derm.rosacea.core.v1PRODUCTION

derm.rosacea.core.v1

Rosacea (dermatology lens)

dermatologychronicadult

Hard-required inputs

0 / 11

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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.

Inputs

Actions

Advance rule

Set

Advance when

chronic phenotype-led rosacea framing set; steroid-trap + fulminans + ocular + mimic escape routes noted

Patient inputs (16)

flushing_syndrome_red_flags*history • BRANCHING_WORKUP

not present

Flushing with diarrhoea/wheeze/palpitations/syncope/urticaria pigmentosa, or non-facial flushing, prompts a carcinoid/phaeochromocytoma/mastocytosis/menopause screen rather than a rosacea label

feature_phenotype_inventory*symptom • CONTEXT

Per-feature inventory (flushing/transient erythema, persistent erythema, telangiectasia, papules/pustules, phyma, ocular) drives feature-targeted therapy — rosacea is managed by feature, not by legacy subtype (global ROSCO 2019 PMID 31392722)

trigger_inventory*history • CONTEXT

not present

UV exposure, heat, hot drinks, alcohol, spicy food, emotional stress, exercise and Demodex density are modifiable flare triggers; trigger avoidance + photoprotection is foundational non-pharm therapy (global ROSCO 2019 PMID 31392722)

psychosocial_qol_burden*symptom • CONTEXT

Facial erythema/visible disease carries a major QoL/anxiety/depression/social-avoidance burden; burden dialogue is a ROSCO recommendation and independently justifies treatment escalation toward complete clearance (global ROSCO 2019 PMID 31392722)

topical_steroid_exposure*history • CONTEXT

not present

Chronic facial topical-corticosteroid use causes and perpetuates a rosacea-like eruption; the steroid must be stopped and a withdrawal flare anticipated — encode topical steroid AGAINST as treatment

comedones_present*symptom • DIFFERENTIAL

Comedones are absent in rosacea; their presence with mixed inflammatory lesions argues acne vulgaris (route derm.acne-vulgaris.core.v1) — the decisive acneiform-differential pivot (global ROSCO 2017 PMID 27718519)

connective_tissue_disease_features*history • DIFFERENTIAL

not present

A photosensitive malar rash SPARING the nasolabial folds with arthralgia/photosensitivity → ANA and SLE/connective-tissue workup (route rheum.sle.core.v1) rather than rosacea

centrofacial_erythema_or_phyma*symptom • ENTRY

Persistent centrofacial erythema with periodic intensification OR phymatous change is independently diagnostic of rosacea under the ROSCO phenotype scheme and is the primary diagnostic anchor (global ROSCO 2017 PMID 27718519)

ocular_involvement_severity*symptom • RED_FLAGS

Lid-margin disease/blepharitis vs sight-threatening keratitis determines lid hygiene + topical therapy vs urgent ophthalmology referral (global ROSCO 2019 PMID 31392722)

acute_fulminant_features*symptom • RED_FLAGS

Abrupt confluent nodules/draining sinuses/coalescing pustules ± systemic upset = rosacea fulminans / pyoderma faciale — needs a systemic-corticosteroid bridge then low-dose isotretinoin, NOT antibiotic-first

pregnancy_lactation*demographic • TREATMENT

Oral isotretinoin and tetracyclines are contraindicated in pregnancy and topical brimonidine/ivermectin are used with caution; gates the entire systemic/topical ladder (rosacea-in-pregnancy review PMID 34391325)

prior_rosacea_therapy_adequacyhistory • CONTEXT

not present

True topical/oral failure (adequate agent × duration ≥8-12 wk × adherence + photoprotection/trigger control) vs under-treatment determines whether to escalate or optimise (global ROSCO 2019 PMID 31392722)

pregnancy_testlab • INITIAL_WORKUP

Negative pregnancy test required before and during oral isotretinoin and tetracycline therapy in patients of reproductive potential (rosacea-in-pregnancy review PMID 34391325)

lipid_panel_lftlab • MONITORING

Baseline + on-treatment lipids and transaminases for oral isotretinoin (even low-dose courses) (van Zuuren GRADE review PMID 30585305)

cbclab • RED_FLAGS

Leucocytosis supports rosacea fulminans / pyoderma faciale and provides a baseline before systemic corticosteroid + isotretinoin

creatininelab • TREATMENT

Race-free eGFR for tetracycline-class selection and isotretinoin co-management in patients with renal impairment (CKD-EPI 2021; Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement

informationallife_threateningocular_rosacea_keratitis_vision_threat
Ocular rosacea with corneal involvement / keratitis — eye pain, photophobia, blurred vision, corneal infiltrate or neovascularisation
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevererosacea_fulminans_pyoderma_faciale
Abrupt onset of confluent inflammatory nodules, draining sinuses and coalescing pustules on the central face ± systemic upset (rosacea fulminans / pyoderma faciale)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterapidly_progressive_phyma
Rapidly progressive phymatous change (skin thickening, patulous follicles, fibrosis — usually rhinophyma) with an active inflammatory component
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatetopical_steroid_induced_rosacea_or_withdrawal
Rosacea-like eruption caused/perpetuated by chronic facial topical-corticosteroid use; or a rebound flare on stopping (topical-steroid withdrawal)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterefractory_papulopustular_isotretinoin
Severe / treatment-refractory papulopustular rosacea failing optimised topicals + an adequate oral anti-inflammatory tetracycline course
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateflushing_syndrome_red_flags
Flushing with diarrhoea/wheeze/palpitations/syncope, urticaria pigmentosa, or non-facial flushing — a systemic flushing syndrome rather than rosacea
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildsevere_psychosocial_qol_burden
Significant anxiety, depression, body-image distress or social avoidance attributable to visible facial rosacea
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment

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Recommended regimen

Rosacea — feature-targeted phenotype ladder (global ROSCO 2017/2019; van Zuuren GRADE/Cochrane)

axis: rosacea_feature_targeted_phenotype_ladderstep 1 - Step 1 — Foundation (every patient, every feature, lifelong): photoprotection + trigger avoidance + gentle skincare

Selected step "Step 1 — Foundation (every patient, every feature, lifelong): photoprotection + trigger avoidance + gentle skincare" — All phenotypes, continuously — the non-negotiable substrate beneath every feature-targeted step

broad_spectrum_photoprotection
first line
trigger_mitigation
Global ROSCO 2019 (PMID 31392722) — daily broad-spectrum SPF≥30 (UV is a dominant flare trigger and aggravates erythema/telangiectasia); foundational for every phenotype.
trigger_avoidance_and_gentle_non_soap_skincare
first line
trigger_mitigation
Global ROSCO 2019 (PMID 31392722) — identify/avoid personal triggers (heat, sun, alcohol, spicy food, hot drinks, emotional stress, exercise), use gentle non-soap cleanser + bland emollient, avoid irritants/astringents.
stop_facial_topical_corticosteroid
contraindication substitute
deprescribing_rule
triggers: chronic_facial_topical_steroid_use, steroid_induced_rosacea
Chronic facial topical corticosteroid causes and perpetuates steroid-induced rosacea/perioral dermatitis — STOP the steroid, anticipate and counsel a withdrawal flare, bridge with non-steroid topical (ivermectin/azelaic) ± oral doxycycline; topical steroid is NOT a rosacea treatment.

outpatient playbook — drug actions (5)

1. photoprotection + trigger avoidance + gentle non-soap skincare; STOP facial topical steroid
SPF≥30 daily • topical • daily, lifelong
trigger: All phenotypes, all severities (global ROSCO 2019 PMID 31392722)
Foundational; topical corticosteroid is causal and recommended against
2. brimonidine 0.33% gel or oxymetazoline 1% cream (persistent erythema/flushing) ± laser/IPL for fixed telangiectasia
rxcui 134615
0.33% gel / 1% cream • topical • once daily
trigger: Persistent erythema / flushing dominant (van Zuuren GRADE PMID 30585305)
α-agonist vasoconstriction; counsel brimonidine rebound; laser/IPL definitive for fixed vessels
3. topical ivermectin 1% (first-line) / azelaic acid 15% / metronidazole 0.75% / minocycline 1.5% foam (papulopustular)
rxcui 6069
ivermectin 1% once daily • topical • once–twice daily
trigger: Inflammatory papules/pustules without comedones (PMID 24595578 / 25919144)
Ivermectin HIGH-certainty + superior to metronidazole; azelaic acid pregnancy-favourable
4. oral doxycycline 40 mg modified-release (anti-inflammatory) for moderate–severe / ocular; azithromycin if pregnant
rxcui 3640
40 mg MR once daily • PO • once daily
trigger: Moderate–severe papulopustular / ocular rosacea inadequate on topicals (PMID 30585305 / 25919144)
40 mg MR as effective as 100 mg with fewer adverse effects; minimises resistance pressure
5. low-dose oral isotretinoin (refractory / inflammatory phyma); corticosteroid bridge if fulminans; surgical/laser for established phyma
rxcui 6064
low-dose 0.25–0.3 mg/kg/day • PO • once daily
trigger: Refractory papulopustular / early phyma / fulminans (PMID 30585305 / 25919144 / 34391325)
Low-dose isotretinoin slightly more effective than doxycycline; absolute pregnancy contraindication

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Persistent centrofacial (cheeks/nose/chin/forehead) erythema with periodic intensification — a ROSCO-diagnostic phenotype for rosacea (Tan et al, global ROSCO 2017; PMID 27718519); Phymatous skin change (patulous follicles, skin thickening, fibrosis — most often rhinophyma) — independently ROSCO-diagnostic for rosacea (global ROSCO 2017; PMID 27718519); Recurrent facial flushing, inflammatory papules/pustules WITHOUT comedones, and/or telangiectasia — major rosacea features triggering phenotype-led workup (global ROSCO 2019; PMID 31392722).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Rosacea (dermatology lens)** (derm.rosacea.core.v1).
Phenotype framing: 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).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Rosacea — feature-targeted phenotype ladder (global ROSCO 2017/2019; van Zuuren GRADE/Cochrane)** — step "Step 1 — Foundation (every patient, every feature, lifelong): photoprotection + trigger avoidance + gentle skincare".
1. broad_spectrum_photoprotection (trigger_mitigation, first line) — Global ROSCO 2019 (PMID 31392722) — daily broad-spectrum SPF≥30 (UV is a dominant flare trigger and aggravates erythema/telangiectasia); foundational for every phenotype.
2. trigger_avoidance_and_gentle_non_soap_skincare (trigger_mitigation, first line) — Global ROSCO 2019 (PMID 31392722) — identify/avoid personal triggers (heat, sun, alcohol, spicy food, hot drinks, emotional stress, exercise), use gentle non-soap cleanser + bland emollient, avoid irritants/astringents.
3. stop_facial_topical_corticosteroid (deprescribing_rule, contraindication substitute) — Chronic facial topical corticosteroid causes and perpetuates steroid-induced rosacea/perioral dermatitis — STOP the steroid, anticipate and counsel a withdrawal flare, bridge with non-steroid topical (ivermectin/azelaic) ± oral doxycycline; topical steroid is NOT a rosacea treatment.

Setting playbook (outpatient) — Diagnose rosacea by the ROSCO phenotype scheme (persistent centrofacial erythema OR phyma diagnostic), inventory features + triggers + psychosocial burden, exclude the acneiform / connective-tissue / flushing-syndrome / steroid-induced mimics, and deliver feature-targeted therapy toward complete clearance gated on pregnancy/renal status (global ROSCO 2017 PMID 27718519 + 2019 PMID 31392722; van Zuuren GRADE PMID 30585305)
4. photoprotection + trigger avoidance + gentle non-soap skincare; STOP facial topical steroid SPF≥30 daily topical daily, lifelong — All phenotypes, all severities (global ROSCO 2019 PMID 31392722) (Foundational; topical corticosteroid is causal and recommended against)
5. brimonidine 0.33% gel or oxymetazoline 1% cream (persistent erythema/flushing) ± laser/IPL for fixed telangiectasia 0.33% gel / 1% cream topical once daily — Persistent erythema / flushing dominant (van Zuuren GRADE PMID 30585305) (α-agonist vasoconstriction; counsel brimonidine rebound; laser/IPL definitive for fixed vessels)
6. topical ivermectin 1% (first-line) / azelaic acid 15% / metronidazole 0.75% / minocycline 1.5% foam (papulopustular) ivermectin 1% once daily topical once–twice daily — Inflammatory papules/pustules without comedones (PMID 24595578 / 25919144) (Ivermectin HIGH-certainty + superior to metronidazole; azelaic acid pregnancy-favourable)
7. oral doxycycline 40 mg modified-release (anti-inflammatory) for moderate–severe / ocular; azithromycin if pregnant 40 mg MR once daily PO once daily — Moderate–severe papulopustular / ocular rosacea inadequate on topicals (PMID 30585305 / 25919144) (40 mg MR as effective as 100 mg with fewer adverse effects; minimises resistance pressure)
8. low-dose oral isotretinoin (refractory / inflammatory phyma); corticosteroid bridge if fulminans; surgical/laser for established phyma low-dose 0.25–0.3 mg/kg/day PO once daily — Refractory papulopustular / early phyma / fulminans (PMID 30585305 / 25919144 / 34391325) (Low-dose isotretinoin slightly more effective than doxycycline; absolute pregnancy contraindication)

Non-pharmacologic actions:
- Trigger diary + lifelong broad-spectrum photoprotection + gentle non-soap skincare education (global ROSCO 2019 PMID 31392722)
- STOP and counsel against facial topical corticosteroid; anticipate a withdrawal flare and bridge with a non-steroid topical
- Vascular laser / IPL referral for fixed telangiectasia and background erythema (van Zuuren GRADE PMID 30585305)
- Lid hygiene + warm compress + artificial tears for ocular rosacea; ophthalmology referral if keratitis/vision threat (global ROSCO 2019 PMID 31392722)
- Surgical/laser-ablation referral for established fibrotic phyma once inflammation controlled (global ROSCO 2019 PMID 31392722)

AVOID / contraindication checks:
- Topical corticosteroid recommended AGAINST causes and perpetuates steroid rosacea (stop facial topical steroid, anticipate withdrawal flare, bridge with non steroid topical ± oral doxycycline)
- Isotretinoin absolute pregnancy contraindication (rosacea in pregnancy review PMID 34391325 — teratogen; pregnancy prevention programme + monthly pregnancy testing in patients who can become pregnant)
- Tetracyclines contraindicated in pregnancy and age under 8y (rosacea in pregnancy review PMID 34391325 — dental staining / skeletal effects; use oral azithromycin instead)
- Brimonidine paradoxical rebound and worsening erythema counsel (Layton JEADV 2015 PMID 26416154; oxymetazoline showed no clinically relevant rebound, REVEAL PMID 30500142 / 29409914)
- Doxycycline photosensitivity and gi upset counsel (van Zuuren Cochrane PMID 25919144)
- Rosacea fulminans pyoderma faciale needs corticosteroid bridge then low dose isotretinoin not antibiotic first (PMID 34391325)
- Ocular rosacea with keratitis or vision threat is an ophthalmic emergency urgent referral (global ROSCO 2019 PMID 31392722)
- Carvedilol off label flushing monitor bp hr and bronchospasm (global ROSCO 2019 PMID 31392722)

Monitoring

Regimen monitoring:
- per feature response reassessed at 8-12wk (erythema/CEA for α-agonist; inflammatory-lesion count/IGA for ivermectin/azelaic/metronidazole/doxycycline; phyma progression; ocular surface) (global ROSCO 2019 PMID 31392722 — target complete clearance)
- brimonidine: counsel + monitor paradoxical rebound/worsening erythema and titrate; oxymetazoline no clinically relevant rebound (PMID 26416154 / 30500142 / 29409914)
- isotretinoin (even low-dose): pregnancy test + lipids/LFT + mood per the pregnancy-prevention programme (van Zuuren GRADE PMID 30585305; rosacea-in-pregnancy PMID 34391325)
- oral doxycycline: photosensitivity/GI counselling; prefer 40 mg modified-release (fewer adverse effects vs 100 mg, RR 0.25; PMID 25919144); cap antibiotic exposure
- ocular rosacea: review ocular surface; ESCALATE to ophthalmology if keratitis / photophobia / blurred vision / corneal involvement (global ROSCO 2019 PMID 31392722)
- reassess diagnosis if no response (topical-steroid trap / flushing syndrome / connective-tissue / Demodex folliculitis) (global ROSCO 2019 PMID 31392722)

Setting (outpatient) monitoring:
- Reassess per-feature response at 8–12 wk toward the complete-clearance target (global ROSCO 2019 PMID 31392722)
- Drug-class safety: brimonidine rebound counselling; isotretinoin pregnancy/lipid/LFT/mood; doxycycline photosensitivity (PMID 30585305 / 34391325)
- Ocular surface review with ophthalmology-referral threshold for keratitis (global ROSCO 2019 PMID 31392722)

Follow-up plan: 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.
- Close-out criterion: photoprotection/trigger + maintenance topical + brimonidine counselling + ocular + psychosocial surveillance documented

Monitoring phase: 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.

Disposition

Current setting: outpatient — Diagnose rosacea by the ROSCO phenotype scheme (persistent centrofacial erythema OR phyma diagnostic), inventory features + triggers + psychosocial burden, exclude the acneiform / connective-tissue / flushing-syndrome / steroid-induced mimics, and deliver feature-targeted therapy toward complete clearance gated on pregnancy/renal status (global ROSCO 2017 PMID 27718519 + 2019 PMID 31392722; van Zuuren GRADE PMID 30585305)

Disposition criteria:
- Continue feature-targeted ladder + maintenance topical + photoprotection + derm follow-up if responding toward complete clearance (global ROSCO 2019 PMID 31392722)
- Step up the ladder if an adequate trial fails after adherence/trigger/photoprotection optimisation
- Route OUT by engine_id if a mimic (acne / contact-photo dermatitis / SLE) or a flushing syndrome is the diagnosis; ophthalmology/surgical referral for ocular-threat/established phyma

Escalation triggers (move to higher acuity):
- Ocular rosacea with keratitis / photophobia / blurred vision / corneal involvement → URGENT ophthalmology (sight-threatening)
- Rosacea fulminans / pyoderma faciale (abrupt confluent nodules/sinuses ± systemic upset) → corticosteroid bridge then low-dose isotretinoin, urgent dermatology (PMID 34391325)
- Rapidly progressive phyma → early isotretinoin + surgical/laser referral; flushing red-flags → carcinoid/mastocytosis/phaeochromocytoma screen

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Ocular rosacea with corneal involvement / keratitis — eye pain, photophobia, blurred vision, corneal infiltrate or neovascularisation
- [SEVERE] Abrupt onset of confluent inflammatory nodules, draining sinuses and coalescing pustules on the central face ± systemic upset (rosacea fulminans / pyoderma faciale)
- [MODERATE] Rapidly progressive phymatous change (skin thickening, patulous follicles, fibrosis — usually rhinophyma) with an active inflammatory component

Citations

- Global ROSacea COnsensus (ROSCO) phenotype consensus — Tan et al, Br J Dermatol 2017;176(2):431-438 (PMID 27718519, DOI 10.1111/bjd.15122: persistent centrofacial erythema OR phymatous change independently diagnostic; transition to phenotype-led diagnosis/classification) updated by Schaller et al global ROSCO 2019, Br J Dermatol 2020;182(5):1269-1276 (PMID 31392722, DOI 10.1111/bjd.18420: phenotype management algorithm, complete-clearance target, combination therapy, burden dialogue). Evidence base: van Zuuren phenotype systematic review + GRADE, Br J Dermatol 2019;181(1):65-79 (PMID 30585305, DOI 10.1111/bjd.17590) + Cochrane "Interventions for rosacea" (PMID 25919144, DOI 10.1002/14651858.CD003262.pub5). Supporting pivotal trials: ivermectin phase 3 (Stein JDD 2014 PMID 24595578), ivermectin vs metronidazole ATTRACT subanalysis (Schaller Dermatol Ther 2016 PMID 27432169) + ivermectin systematic review/NNT (Ebbelaar Dermatol Ther 2018 PMID 29943217), brimonidine RCT (Layton JEADV 2015 PMID 26416154), oxymetazoline pooled phase 3 REVEAL (Stein-Gold JDD 2018 PMID 30500142) + 52-wk REVEAL (Draelos JAAD 2018 PMID 29409914), minocycline 1.5% foam phase 3/OLE (Stein Gold JCAD 2020 PMID 33282103), rosacea-in-pregnancy/fulminans review (Gomolin Dermatol Online J 2021 PMID 34391325) [PMID:27718519](https://pubmed.ncbi.nlm.nih.gov/27718519/)
- Cited evidence (PMID 31392722) [PMID:31392722](https://pubmed.ncbi.nlm.nih.gov/31392722/)
- Cited evidence (PMID 30585305) [PMID:30585305](https://pubmed.ncbi.nlm.nih.gov/30585305/)
- Cited evidence (PMID 25919144) [PMID:25919144](https://pubmed.ncbi.nlm.nih.gov/25919144/)
- Cited evidence (PMID 24595578) [PMID:24595578](https://pubmed.ncbi.nlm.nih.gov/24595578/)

Last reconciled with current guidelines: 2026-05-22.

References

Global ROSacea COnsensus (ROSCO) phenotype consensus — Tan et al, Br J Dermatol 2017;176(2):431-438 (PMID 27718519, DOI 10.1111/bjd.15122: persistent centrofacial erythema OR phymatous change independently diagnostic; transition to phenotype-led diagnosis/classification) updated by Schaller et al global ROSCO 2019, Br J Dermatol 2020;182(5):1269-1276 (PMID 31392722, DOI 10.1111/bjd.18420: phenotype management algorithm, complete-clearance target, combination therapy, burden dialogue). Evidence base: van Zuuren phenotype systematic review + GRADE, Br J Dermatol 2019;181(1):65-79 (PMID 30585305, DOI 10.1111/bjd.17590) + Cochrane "Interventions for rosacea" (PMID 25919144, DOI 10.1002/14651858.CD003262.pub5). Supporting pivotal trials: ivermectin phase 3 (Stein JDD 2014 PMID 24595578), ivermectin vs metronidazole ATTRACT subanalysis (Schaller Dermatol Ther 2016 PMID 27432169) + ivermectin systematic review/NNT (Ebbelaar Dermatol Ther 2018 PMID 29943217), brimonidine RCT (Layton JEADV 2015 PMID 26416154), oxymetazoline pooled phase 3 REVEAL (Stein-Gold JDD 2018 PMID 30500142) + 52-wk REVEAL (Draelos JAAD 2018 PMID 29409914), minocycline 1.5% foam phase 3/OLE (Stein Gold JCAD 2020 PMID 33282103), rosacea-in-pregnancy/fulminans review (Gomolin Dermatol Online J 2021 PMID 34391325) — PMID:27718519
Cited evidence (PMID 31392722) — PMID:31392722
Cited evidence (PMID 30585305) — PMID:30585305
Cited evidence (PMID 25919144) — PMID:25919144
Cited evidence (PMID 24595578) — PMID:24595578