Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

Published:October 28, 2017DOI:
      In 2002, the National Rosacea Society assembled an expert committee to develop the first standard classification of rosacea. This original classification was intended to be updated as scientific knowledge and clinical experience increased. Over the last 15 years, significant new insights into rosacea's pathogenesis and pathophysiology have emerged, and the disorder is now widely addressed in clinical practice. Growing knowledge of rosacea's pathophysiology has established that a consistent multivariate disease process underlies the various clinical manifestations of this disorder, and the clinical significance of each of these elements is increasing as more is understood. This review proposes an updated standard classification of rosacea that is based on phenotypes linked to our increased understanding of disease pathophysiology. This updated classification is intended to provide clearer parameters to conduct investigations, guide diagnosis, and improve treatment.

      Key words

      Abbreviations used:

      NRS (National Rosacea Society), RosaQoL (Rosacea Quality of Life Index)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Berg M.
        • Liden S.
        An epidemiological study of rosacea.
        Acta Derm Venereol. 1989; 69: 419-423
      1. McAleer MA, Fitzpatrick P, Powell FC. The prevalence and pathogenesis of rosacea. Poster presented at: 88th Annual Meeting of the British Association of Dermatologists. July 1-4, 2008; Liverpool, United Kingdom.

        • Abrams K.
        • Silm H.
        • Oona M.
        Prevalence of rosacea in an Estonian working population using a standard classification.
        Acta Derm Venereol. 2010; 90: 269-273
        • Tan J.
        • Schöfer H.
        • Araviiskaia E.
        • et al.
        Prevalence of rosacea in the general population of Germany and Russia—the RISE study.
        J Eur Acad Dermatol Venereol. 2016; 30: 428-434
        • Al-Dabagh A.
        • Davis S.A.
        • McMichael A.J.
        • et al.
        Rosacea in skin of color: not a rare diagnosis.
        Dermatol Online J. 2014 Oct 15; 20 (pii:13030/qtlmv9r0ss)
        • Bae Y.I.
        • Yun S.J.
        • Lee J.B.
        • et al.
        Clinical evaluation of 168 Korean patients with rosacea: the sun exposure correlates with the erythematotelangiectatic subtype.
        Ann Dermatol. 2009; 21: 243-249
        • Khaled A.
        • Hammami H.
        • Zéglaoui F.
        • et al.
        Rosacea: 244 Tunisian cases.
        Tunis Med. 2010; 88: 597-601
        • Dlova N.
        • Mosam A.
        Rosacea in black South Africans with skin phototypes V and VI.
        Clin Exp Dermatol. 2017; 42: 670-673
        • Wilkin J.
        • Dahl M.
        • Detmar M.
        • et al.
        Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.
        J Am Acad Dermatol. 2002; 46: 584-587
        • Del Rosso J.Q.
        • Gallo R.L.
        • Tanghetti E.
        • et al.
        An evaluation of potential correlations between pathophysiologic mechanisms, clinical manifestations, and management of rosacea.
        Cutis. 2013; 91: 1-8
        • Del Rosso J.Q.
        • Thiboutot D.
        • Gallo R.
        • et al.
        Consensus recommendations from the American Acne and Rosacea Society on the management of rosacea, part 1: a status report on the disease state, general measures, and adjunctive skin care.
        Cutis. 2013; 92: 234-240
        • Tan J.
        • Almeida L.
        • Bewley A.
        • et al.
        Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel.
        Br J Dermatol. 2017; 176: 431-438
        • Schwab V.D.
        • Sulk M.
        • Seeliger S.
        • et al.
        Neurovascular and neuroimmune aspects in the pathophysiology of rosacea.
        J Invest Dermatol Symp Proc. 2011; 15: 53-62
        • Seeliger S.
        • Buddenkotte J.
        • Schmidt-Choudhury A.
        • et al.
        Pituitary adenylate cyclase activating polypeptide: an important vascular regulator in human skin in vivo.
        Am J Pathol. 2010; 177: 2563-2575
        • Sulk M.
        • Seeliger S.
        • Aubert J.
        • et al.
        Distribution and expression of non-neuronal transient receptor potential (TRPV) ion channels in rosacea.
        J Invest Dermatol. 2012; 132: 1253-1262
        • Wladis E.J.
        • Iglesias B.V.
        • Adam A.P.
        • et al.
        Molecular biologic assessment of cutaneous specimens of ocular rosacea.
        Ophthal Plast Reconstr Surg. 2012; 28: 246-250
        • Tan J.
        • Blume-Peytavi U.
        • Ortonne J.P.
        • et al.
        An observational cross-sectional survey of rosacea: clinical associations and progression between subtypes.
        Br J Dermatol. 2013; 169: 555-562
        • Holmes A.D.
        • Steinhoff M.
        Integrative concepts of rosacea pathophysiology, clinical presentation and new therapeutics.
        Exp Dermatol. 2017; 26: 659-667
        • Steinhoff M.
        • Buddenkotte J.
        • Aubert J.
        • et al.
        Clinical, cellular, and molecular aspects in the pathophysiology of rosacea.
        J Invest Dermatol Symp Proc. 2011; 15: 2-11
        • Trivedi N.R.
        • Gilliland K.L.
        • Zhao W.
        • et al.
        Gene array expression profiling in acne lesions reveals marked upregulation of genes involved in inflammation and matrix remodeling.
        J Invest Dermatol. 2006; 126: 1071-1079
        • Buhl T.
        • Sulk M.
        • Nowak P.
        • et al.
        Molecular and morphological characterization of inflammatory infiltrate in rosacea reveals activation of Th1/Th17 pathways.
        J Invest Dermatol. 2015; 135: 2198-2208
        • Aubdool A.A.
        • Brain S.D.
        Neurovascular aspects of skin neurogenic inflammation.
        J Invest Dermatol Symp Proc. 2011; 15: 33-39
        • Lonne-Rahm S.-B.
        • Fischer T.
        • Berg M.
        Stinging and rosacea.
        Acta Derm Venereol. 1999; 79: 460-461
        • Steinhoff M.
        • von Mentzer B.
        • Geppetti P.
        • et al.
        Tachykinins and their receptors: contributions to physiological control and the mechanisms of disease.
        Physiol Rev. 2014; 94: 265-301
        • Gao Y.Y.
        • Di Pascuale M.A.
        • Li W.
        • et al.
        High prevalence of Demodex in eyelashes with cylindrical dandruff.
        Invest Ophthalmol Vis Sci. 2005; 46: 3089-3094
        • Muto Y.
        • Wang Z.
        • Vanderberghe M.
        • et al.
        Mast cells are key mediators of cathelicidin-initiated skin inflammation in rosacea.
        J Invest Dermatol. 2014; 134: 2728-2736
        • Yamasaki K.
        • Kanada K.
        • Macleod D.T.
        • et al.
        TLR2 expression is increased in rosacea and stimulates enhanced serine protease production by keratinocytes.
        J Invest Dermatol. 2011; 131: 688-697
        • Schauber J.
        • Gallo R.L.
        The vitamin D pathway: a new target for control of the skin's immune response?.
        Exp Dermatol. 2008; 17: 633-639
        • Yamasaki K.
        • Di Nardo A.
        • Bardan A.
        • et al.
        Increased serine protease activity and cathelicidins promotes skin inflammation in rosacea.
        Nat Med. 2007; 13: 975-980
        • Helfrich Y.R.
        • Maier L.E.
        • Cui Y.
        • et al.
        Clinical, histologic, and molecular analysis of differences between erythematotelangiectatic rosacea and telangiectatic photoaging.
        JAMA Dermatol. 2015; 151: 825-836
        • Kawata A.K.
        • Revicki D.A.
        • Thakkar R.
        • et al.
        Flushing Assessment Tool (FAST): psychometric properties of a new measure assessing flushing symptoms and clinical impact of niacin therapy.
        Clin Drug Investig. 2009; 29: 215-229
        • Norquist J.M.
        • Watson D.J.
        • Yu Q.
        • et al.
        Validation of a questionnaire to assess niacin-induced cutaneous flushing.
        Curr Med Res Opin. 2007; 23: 1549-1560
        • Tan J.
        • Liu H.
        • Leyden J.J.
        • et al.
        Reliability of Clinician Erythema Assessment grading scale.
        J Am Acad Dermatol. 2014; 71: 760-763
        • Tan J.
        • Leoni M.
        Erythema of rosacea: validation of Patient's Self-Assessment Grading Scale.
        J Drugs Dermatol. 2015; 14: 841-844
      2. Holt S, Braithwaite I, Hunt A, et al. A topical kanuka honey formulation is an effective treatment for rosacea. Poster presented at: the 73rd Annual Meeting of the American Academy of Dermatology. March 20-24, 2015;San Francisco, CA.

        • Nicholson K.
        • Abramova L.
        • Chren M.M.
        • et al.
        A pilot quality-of-life instrument for acne rosacea.
        J Am Acad Dermatol. 2007; 57: 213-221
        • Wilkin J.
        • Dahl M.
        • Detmar M.
        • et al.
        Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea.
        J Am Acad Dermatol. 2004; 50: 907-912
      3. Emotional toll of facial redness equal to bumps, pimples: survey. Rosacea Review.
        (Available at: 2013;fall:2) (Accessed March 1, 2017)
      4. Survey shows controlling stress can reduce flare-up frequency. Rosacea Review.
        (Available at: 2011;fall:2) (Accessed March 1, 2017)
      5. Rosacea patients feel effects of their condition in patient setting. Rosacea Review.
        (Available at: 2012;fall:2) (Accessed March 1, 2017)
      6. Rosacea can affect workplace interactions, survey reveals. Rosacea Review.
        (Available at: 2015;fall:2) (Accessed March 1, 2017)
        • Aksoy B.
        • Altaykan-Hapa A.
        • Egeman D.
        • et al.
        The impact of rosacea on quality of life: effects of demographic and clinical characteristics and various treatment modalities.
        Br J Dermatol. 2010; 163: 719-725
        • Su D.
        • Drummond P.D.
        Blushing propensity and psychological distress in people with rosacea.
        Clin Psychol Psychother. 2012; 19: 488-495
        • Dirschka T.
        • Micali G.
        • Papadopoulos L.
        • et al.
        Perceptions on the psychological impact of facial erythema associated with rosacea: results of international survey.
        Dermatol Ther (Heidelb). 2015; 5: 117-127
        • Van der Linden M.M.D.
        • van Rappard D.C.
        • Daams J.G.
        • et al.
        Health-related quality of life in patients with cutaneous rosacea: a systematic review.
        Acta Derm Venereol. 2015; 95: 395-400
        • Elewski B.E.
        Results of a national rosacea patient survey: common issues that concern rosacea sufferers.
        J Drugs Dermatol. 2009; 8: 120-123
        • Bewley A.
        • Fowler J.
        • Schöfer H.
        • et al.
        Erythema of rosacea impairs health-related quality of life: results of a meta-analysis.
        Dermatol Ther. 2016; 6: 237-247
        • Haliou B.
        • Cribier B.
        • Frey M.
        • et al.
        Feelings of stigmatization in patients with rosacea.
        J Eur Acad Dermatol Venereol. 2017; 31: 163-168
        • Finlay A.Y.
        • Khan G.K.
        Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use.
        Clin Exp Dermatol. 1994; 19: 210-216
        • Lovibond S.H.
        • Lovibond P.F.
        Manual for the Depression Anxiety Stress Scales.
        2nd ed. Psychology Foundation, Sydney, Australia1995
        • Meyer T.J.
        • Miller M.L.
        • Metzger R.L.
        • et al.
        Development and validation of the Penn State Worry Questionnaire.
        Behav Res Ther. 1990; 28: 487-495