Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the National Rosacea Society.

Rosacea Treatment Algorithm

National Rosacea Society

Publication Date: Mar 24, 2025

Page Last Updated: May 6, 2026

Flushing

Formerly part of Subtype 1
- Clinical Features
  - Frequent and typically prolonged flushing or blushing is common except in darker skin tones, in which case flushing may be experienced as burning and stinging. In contrast to other erythematous changes, flushing may occur within seconds to minutes in response to neurovascular stimulation by trigger factors.
Grade 1 (mild)
- Typical Features: Occasional mild flushing
- Therapeutic Approach: Cool compress. IPL treatment may diminish flushing.
Grade 2 (moderate)
- Typical Features: Frequent and troublesome flushing accompanied by burning and stinging sensation
- Therapeutic Approach: In addition to approaches in Grade 1: topical therapies such as oxymetazoline, brimonidine or ivermectin, or oral therapies such as carvedilol, clonidine or propranolol may reduce flushing response.
Grade 3 (severe)
- Typical Features: Frequent severe flushing that extends to the neck and chest, accompanied by severe burning and stinging
- Therapeutic Approach: In addition to approaches in Grades 1 and 2: KTP laser treatment may reduce flushing. Flushing may be modulated by drugs specific to individual causes, such as NSAIDs for dry flushing, alpha-agonists or beta-blockers for neurally induced flushing (off-label) and HRT for menopausal flushing. Thermoregulatory flushing can be reduced by cooling the neck and mouth; emotionally induced flushing may benefit from psychological counseling or biofeedback.
Additional Approaches
- In addition to prescription therapies and light devices, gentle skin care may be beneficial to rosacea patients with flushing. Because sun exposure may be a leading influence on the development of flushing and erythema, advise patients to always use sunscreens, preferably mineral inorganic products that contain zinc oxide or titanium dioxide, because they do not produce heat as a byproduct. Skin-care products that contain anti-inflammatory ingredients, such as allantoin, licorice root extract, sulfur or aloe vera may also be helpful.

Ocular Rosacea

Formerly part of Subtype 4 Clinical Features
- Ocular rosacea may appear as a spectrum of disease, from dry eye to blepharitis to meibomian gland dysfunction, all of which may be related to underlying inflammation. Signs and symptoms associated with ocular rosacea include lid margin telangiectasia, interpalpebral conjunctival injection, spade-shaped infiltrates in the cornea, and scleritis and sclerokaratitis. Ocular signs and symptoms that commonly appear with rosacea but are not specific to the disorder include watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, light sensitivity, lid and periocular erythema, meibomian gland dysfunction and blepharitis, “honey crust” and collarette accumulation at the base of eyelashes, styes (chalazion, hordeolum), chronic conjunctivitis, irregularity of the lid margin and evaporative tear dysfunction. Approximately 20% of patients have ocular findings before dermatologic evidence of rosacea, and the diagnosis may not be clear in those who never progress to the cutaneous form of the disorder.
Grade 1 (mild)
- Typical Features: Signs and symptoms affecting the eyelid margin and meibomian glands
- Therapeutic Approach: Apply a warm compress and cleanse eyelashes twice daily with baby shampoo. Artificial tears for patients with dry eye or meibomian gland dysfunction.
Grade 2 (moderate)
- Typical Features: Signs and symptoms affecting the inner eyelid, tear secretion and/or ocular surface
- Therapeutic Approach: In addition to approaches in Grade 1: ophthalmic azithromycin or tacrolimus ointment may be applied to eyelashes; topical cyclosporin drops may also be effective to reduce inflammation. A course of oral cyclosporine for 2-3 months may reduce inflammation; oral antibiotics such as sub-antimicrobial minocycline or doxycycline, azithromycin, or trimethoprim/sulfamethoxazole may also be used. IPL may improve the health of the ocular surface and meibomian gland function. If severity increases, consultation with an ophthalmologist may be needed.
Grade 3 (severe)
- Typical Features: Advanced or nonresponsive disease of the eyelid margin or ocular surface; episcleritis, iritis, or keratitis in addition to corneal damage and potential vision loss
- Therapeutic Approach: In addition to approaches in Grades 1 and 2: care by an ophthalmologist is required and may include a topical steroid, alternative oral medications and potential surgery.

Document Overview

Document Title: Rosacea Treatment Algorithm

Authoring Society: National Rosacea Society

Document Publication Date: Mar 24, 2025

Page Last Reviewed/Updated: May 6, 2026

Document Type: Consensus Statement

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: www.rosacea.org/physicians/rosacea-treatment-algorithms

Document Scope, Criteria, and Use Cases

Document Objectives: Because rosacea’s signs and symptoms can vary so widely, the chronic facial skin disorder was initially classified into four subtypes. However, with the explosion of research in the last 20 years, it has become clear that rosacea’s often fluctuating and seemingly unrelated signs and symptoms are part of a single underlying inflammatory continuum.1 Rosacea is now identified according to its individual characteristics, or phenotypes, which may appear in different combinations and at different times. This new targeted approach encourages consideration of the full range of potential signs and symptoms, better assessment of their severity, and selection of treatment that is more precisely tailored for each individual case.

Scope: Management

Diseases/Conditions (MeSH)

D012393 - Rosacea

Keywords: Rosacea

Target Patient Population: Patients with rosacea

Target Provider Population: Dermatologists and other clinicians caring for patients with rosacea

Inclusion Criteria: Male, Female, Adolescent, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Rosacea Treatment Algorithm

Summary of Recommendations

Diagnostic Phenotypes

Persistent Erythema

Phymatous Changes

Major Phenotypes

Papules and Pustules

Telangiectasia

Flushing

Ocular Rosacea

Treatment Brand Name Index

Document Overview

Document Scope, Criteria, and Use Cases