Rosacea Unveiled: A YoungMD Connect Open Discussion with Dr. Corey Hartman 

In his YoungMD Connect virtual session on the topic of rosacea, Dr. Corey Hartman shared extensive experience with the eager viewing audience. Topics discussed included treating patients with rosacea, including those with skin of color, as well as clinical pearls on diagnosing and managing this common condition. 

Here are some of the key clinical pearls shared by Dr. Hartman during the session. 

ROSACEA MIMICKERS 

Both acne and rosacea are very common, and location is helpful in differentiating them, as rosacea classically affects central facial areas. Patients with rosacea can also report a “warm sensation throughout the day,” associated triggers (eg, stress, sun, hot food, wind, etc), and eye symptoms as in ocular rosacea. It is important to keep seborrheic dermatitis in mind as it can affect similar areas on the face as rosacea. Periorificial dermatitis can also have overlapping features with rosacea. It is possible that patients may have more than one of these conditions at the same time, too. Sodium sulfacetamide cleanser or leave-on products, with or without sulfur, can be a good option when the diagnosis is unclear. Topical ivermectin is effective for both rosacea and periorificial dermatitis when overlapping features present. 

PRESENTATION IN SKIN OF COLOR (SOC) 

Rosacea in skin of color patients is underrecognized and has unique clinical features. Rosacea can involve less typical areas, such as the lower face. Morphologically, it can have a cobblestone appearance. Topical ivermectin is an effective treatment for cobblestone-like lesions but less so for telangiectasia. Resolving hyperpigmentation can be very bothersome; thus, early diagnosis and treatment are very important. Hyperpigmentation or very subtle darkness over the classic location of rosacea can be another subtle presentation in SOC. 

ON COUNSELING 

It is important to point out to patients that rosacea is a chronic inflammatory condition and is likely to flare. Although it is often not possible to avoid all triggers, it is essential to advise patients to monitor their own triggers. Lifestyle modifications are particularly important in treatment-resistant cases. 

TOPICAL TREATMENT 

Topical ivermectin is the first-line treatment and can effectively put patients into remission. It can sometimes lead to an initial flare. Streaks of redness can be present if it is not used on the entire face. Other topical options include metronidazole, azelaic acid, niacinamide, and sodium sulfacetamide. Although not first-line, sodium sulfacetamide (preferably cream formulation) can be an excellent option for patients with sensitive skin. 

Similarly, azelaic acid foam can be another great option, while gel should be avoided as it contains alcohol, which can lead to more irritation. Compounding different ingredients is a great option, too, but this involves shorter expiry dates. 

SYSTEMIC TREATMENT 

If patients have severe papulopustular disease, systemic treatments should be considered. Patients with early-onset disease often have more severe disease. Doxycycline is commonly prescribed to be taken orally. It should be given for less than 12 weeks along with a topical benzoyl peroxide, which can decrease antimicrobial resistance. A low-dose extended-release formulation of 40 mg is desirable, but be cautious of resultant vaginal candidiasis in female patients. Oral ivermectin can also be considered sometimes. 

SKINCARE AND COSMETIC TREATMENT 

Rosacea patients have sensitive skin, so it is important to be cautious when using retinol or prescription retinoids, as they can irritate the skin. Adapalene can be a more tolerable option if retinoids are indicated. Mineral sunscreen is better tolerated than chemical sunscreen. For chemical peels, compared with salicylic acid, glycolic acid is more favorable as it is more hydrating; always start with a low concentration. Similarly, intense pulsed light can also cause a rosacea flare. HydraFacial causes less friction than other facial aesthetic treatments. Another practical tip is if an acne patient flares with an acne regimen, consider an alternative diagnosis of rosacea. 

LASER AND ENERGY-BASED DEVICES 

Vascular lasers, including KTP and PDL (eg, VBeam), are effective for treating telangiectasia in rosacea. Unlike vascular malformations, we do not aim for bruising as an endpoint, but reminding patients about the small chance of bruising is important. Setting expectations is very important to ensure effective clinical outcomes and patient satisfaction. At least three treatments, 4 to 6 weeks apart, are usually recommended, but some patients may be happy with two treatments. Most patients can expect approximately 50% improvement after each treatment as the vessels are prominent targets with the first treatment. As mentioned earlier, rosacea is a chronic condition and can recur; therefore, patients often need booster treatment every 5 years or sooner, depending on their expectations. Meanwhile, discussing trigger control with patients can help increase the remission interval. CO2 laser treatment and dermabrasion, when lasers are less accessible, can effectively treat rhinophyma. 

It was a great pleasure to have Dr. Hartman join us and share his extensive knowledge and practical clinical pearls. His insights into diagnosing and managing rosacea were both enlightening and valuable. On behalf of all members of YoungMD Connect Dermatology & Aesthetics, we deeply appreciate the time he took to teach us and the expertise he brought to the discussion.