12-phase flow (12)

1. 1FRAME
   Frame as a CHRONIC, relapsing, PHENOTYPE-driven centrofacial inflammatory disease with a major psychosocial burden, managed by FEATURE on a feature-targeted ladder — NOT by legacy subtype and NOT as a transient rash. Persistent centrofacial erythema OR phyma is independently diagnostic (ROSCO 2017). Steroid-induced rosacea, rosacea fulminans, sight-threatening ocular disease, and the flushing-syndrome / connective-tissue mimics are recognised here and routed/escalated.
   advance: chronic phenotype-led rosacea framing set; steroid-trap + fulminans + ocular + mimic escape routes noted
2. 2ENTRY
   Recognise the ROSCO-diagnostic phenotypes (persistent centrofacial erythema with periodic intensification, or phymatous change) vs the major-feature entries (flushing, papulopustules without comedones, telangiectasia, ocular) vs the steroid-induced entry; anchor on the diagnostic phenotype up front.
   inputs: centrofacial_erythema_or_phyma
   actions: workup.chronic_pruritus
   advance: a diagnostic phenotype or major-feature entry present and recorded
3. 3CONTEXT
   Build context: full per-FEATURE phenotype inventory (flushing/transient erythema, persistent erythema, telangiectasia, papules/pustules, phyma, ocular), trigger inventory (UV/heat/alcohol/spicy food/stress/exercise/Demodex), psychosocial/QoL burden dialogue (a ROSCO recommendation), topical-corticosteroid exposure (causal — must stop), and a rigorous prior-therapy-adequacy assessment (agent × ≥8-12 wk × adherence × photoprotection).
   inputs: feature_phenotype_inventory, trigger_inventory, psychosocial_qol_burden, topical_steroid_exposure, prior_rosacea_therapy_adequacy
   actions: workup.chronic_pruritus
   advance: feature inventory + trigger + burden + steroid-exposure + true-adequacy context established
4. 4RED_FLAGS
   Ocular rosacea with keratitis / vision threat (pain, photophobia, blurred vision, corneal involvement) → urgent ophthalmology — the sight-threatening complication. Rosacea fulminans / pyoderma faciale (abrupt confluent nodules/sinuses/coalescing pustules ± systemic upset) → systemic corticosteroid bridge then low-dose isotretinoin, NOT antibiotic-first. Rapidly progressive phyma → early isotretinoin/surgical referral. These are recognised + escalated here.
   inputs: ocular_involvement_severity, acute_fulminant_features, cbc
   actions: panel.cbc
   advance: sight-threatening ocular disease / fulminans / rapid phyma screened and escalated if present
5. 5INITIAL_WORKUP
   Rosacea is a clinical (phenotype) diagnosis — no test confirms it. Targeted workup: pregnancy test before oral isotretinoin/tetracycline in reproductive-potential patients; baseline lipids/LFT if isotretinoin planned; CBC if fulminans; CKD-EPI 2021 eGFR for tetracycline/renal review. Demodex density (skin-surface biopsy/dermoscopy) and KOH only when a Demodex-folliculitis or tinea mimic is suspected. Routine microbiology/serology is NOT required for typical rosacea (global ROSCO 2019 PMID 31392722).
   inputs: pregnancy_test
   actions: panel.cbc, panel.lft, panel.renal
   advance: pre-systemic safety/pregnancy testing drawn if escalation likely; routine testing deferred otherwise
6. 6BRANCHING_WORKUP
   Flushing branch: flushing with diarrhoea/wheeze/palpitations/syncope/urticaria-pigmentosa or non-facial flushing → carcinoid (5-HIAA/chromogranin A), phaeochromocytoma (metanephrines), mastocytosis (tryptase), menopause screen rather than rosacea. Connective-tissue branch: malar rash sparing nasolabial folds + photosensitivity/arthralgia → ANA, route rheum.sle.core.v1. Demodex branch: monomorphic follicular pustules + high Demodex density → Demodex folliculitis (topical ivermectin/permethrin). Otherwise typical rosacea confirmed clinically by phenotype.
   inputs: flushing_syndrome_red_flags
   actions: workup.chronic_pruritus
   advance: flushing-syndrome / connective-tissue / Demodex branches sent if indicated OR typical rosacea confirmed by phenotype
7. 7DIFFERENTIAL
   Terminal facial-eruption differential with named pivots: rosacea (persistent centrofacial erythema/phyma, NO comedones) vs acne vulgaris (COMEDONES present + mixed lesions — route derm.acne-vulgaris.core.v1) vs seborrhoeic dermatitis (greasy scale, scalp/nasolabial — can OVERLAP) vs perioral/periorificial dermatitis (perioral micropapules sparing vermilion, often steroid-driven) vs SLE/malar rash (nasolabial SPARING, photosensitive, ANA+ — route rheum.sle.core.v1) vs photo/contact dermatitis (exposure-mapped, eczematous — route derm.contact-dermatitis.core.v1) vs Demodex folliculitis vs steroid-induced rosacea / topical-steroid withdrawal vs lupus pernio/cutaneous sarcoid vs flushing syndromes (carcinoid/mastocytosis/phaeochromocytoma/menopause).
   inputs: comedones_present, connective_tissue_disease_features
   advance: single best diagnosis selected by phenotype; comedone / nasolabial-sparing / steroid-history / flushing pivots applied; mimic routed by engine_id
8. 8RISK_STRATIFICATION
   Severity = per-feature severity (IGA / Clinician Erythema Assessment / inflammatory-lesion count / phyma grade / ocular severity — schema-blocked as TS calculators, captured narratively) × psychosocial burden × refractoriness. Mild single-feature → targeted topical; moderate multi-feature → combination topical ± oral; severe/refractory papulopustular or rapidly progressive phyma or sight-threatening ocular or fulminans → systemic (oral doxycycline 40 mg MR / low-dose isotretinoin / corticosteroid bridge) ± procedural. ROSCO target is COMPLETE clearance (durability benefit), not partial response.
   inputs: feature_phenotype_inventory, psychosocial_qol_burden
   advance: per-feature severity + psychosocial overlay + complete-clearance treatment-goal + ladder-step decision assigned
9. 9TREATMENT
   FEATURE-TARGETED therapy (not one linear ladder) + foundational photoprotection/trigger avoidance/gentle skincare (non-pharm, all patients). Persistent erythema/flushing: topical brimonidine or oxymetazoline (α-agonist); fixed telangiectasia → laser/IPL (non-pharm); refractory flushing → off-label carvedilol. Papulopustular: topical ivermectin (first-line, anti-Demodex/anti-inflammatory), azelaic acid, metronidazole, minocycline 1.5% foam; moderate-severe → add oral doxycycline 40 mg modified-release (anti-inflammatory dose); refractory → low-dose oral isotretinoin. Phymatous: early isotretinoin (inflammatory phase) then surgical/laser ablation (non-pharm) for established phyma. Ocular: lid hygiene + warm compress + artificial tears (non-pharm), topical ciclosporin or azithromycin, oral doxycycline; ophthalmology if keratitis. Rosacea fulminans: systemic corticosteroid bridge then low-dose isotretinoin (NOT antibiotic-first). Topical corticosteroid is recommended AGAINST (causes/perpetuates steroid rosacea). Combination therapy for multi-feature disease (ROSCO 2019). Pregnancy gating: avoid isotretinoin/tetracyclines; azelaic acid / topical erythromycin / oral azithromycin are the pregnancy-favourable options.
   inputs: pregnancy_lactation, creatinine
   advance: feature-targeted regimen + photoprotection started; complete-clearance goal set; agent gated on pregnancy/renal status; steroid-against enforced
10. 10DISPOSITION
    Almost entirely outpatient/derm-clinic. Urgent ophthalmology for ocular rosacea with keratitis/vision threat. Rosacea fulminans / pyoderma faciale → urgent dermatology (corticosteroid bridge then low-dose isotretinoin). Isotretinoin initiated/monitored under the relevant pregnancy-prevention pathway via dermatology; flushing-syndrome and connective-tissue cases routed OUT by engine_id; established phyma → surgical/laser referral.
    inputs: ocular_involvement_severity
    advance: disposition documented; ophthalmology/dermatology/procedural routing for ocular-threat/fulminans/phyma; mimic routed; derm follow-up arranged
11. 11MONITORING
    Disease: reassess per-feature response at 8-12 wk per agent (erythema/CEA for α-agonist; inflammatory-lesion count/IGA for ivermectin/azelaic/metronidazole/doxycycline; phyma progression; ocular surface). Drug safety: brimonidine — counsel paradoxical rebound/worsening erythema and titrate (no rebound with oxymetazoline in the REVEAL data); oral isotretinoin — pregnancy test + lipids/LFT + mood per the pregnancy-prevention programme; doxycycline — photosensitivity/GI counselling; ocular non-response or worsening → ophthalmology referral threshold. Re-evaluate the diagnosis (steroid trap, flushing syndrome, mimic) if no response.
    inputs: lipid_panel_lft, creatinine
    actions: panel.lft
    advance: per-feature response assessed at the agent-appropriate interval; drug-class safety monitoring + ocular-referral threshold on schedule
12. 12FOLLOWUP
    Chronic-disease maintenance: lifelong photoprotection + trigger-diary + gentle non-soap skincare habit, maintenance topical (ivermectin/azelaic/metronidazole) to sustain remission (relapse is common after stopping — ~⅔ within 36 wk for topical agents), brimonidine rebound-erythema counselling, periodic ocular review, psychosocial/QoL surveillance, and a clear step-up/step-down plan toward the complete-clearance target. Dermatology continuity for any systemic agent; reassess the diagnosis if the course remains atypical or steroid-driven.
    inputs: trigger_inventory, psychosocial_qol_burden
    actions: workup.chronic_pruritus
    advance: photoprotection/trigger + maintenance topical + brimonidine counselling + ocular + psychosocial surveillance documented