Find out what an international expert has to say about the common skin condition.
A presentation at the Australasian Society for Cosmetic and Procedural Dermatologists Symposium discussed the classification, pathological mechanisms and new treatment options for the condition.
Professor Firas Al-Niaimi, a UK-based dermatologist, gave attendees at last month’s ASCPD symposium an update on his experience in treating patients with rosacea.
“The classifications keep changing depending on which paper you read… but the most recent classifications – and this is the globally accepted classification – is that we go by the clinical phenotype,” he told delegates, before outlining the four main phenotypes.
Erythematotelangiectatic (vascular) rosacea may frequently overlap with papulopustular (inflammatory) rosacea, but ocular rosacea is very much its own entity.
“The thing about ocular rosacea is [that] it can sometimes precede the skin manifestation, so the ophthalmologist might be the first one diagnosing ocular rosacea,” Professor Al-Niaimi said.
“There might not necessarily be any clinical phenotype of rosacea, but a few years afterwards the patient might develop the flushing [and] the papulopustular components.”
The fourth phenotype, phymatous rosacea, was not mentioned further. However, this condition typically affects the nose, forehead and chin and is more common in older White men.
The underlying pathogenesis of rosacea involves neurovascular dysregulation and adaptive immune balance. Toll-like receptor 2 activity is increased, and kallikrein-5 also plays a major role.
“One of the other things that we also know is that there is a specific type of receptors called the transient potential receptors (TRPs), and they are increased in number and activity in patients with rosacea,” said Professor Al-Niaimi.
TRPV1 receptors, one of the discoveries highlighted in the 2019 Nobel Prize for Medicine, are involved in the transmission and modulation of pain and are triggered at a temperature around 43 degrees.
“So, this is why when a patient says, ‘if I go to the sauna my face starts burning and tingling’, it’s not because of the ultraviolet light, but it’s the heat that stated stimulating these TRPV1 receptors, which is why they get the burning sensation,” Professor Al-Niaimi continued.
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Rosacea can be managed with either topical (metronidazole, azelaic acid or ivermectin) or oral (low dose tetracyclines, isotretinoin or metronidazole) therapies, all of which work by modulating TLR-2 activity in one way or another.
Professor Al-Niaimi went on to share some of the other new treatment approaches he uses in his practice, starting with topical minocycline, which has shown to be effective and well-tolerated over a 12-week period in patients with moderate to severe papulopustular rosacea.
“[And] for the last two years I’ve been using a topical beta-blocker, timolol. Initially I used it as topical drops, as an off-label use for [an existing] glaucoma [medication], but now many pharmacies can compound a gel formulation for it,” Professor Al-Niaimi said.
“Here’s one tip, because it’s a water-rich gel, ask the patient to put it in the fridge so that when they apply it to their skin, they get the vasoconstriction and cooling effects as well as the anti-flushing effect.”
Topical tranexamic acid appears to work on everything, according to Professor Al-Niaimi, but there is a growing body of evidence suggesting that these beneficial effects extend to rosacea.
“And it kind of makes sense, because we’re targeting the vascular endothelial growth factor and the vascular components,” said Professor Al-Niaimi.
“It works particularly well in steroid-induced rosacea.”
Pimecrolimus was also recommended for use in patients with sensitive skin.
In terms of systemic treatment, omega-3 has been found to be very helpful in patients with ocular rosacea, particularly for patients who experience dry eyes because of isotretinoin treatment. Oral metronidazole and ivermectin can also be used as a last resort if other treatment approaches have failed.
Hydroxychloroquine is not a new drug but has been repurposed as a treatment for rosacea patients who have refractory flushing erythema and have not responded to oral beta blockers or isotretinoin.
Professor Al-Niaimi highlighted that there were currently several trials examining the effects of biologics in patients with rosacea, including interleukin-17 blockers, as well as vagus nerve stimulation.
“This is something that is gathering momentum, and you can see why that would work. There are effects on the blood vessels, but also on the acetylcholine [receptors]… which is one of the triggers for the neurogenic subtype of rosacea,” he said.
The 2026 ASCPD Symposium was held in Melbourne from 20 to 22 March.
