Rosacea Uncovered: Current Practices and Therapies on the Horizon

Each April, Rosacea Awareness Month offers a moment to revisit a condition that is both common and surprisingly complex. Although rosacea is a familiar diagnosis in dermatology clinics, our understanding of the disease continues to evolve. Ongoing research is shedding new light on its underlying mechanisms while also expanding the range of treatment options available to patients.¹

Pathophysiology

Rosacea is a chronic inflammatory skin disorder with a complex and multifactorial etiology. Although the precise mechanisms remain incompletely understood, several key contributors have been identified, including the following:

• Genetic predisposition
• Immune dysregulation
• Neurovascular dysfunction
• Skin barrier impairment
• Environmental influences²

Increasing evidence supports the interplay between innate immune activation, inflammatory cytokine release, and abnormal angiogenesis in driving persistent erythema and vascular reactivity.³

Clinical Subtypes

Rosacea is traditionally classified into 4 subtypes, listed below⁴:

• Papulopustular rosacea: Characterized by centrofacial inflammatory papules and pustules
• Erythematotelangiectatic rosacea: Presents with persistent midfacial erythema, telangiectasias, and episodic flushing
• Phymatous rosacea: Marked by tissue hypertrophy and sebaceous gland hyperplasia, more commonly affecting men
• Ocular rosacea: Features lid margin telangiectasias, conjunctivitis, and keratitis, with symptoms of burning, stinging, dryness, and foreign body sensation

Overlap between subtypes is common, requiring individualized therapeutic strategies.⁵

Exacerbating Factors

Rosacea is highly sensitive to environmental and lifestyle triggers. Common exacerbating factors include the following⁶:

• UV exposure
• Heat, cold, and wind
• Emotional stress
• Physical exertion
• Alcohol (particularly red wine), hot beverages, and spicy foods
• Skin care products containing alcohol or fragrance
• Topical corticosteroids and vasodilatory medications
• Hormonal fluctuations, including menopause

Identifying and mitigating triggers remains foundational to long-term disease control.⁷

Management Principles

Effective rosacea management begins with restoration and maintenance of the skin barrier, as follows⁸:

• Gentle cleansers that preserve physiologic skin pH
• Daily moisturization to reduce transepidermal water loss
• Mineral-based sunscreen (SPF ≥ 30) to minimize UV-induced inflammation

Barrier dysfunction contributes significantly to disease activity, making foundational skin care essential.⁹

Current Therapeutic Options

Topical Therapies

Several FDA-approved topical agents are available for rosacea management, including the following⁶:

• Brimonidine (Mirvaso; Galderma)
• Oxymetazoline (Rhofade; Allergan)
• Ivermectin (Soolantra; Galderma)
• Azelaic acid (Finacea; Bayer)
• Sodium sulfacetamide/sulfur (Avar; Mission Pharmacal)
• Metronidazole (MetroGel; Galderma)
• Encapsulated benzoyl peroxide (Epsolay; Sol-Gel Technologies)
• Topical minocycline (Zilxi; Foamix Pharmaceuticals)

For erythematotelangiectatic rosacea, brimonidine and oxymetazoline provide targeted vasoconstriction to reduce persistent erythema.⁶ For papulopustular rosacea, commonly utilized therapies include metronidazole, ivermectin, azelaic acid, sodium sulfacetamide/sulfur, encapsulated benzoyl peroxide, and minocycline. Notably, ivermectin and sulfur-based therapies demonstrate efficacy against Demodex mites, which are implicated in inflammatory lesion development.¹

Oral Therapies

Systemic treatment options include the following⁹:

• Tetracyclines (doxycycline, minocycline)
• Modified-release doxycycline (Oracea; Galderma)
• Modified-release minocycline (Emrosi; Journey Medical Corporation)
• Low-dose isotretinoin (Accutane; Roche)
• Off-label β-blockers (propranolol [Inderal; Ayerst Laboratories], carvedilol [Coreg; GSK])

Tetracyclines remain a mainstay due to their anti-inflammatory properties. Low-dose isotretinoin may be considered for refractory disease but requires careful monitoring due to teratogenicity and iPLEDGE requirements. β-blockers are sometimes used off-label to reduce flushing and persistent erythema.^1,6

Procedural Interventions

Laser and light-based therapies play an important role in managing vascular manifestations:

• Pulsed dye laser
• Nd:YAG laser¹⁰

For phymatous rosacea, treatment options include the following:

• Carbon dioxide ablative laser
• Electrosurgery¹¹

These modalities effectively reduce telangiectasias, erythema, and tissue hypertrophy.

Emerging Therapies

Despite advances, unmet therapeutic needs remain—particularly for persistent erythema and refractory inflammatory disease. Emerging pipeline therapies include the following:

IL-17 Inhibitors

Elevated proinflammatory cytokines and angiogenic signaling have been identified in rosacea skin. Targeted biologics such as secukinumab (Cosentyx; Novartis) may offer precision modulation of IL-17–mediated inflammation.^1,3

Janus Kinase (JAK) Inhibitors

JAK-STAT pathway activation, particularly involving JAK2 and STAT3, has been implicated in rosacea-associated cytokine production. Early clinical data demonstrate promising reductions in facial erythema. In one study, oral tofacitinib (Xeljanz; Pfizer) resulted in a 71.4% decrease in facial erythema among treated patients.

Although still investigational, these targeted therapies may represent the next evolution in rosacea management.^3,9

Conclusion

Rosacea is a complex, multifactorial inflammatory disorder that requires a comprehensive, individualized approach to care. Successful management integrates trigger avoidance, barrier restoration, pharmacologic therapy, and procedural interventions when appropriate.⁶

As our understanding of immunologic and vascular pathways continues to evolve, emerging biologic and JAK-based therapies hold promise for more targeted and durable disease control.^1,3

Jill Cowan, APRN, FNP-BC, is a board-certified nurse practitioner specializing in dermatology in Cincinnati, Ohio. She is passionate about delivering patient-centered, evidence-based dermatologic care and is actively engaged in professional speaking and writing.

References

1. Fisher GW, Travers JB, Rohan CA. Rosacea pathogenesis and therapeutics: current treatments and a look at future targets. Front Med (Lausanne). 2023;10:1292722. doi:10.3389/fmed.2023.1292722

2. Wang H, Zhou C. Advances in the pathogenesis of rosacea. Front Immunol. 2026;16:1705588. doi:10.3389/fimmu.2025.1705588

3. Yang F, Wang L, Song D, et al. Signaling pathways and targeted therapy for rosacea. Front Immunol. 2024;15:1367994. doi:10.3389/fimmu.2024.1367994

4. Mohamed-Noriega K, Loya-Garcia D, Vera-Duarte GR, et al. Ocular rosacea: an updated review. Cornea. 2025;44(4):525-537. doi:10.1097/ICO.0000000000003785

5. Frazier W, Zemtsov RK, Ge Y. Rosacea: common questions and answers. Am Fam Physician. 2024;109(6):533-542.

6. Nguyen C, Kuceki G, Birdsall M, Sahni DR, Sahni VN, Hull CM. Rosacea: practical guidance and challenges for clinical management. Clin Cosmet Investig Dermatol. 2024;17:175-190. doi:10.2147/CCID.S391705

7. Factors that may trigger rosacea flare-ups. National Rosacea Society. Accessed March 10, 2026. https://www.rosacea.org/patients/rosacea-triggers/factors-that-may-trigger-rosacea-flare-ups

8. Addor FA. Skin barrier in rosacea. An Bras Dermatol. 2016;91(1):59-63. doi:10.1590/abd1806-4841.20163541

9. Oge' LK, Muncie HL, Phillips-Savoy AR. Rosacea: diagnosis and treatment. Am Fam Physician. 2015;92(3):187-196.

10. Husein-ElAhmed H, Steinhoff M. Light-based therapies in the management of rosacea: a systematic review with meta-analysis. Int J Dermatol. 2022;61(2):216-225. doi:10.1111/ijd.15680

11. Li Y, Wang R. Efficacy comparison of pulsed dye laser vs microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser in the treatment of rosacea: a meta-analysis. Front Med (Lausanne). 2022;8:798294. doi:10.3389/fmed.2021.798294