Rosacea Subtypes

The Rosacea Society Medical Committee has recently developed a "Rosacea Classification System" to help diagnose rosacea subtypes. While there is a trend for rosacea sufferers to proceed through the stages listed above, it is helpful to understand that based on genetics some rosacea sufferers are more susceptible to develop certain symptoms; therefore it was necessary to develop a rosacea classification system. This system helps rosacea sufferers better understand their symptoms and find the proper treatments. Below is a summary of each subtype adapted from the Journal of the American Academy of Dermatology. 2002; 46:584-587.

Erythematotelangiectatic Rosacea:
Erythematotelangiectatic rosacea is mainly characterized by flushing and persistent central facial redness. The appearance of telangiectasia is common but not essential for a diagnosis of this subtype. Central facial edema, stinging and burning sensations, and roughness may also occur. A history of flushing alone is common among patients presenting with erythematotelangiectatic rosacea.

Papulopustular Rosacea
Papulopustular rosacea is characterized by persistent central facial redness with transient papules or pustules. The papulopustular subtype resembles acne vulgaris, except that comedones are absent. Burning and stinging sensations may be reported by patients with papulopustular rosacea.
This subtype is often reported in combination with subtype 1, including the presence of telangiectasia. The telangiectasia may be obscured by persistent redness, papules, or pustules.

Phymatous Rosacea
Phymatous rosacea includes thickening of the nose skin, irregular surface nodularities, and enlargement. Rhinophyma is the most common presentation, but phymatous rosacea may occur in other locations, including the chin, forehead, cheeks, and ears.

Ocular Rosacea
The diagnosis of ocular rosacea should be considered when a patient's eyes have one or more of the following signs and symptoms: watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity, blurred vision, telangiectasia of the conjunctiva and lid margin. Blepharitis, conjunctivitis, and irregularity of the eyelid margins also may occur.

Neuropathic Rosacea
This classification system has proven helpful to many general dermatologists. However, a gaping hole has been left in the system setup. This system has excluded one of the most important rosacea subtypes. It's important that all dermatologists become aware that a new clinical subtype has recently been identified. Though not officially recognized yet, Neuropathic Rosacea is believed to be the most debilitating form of the disorder.
Hallmarks of Neuropathic Rosacea include bouts of centrofacial burning and pain sensations following exposure to triggers. Such bouts usually last longer than 30 minutes. More serious cases can become semi-permanent if dermal inflammation or various inflammatory cytokines damage or permanently activate sensory nociceptors. In severe cases, underlying facial inflammation may trigger these sensory nociceptors in the absence of external triggers. It must be stressed that this subtype can cause physical disability comparable to diabetic neuropathy and other painful peripheral neuropathies.
Rosacea sufferers with Neuropathic Rosacea are best treated by a collaborative effort between dermatologists, neurologists with peripheral nerve treatment training and pain specialists.