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Despite universal recognition, rosacea is clinically varied and of uncertain pathophysiology. Practitioners and the public can easily identify the prototypical red face of rosacea; however, confusion arises when photodamage, perioral dermatitis, postadolescent acne, and topical steroid overuse present in a similar guise. Recent theory has shifted conceptually from staged progression of rosacea signs and symptoms to a new classification that defines four subtypes with variable severity and potential overlap.
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Rosacea is characterized by erythema of the central face that has persisted for months or more. The convex areas of the nose, cheeks, chin, and forehead are the characteristic distribution. Primary features of rosacea, which may be observed but are not required for the diagnosis, include flushing, papules, pustules, and telangiectases. Secondary features include facial burning or stinging, edema, plaques, a dry appearance, phyma, peripheral flushing, and ocular manifestations. Erythema in peripheral locations (the scalp, ears, lateral face, neck, and chest) can be observed in rosacea, but is also a common feature of physiologic flushing and chronic sun damage, and therefore must be interpreted carefully.1
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Subtype Classification
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The subtypes of rosacea were defined provisionally by the National Rosacea Society (NRS) Expert Committee in 2002 and include erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes.1 These represent the most common groupings of rosacea signs and symptoms. The subtypes coincide with the first rosacea “staging” classification devised by Plewig and Kligman.2 The erythematotelangiectatic subtype is analogous to Plewig–Kligman stage I disease, the papulopustular subtype to Plewig–Kligman stage II, and the phymatous subtype to Plewig–Kligman stage III. In contrast, the NRS classification maintains that progression of rosacea in stages (from one subtype to another) does not occur, but that subtypes may overlap in the same individual. A provisional grading system was also incorporated by the NRS Expert Committee to standardize the clinical assessment of rosacea.3 Rosacea severity assessments must additionally include consideration of the psychological, social, and occupational impacts of this disorder and individual responsiveness to treatment.
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Although the prevalence of rosacea is unknown, the vast majority of cases occur in fair-skinned populations and it is common. ...