Rosacea's various phenotypes may appear in other combinations and at different times.29 Research suggests that all are manifestations of the same underlying disease process and that rosacea may progress in severity and include additional phenotypes (Box 1).3,29-33 According to the authors,3,29-33 a patient's phenotypic characteristics and symptomatology are more consistent with the patient's individual experience than the older subtype classification, which may not fully cover the range of clinical presentations and is likely to confound severity assessment.
Education and behavioral measures
Rosacea patients need education on the chronic and recurrent nature and the triggers of the condition.6 The USCRO advisors agree that early education of patients on rosacea prevention, treatment, and maintenance measures, including skincare, is an important step in building a therapeutic relationship with the patients enabling their active participation in the treatment plan.6,34-36 Before starting the rosacea treatment, a detailed discussion between the patient and the treating clinician should address the treatment and maintenance protocol, potential side effects, diagnostic tests, management of adverse events (AEs), and preventative measures (Box 2).6 The discussion should be supported by written or digital material to allow the patient to process the information.34-36 This session's outcome should be: 1) The patient has been educated on the nature of her/his disease along with the role of lifestyle interventions. 2) The patient expresses an understanding of prevention measures such as avoiding triggers, using skincare and sun protection measures.6,34-36 The patient understands the medications and OTC products for treatment, and maintenance, proper skincare, and how to access the relevant information.6,34-36
The National Rosacea Society (NRS) raises public awareness and supports research, and provides medical professionals with patient education and professional tools.34 A further source of information is physicians' patient education on rosacea.35
Skincare and UV protection
Addressing barrier repair early in the treatment phase, continuing such care through acute treatment, and maintenance are paramount in rosacea management.6,9,10 Regardless of its origin, the disturbed barrier often results in the inability of the patient to use the medications and products that would otherwise result in clinical improvement.6,9,10 A previously published review by the USCRO advisors on skin barrier deficiency in rosacea and the integration of OTC products and skincare explored recent guidelines and algorithms for rosacea management to provide a basis for OTC recommendations.2,6,30,32,37-39-42 The advisors confirmed that guidelines recommend skincare with gentle cleansers and moisturizers to relieve and prevent dry skin, improve irritation symptoms, and restore skin barrier function. 2,6,30,32,37-42 According to the guidelines, skincare should include a gentle cleanser, avoidance of topically applied triggers, use of a moisturizer containing barrier lipids such as ceramides, and a sunscreen.2,6,30,32,37-42
Cleansers
A gentle cleanser has a near-physiological skin surface pH (4-6) and does not disrupt the beneficial lipids, proteins, and normal flora that contribute to the skin barrier's integrity and function.6,15,43-45 The advisors felt that using a foaming cleanser may not be suitable for rosacea patients.6 Ingredients to be avoided are fragrances, perfumes, soaps, surfactants, detergents, and products with an alkaline pH (>7). These have been found to elevate skin surface pH, which in turn depletes
