Synopsis
Recognise overlapping vascular, inflammatory, ocular and phymatous rosacea features across skin tones, exclude important mimics, and select phenotype-directed skin care, topical, systemic and referral options.
- Diagnose by features rather than rigid subtypes: persistent centrofacial erythema, flushing, telangiectasia, papules or pustules, ocular disease and phymatous change overlap.
- Comedones are not a rosacea feature; their presence suggests acne coexistence or an alternative diagnosis.
- In darker skin, persistent erythema may appear dusky, violaceous or brown and is often detected more reliably through warmth, burning, swelling, photographs and dermoscopy.
Key red flags
Eye pain, photophobia, reduced vision, marked corneal redness, rapidly progressive facial swelling, systemic illness or an atypical scarring or photosensitive eruption needs urgent ophthalmic or diagnostic assessment rather than routine rosacea treatment.
Eye pain, photophobia, reduced acuity or corneal opacity suggests keratitis or ulceration and requires urgent same-day ophthalmic assessment.
Investigation priorities
Document dominant phenotype, severity and urgent ocular findings.
Management branches
Facial papules or pustules occur without comedones and without sight-threatening ocular features.
- Start gentle cleanser, non-comedogenic moisturiser and SPF 30 or higher, remove inappropriate facial corticosteroid exposure through a planned approach, and agree one topical anti-inflammatory option.
- Use ivermectin once daily, azelaic acid twice daily or metronidazole twice daily according to the chosen product; apply away from eyes and set the product-specific response point.
Persistent lid or eye symptoms, corneal warning features or established tissue thickening is present.