At the 2025 ODAC Dermatology Conference, renowned dermatologist and conference co-chair Adam Friedman, MD, delivered an insightful lecture, How I Treat Rosacea in 2025. He explored the latest advancements in managing one of dermatology’s most prevalent conditions, highlighting key triggers, associated comorbidities, and evolving treatment strategies. With global rosacea prevalence reported as high as 10%, his presentation underscored the importance of a tailored, evidence-based approach to care.
Triggers
Triggers of rosacea include exposure to sunlight, stress, extreme temperatures, strong winds, strenuous exercise, alcohol, hot baths, and certain dietary factors. For example, heat induces vasodilation by activating transient receptor potential vanilloid 1 (TRPV1), an ion channel located in keratinocytes, neurons, endothelial cells, and immune cells. Histamine-containing or histamine-releasing foods, such as certain fruits (e.g., avocado, bananas, papaya, and pineapple), dried fruits (e.g., apricots, dates, raisins, and figs), vegetables (e.g., tomatoes, spinach, and eggplant), nuts (e.g., cashews, walnuts, and peanuts), chocolate, cow’s milk, fermented foods, and smoked fish, can also exacerbate rosacea. Notably, histamine receptors H2R and H3R are upregulated in the skin of patients with rosacea. Ongoing research is exploring new triggers, including the role of the gut microbiome.
Co-Morbidities
Rosacea is associated with inflammatory, vascular, and neurological co-morbidities. The 2017 update by the National Rosacea Society Expert Committee identified over 15 potential co-morbidities. Recent studies highlight a strong association between rosacea and obesity, in contrast to obesity’s relationship with other inflammatory skin conditions. Dermatologists may consider screening patients with rosacea for co-morbidities and educating them about potential risks, though these practices require further research.
Diagnostic and Treatment Approaches
The global ROSacea COnsensus (ROSCO) panel emphasizes phenotype- and feature-based approaches to diagnosis and treatment rather than traditional subtypes. Diagnostic criteria include fixed centrofacial erythema in a characteristic pattern that may periodically intensify, along with phymatous changes. Major criteria comprise flushing, papules and pustules, telangiectasia, and ocular manifestations. Secondary criteria include burning or stinging sensations, edema, dryness, and additional ocular symptoms. Tailoring treatment based on these phenotypic criteria can optimize outcomes.
General Treatment Strategy
Rosacea treatment is built on three pillars: general skin care, physical modalities, and pharmaceutical agents. For instance, a patient with moderate-to-severe rosacea might follow this regimen:
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- Morning: Wash the face with water, apply oxymetazoline 1% cream, and use a broad-spectrum facial moisturizer with SPF 30+ (preferably with micronized inorganic filters).
- Evening: Doxycycline 40 mg ER (of note, doxycycline 20 mg twice daily is often more accessible but must be doses twice daily as 20 mg x 2 once daily does not equal 40 mg ER) with dinner (also beneficial for ocular symptoms), use a mild facial cleanser formulated for rosacea-prone skin, and apply ivermectin 1% cream.
In severe or refractory cases, low-dose isotretinoin (0.25 mg/kg/day) may be effective, though recurrence is common following cessation. Newer treatments include microencapsulated 5% benzoyl peroxide, minocycline 1.5% foam, oral minocycline 45 mg, and paroxetine 25 mg.
Special Phenotypes
Ocular Rosacea
Ocular rosacea presents with features such as blepharitis, blurred vision, foreign body sensation, interpalpebral bulbar hyperemia, photophobia, redness, tearing, and telangiectasia. Current recommendations include artificial tears for mild symptoms, UV-coated sunglasses, and proper lid hygiene. Additional treatment options include topical ivermectin 1% cream, omega-3 fatty acids (as supplements or through dietary sources), and azithromycin 500 mg three times a week (of note, antimicrobial resistance rates at this dosing are low).
Neurologic Rosacea
Treatment of neurologic rosacea depends on the type of flushing:
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- Wet flushing: Cooling with ice chips in the mouth and beta blockers (propranolol 5-10 mg daily).
- Dry flushing: Low-dose clonidine (0.05 mg twice daily starting dose; can increase to 0.15 mg twice daily), amitriptyline 10 mg daily for dysesthesia, and prophylactic antihistamines may be considered.
Conclusion
Rosacea is a common dermatologic condition with a variety of treatment approaches tailored to its phenotypic presentation. Combination regimens offer a personalized approach, and creative problem-solving is crucial in managing challenging or refractory cases. Continuous research into new triggers, co-morbidities, and treatment modalities will further enhance patient outcomes.
This information was presented by Dr. Adam Friedman at the 2025 Annual ODAC Dermatology, Aesthetic and Surgical Conference held January 17–20, 2025 in Orlando, FL. The above highlights from his lecture were written and compiled by Samip Sheth, MD, a PGY-2 resident in the medical dermatology combined program at the University of Minnesota. Dr. Sheth was one of the five residents selected to participate in the Young Dermatology Leader Mentorship Program sponsored by Sun Pharma and organized by Derm In-Review.
