,3,29-31
Algorithm for Cutaneous Rosacea Treatment and Maintenance Integrating Skincare
The USCRO algorithm for cutaneous rosacea treatment and maintenance used the mnemonic RECUR (Reliable, Efficient, Clear instructions, Understandable, Remember easily).24 A clinical algorithm's function is to standardize and support medical decision-making, such as regulating the selection and use of treatment regimens, thereby improving adherence to evidencebased guidelines.21-24 The algorithms have inputs and outputs, precisely defined specific steps, and uniquely defined results that depend on the preceding steps.24 The current algorithm for managing and maintaining rosacea focuses on promoting a healthy skin barrier reducing and managing the signs and symptoms of rosacea, and integrating OTC products and skincare (Figure 2). Detailed information on aspects of rosacea diagnosis, the main concern or rosacea subtype, is given in Box 1.
Foundational measures to be taken by all patients with rosacea and rosacea-prone skin are detailed in the algorithm. These measures include education, behavioral modifications, avoidance of triggers and skin irritants, preventative skincare, and sun avoidance and sunscreen use. Finally, the algorithm describes how assessment of skin condition and grading of cutaneous rosacea should take place during treatment and maintenance while the preventative measures continue. Each section is discussed in order as they appear in the algorithm.
Foundational Measures for All Rosacea Patients
Is rosacea a skin barrier disorder?
The discussion of "what comes first, the chicken or the egg" is relevant to many aspects of the pathogenesis of rosacea, including inflammation, skin microbiome dysbiosis, and loss of antimicrobial peptides.6,16-20 Studies in rosacea patients showing skin barrier deficiency such as increased TEWL, decreased hydration, and elevated skin surface pH point towards rosacea being a barrier defect disorder but are not conclusive.6,10-20
One study investigated the difference in skin barrier function and the cutaneous microbiome between lesional and non-lesional areas of papulopustular rosacea.16 The pilot study, including 25 patients, showed that rosacea's physiological features (lower water content and higher TEWL) are closely associated with changes in the skin microbiome.16 The main skin surface microorganisms include Propionibacterium, Staphylococcus, and low-abundant bacteria.18 There is a significant decrease in cutibacterium acnes (c. acnes) in rosacea-prone skin, which may be of pathological significance.25,26
Staphylococcus epidermidis tends to form biofilms when concentrations of c.acnes decrease.25,26 Demodex mites play a role in rosacea; however, it remains unknown whether rosaceaaffected skin favors Demodex, causing dysbiosis, or whether the mites themselves contribute to disease progression.27,28
There are important associations between skin barrier deficiency and microbiome dysbiosis in many skin diseases, including rosacea.19,20 However, it has not been clearly delineated whether the dysbiosis triggers rosacea or dysbiosis is a response to skin changes resulting from rosacea-induced inflammation.6,16
Some rosacea patients have overlapping conditions, such as seborrheic dermatitis, acne, or perioral dermatitis, complicating treatment and maintenance. Rosacea is a great imitator of other conditions, and it is, on occasion, challenging to diagnose.6
Diagnosis of cutaneous rosacea
In the last ten years, expert and consensus groups have called for the replacement of subtype classification with phenotype descriptors.1,3 Rosacea may be considered in the presence of at least one diagnostic sign.1,3,29-33 These signs include persistent redness of the central facial skin and thickened skin in the central face (phymatous changes).1,3,29-33 Major signs include papules, pustules, flushing, telangiectasias, and eye irritation.1,3,29-33 Secondary signs and symptoms, such as burning or stinging, edema, and dryness, may also develop but are not diagnostic.1,3,29-31
