• There are no specific lab tests to confirm diagnosis; hence, the diagnosis is based on clinical characteristics

Phenotype Classification

• Based on phenotypes which are observable features that result from genetic and/or environmental influences
  • Classification based on phenotype as recommended by the Global Rosacea Consensus (ROSCO) provides a necessary means of assessing and managing rosacea which is consistent with each individual patient's presentation

• Presence of ≥1 diagnostic or ≥2 major phenotypes are required for the diagnosis of rosacea

Diagnostic Phenotypes

• Persistent centrofacial erythema associated with periodic intensification by potential trigger factors
  • Most common sign of rosacea
  • Personal history, drug history and complete physical examination will help exclude other diagnoses such as lupus erythematosus, seborrheic eczema or steroid-induced rosacea

• Phymatous changes
  • Most common form is rhinophyma
  • Include glandular hyperplasia, patulous follicles, skin thickening or fibrosis, and bulbous appearance of nose

Major Phenotypes

• Flushing or transient centrofacial erythema
  • Trigger/exacebating factors cause neurovascular stimulation resulting to flushing which occurs within seconds to minutes

• Papules and pustules
  • Red, dome-shaped papules with or without accompanying pustules, often occurring in crops and primarily located in the centrofacial area

• Telangiectasia
  • Cutaneous blood vessels which are enlarged and visible

• Ocular manifestations:
  • Interpalpebral conjunctival injection
  • Lid margin telangiectasia
  • Scleritis and sclerokeratitis
  • Spade-shaped infiltrates in cornea

Secondary or Minor Phenotypes

• Burning or stinging sensation of the skin
  • Typically occurs on erythematous skin without scales

• Dry appearance of the skin
  • Central facial skin resemble dry skin appearing rough and scaly

• Edema
  • May occur during or after prolonged erythema or flushing due to capillary extravasation during inflammation and may persist for days

• Ocular manifestations
  • Evaporative tear dysfunction
  • Irregularity of the lid margin architecture
  • "Honey crust" and cylindrical collarette accumulation at the base of lashes

Subtype Classification

• Former standard classification of rosacea grouping the most common presentations into:
  • Erythematotelangiectatic rosacea
  • Inflammatory papulopustular rosacea
  • Phymatous rosacea
  • Ocular rosacea

• Does not fully cover patient's clinical presentation confounding the assessment of degree of severity

Variant

Granulomatous

• Noninflammatory
• Hard, brown, yellow or red cutaneous papules or nodules of similar size
• May be severe and eventually lead to scarring

• No firmly established severity grading scale
• Severity of each feature/phenotype must be rated independently
  • Physicians give their assessment based on severity of signs and symptoms; duration and extent of disease at the time of examination may also be considered in the evaluation
  • Patient participates in the grading by giving the assessment of his/her condition considering the physical manifestations and its impact on quality of life (psychological, occupational and social effects)

• Scales used to assess the severity of rosacea phenotypes are:
  • Flushing: Flushing Assessment Tool (FAST) and Global Flushing Severity Score (GFSS)
  • Persistent erythema: Clinician's Erythema Assessment (CEA) and Patient's Self-Assessment (PSA)
  • Papules and pustules: Lesion counts and Investigator's Global Assessment (IGA)

• Suggested severity scale for papulopustular lesions and facial erythema with or without symptoms
  • Mild: <10 papules/pustules with mild erythema
  • Moderate: 10-19 papules/pustules with moderate erythema
  • Severe: ≥20 papules/pustules with severe erythema

• Severity scale for ocular manifestations
  • Mild: Mild blepharitis with lid margin telangiectasia
  • Mild-moderate: Blepharoconjunctivitis
  • Moderate-severe: Blepharokeratoconjunctivitis
  • Severe: Sclerokeratitis, anterior uveitis