The Rosacea Research Digest from the National Rosacea Society keeps you up to date on recently published basic and clinical research on rosacea, as well as news, reviews, and presentations. It goes out on the last weekday of each month.

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Research

Environmental and lifestyle triggers of rosacea.

Sánchez-Feliciano A, Ershadi S, Barbieri JS. Cutis. 2026 February;117(2):65-68 DOI: 10.12788/cutis.1333

Rosacea is a chronic inflammatory skin condition characterized by facial erythema, flushing, telangiectasias, papules, and pustules. Its pathophysiology involves a multifactorial interplay of genetic, immune, microbial, and neurovascular factors contributing to inflammation and vascular dysregulation. Environmental and lifestyle triggers are important contributors to disease exacerbation. In this review, we highlight 4 major modifiable triggers—UV radiation exposure, temperature fluctuation, skin care practices, and diet—and their roles in rosacea pathogenesis and management. Lifestyle modifications targeting these triggers combined with topical, oral, and/or laser therapies can improve disease control. A holistic, patient-specific approach to treatment that involves education on environmental influences and tailored management strategies is essential.

Rosacea through the lens of the exposome: From triggers to systems biology.

Nemeth K. J Eur Acad Dermatol Venereol. 2026 Mar;40(3):337-338. doi: 10.1111/jdv.70298. PMID: 41738506.

Commentary: The dermatologic exposome encompasses the full spectrum of environmental and lifestyle exposures that interact with an individual's genome and immune system to influence skin biology. Originally introduced within environmental and molecular epidemiology, the exposome framework has been increasingly applied in dermatology to explain complex, multifactorial conditions. While it has been most extensively studied in atopic dermatitis, its relevance to other chronic inflammatory dermatoses is becoming increasingly apparent.

Advances in the pathogenesis of rosacea.

Wang H, Zhou C. Front Immunol. 2026 Jan 21;16:1705588. DOI: 10.3389/fimmu.2025.1705588. PMID: 41646975; PMCID: PMC12868226.

Rosacea is a chronic inflammatory cutaneous disorder predominantly affecting the centrofacial region, whose pathogenesis is complex and not yet fully understood. In this review we summarized the latest significant advances in the pathogenesis of rosacea in recent years. In genomic studies, the application of bioinformatics techniques such as whole-genome sequencing has identified novel susceptibility genes and linked multiple pathogenic mechanisms. Neurovascular dysfunction resulting from abnormal neuropeptides expression and dysregulated amino acid metabolism constitutes an important pathogenic factor in rosacea. The TLR2/LL-37/mTORC1 signaling axis, as a core regulatory pathway in innate immunity has been elucidated in detail. In addition, the dysbiosis of skin and gut microbiota, together with the impairment of skin barrier function, is also closely associated with the onset and progression of this disease. The deeper understanding of the pathogenesis of rosacea will benefit the development of new drugs and promote individualized diagnosis and treatment.

Revisiting rosacea through the skin-gut-brain axis: a neuroimmune perspective.

Lazić Mosler E, Vekić Mužević M, Karlović D, et al. Life (Basel). 2026 Feb 18;16(2):347. DOI: 10.3390/life16020347. PMID: 41752982.

Rosacea is increasingly recognized as a complex inflammatory disorder extending beyond isolated cutaneous pathology, involving dysregulated interactions between the skin, gastrointestinal system, and central nervous system. The skin-gut-brain axis has emerged as a relevant conceptual framework for understanding this multifactorial disease, integrating gut microbiota dysbiosis, neuroimmune signaling, autonomic nervous system dysfunction, and stress-related mechanisms. The aim of this narrative hypothesis-driven overview is to reframe rosacea as a neuroimmune disorder in which central nervous system involvement plays an active regulatory role, rather than as a purely peripheral or dermatological condition. We synthesize the mechanistically relevant evidence linking gastrointestinal inflammation and microbial imbalance with neurogenic inflammation, mast cell activation, sebaceous gland dysfunction, and aberrant innate immune responses in the skin, with particular emphasis on neurovascular and trigeminal pathways. A key novelty of this perspective lies in highlighting brain-centered mechanisms, including central sensitization, autonomic dysregulation, and stress-related neural modulation, as integral components of the skin-gut-brain axis in rosacea. By integrating peripheral and central processes, we propose rosacea as a model condition for studying neuroimmune dysregulation across interconnected regulatory systems. Finally, we discuss the clinical and translational implications of this framework and outline future research directions, focusing on autonomic regulation, patient stratification, and personalized, multidisciplinary therapeutic approaches.

Brimonidine beyond a single specialty: pharmacological profile, dermatologic applications, and advances in drug delivery systems.

Jóźwiak W, Pietrusiewicz M, Piechota-Urbańska M, Markowicz-Piasecka M. Int J Mol Sci. 2026 Jan 27;27(3):1281. DOI: 10.3390/ijms27031281. PMID: 41683709; PMCID: PMC12898228.

Brimonidine, a highly selective α2-adrenergic receptor agonist originally developed for glaucoma treatment, has emerged as an important dermatological agent due to its potent vasoconstrictive and anti-inflammatory properties. This review summarizes its pharmacological characteristics, and clinical applications. By activating α2-adrenergic receptors in cutaneous vessels, brimonidine induces rapid, reversible vasoconstriction and reduces neurogenic inflammation, leading to significant improvement of facial erythema in rosacea. Beyond its approved indication, topical brimonidine demonstrates efficacy in alcohol flushing syndrome, telangiectasia, post-procedural erythema, and as a local hemostatic agent in dermatologic surgery. Its favorable safety profile and minimal systemic absorption make it suitable for long-term use, though transient rebound erythema may occur. Advances in nanotechnology-such as supramolecular hydrogels and lipid-based carriers-enhance skin retention, prolong therapeutic action, and improve tolerability. These developments, together with ongoing synthesis of new quinoxaline-imidazoline analogues, open prospects for next-generation α2-agonists with optimized selectivity and dermatologic applicability. Brimonidine's emerging role extends to dermatologic formulations for transient redness and sensitive skin management. Integrating pharmacological, formulation, and molecular insights may transform brimonidine from a niche rosacea therapy into a versatile platform for vascular, inflammatory, and aesthetic skin treatments.

Audio-vestibular abnormalities in patients with rosacea: a prospective case-control study.

Tosun M, Kekül Sapcı M, Yasak Güner R, et al. Cutan Ocul Toxicol. 2026 Feb 20:1-7. DOI: 10.1080/15569527.2026.2632925. Epub ahead of print. PMID: 41720755.

Background: Rosacea is a chronic inflammatory dermatosis characterized by neurovascular dysregulation and systemic inflammatory features that may extend beyond the skin and potentially affect highly vulnerable sensory organs such as the inner ear. To investigate audiologic and vestibular functions in patients with rosacea and to explore whether subclinical alterations may be detected compared with healthy controls. Methods: In this prospective, age- and sex-matched case-control study, 53 patients with rosacea and 58 healthy controls were enrolled. All participants underwent pure-tone audiometry and the Video Head Impulse Test (vHIT). Disease severity, disease duration, sex, Demodex mite count, and rosacea subtypes were recorded. Data were analyzed using appropriate statistical tests. Results: Compared with controls, patients with rosacea had significantly higher air-conduction thresholds in both ears (left: p < 0.001; right: p < 0.001). In contrast, bone-conduction thresholds did not show clinically meaningful between-group differences; the small numerical difference observed for the left ear was not statistically significant (p = 0.084), and right bone-conduction thresholds were similar between groups (p = 0.331). On vHIT, vestibulo-ocular reflex (VOR) gains were significantly reduced in the left anterior (p < 0.001) and right posterior (p = 0.001) semicircular canals in the rosacea group. No significant associations were identified between vestibular parameters and disease severity, disease duration, Demodex count, rosacea subtype, or sex. Conclusion: These findings suggest that patients with rosacea may exhibit subtle audiologic and vestibular functional differences compared with healthy individuals. However, given the case-control design and the limited magnitude of the observed differences, these results should be interpreted cautiously, and audiovestibular evaluation may be considered primarily in symptomatic patients or selected subgroups rather than as a routine screening approach.

Dermoscopic response predictors in papulopustular rosacea treated with topical ivermectin and metronidazole: a prospective observational comparative study.

Plozner N, Lai M, Figini M, et al. Clin Cosmet Investig Dermatol. 2026 Feb 13;19:589715. DOI: 10.2147/CCID.S589715. PMID: 41716253; PMCID: PMC12915394.

Background: Over recent years, dermoscopy has proven useful not only for diagnosing skin conditions but also as a tool for predicting treatment response in inflammatory dermatoses. However, no data are available on dermoscopic predictors in papulopustular rosacea (PPR). Objective: To evaluate whether certain clinical and dermoscopic findings serve as positive or negative predictors of response to topical ivermectin or metronidazole in PPR. Methods: Twenty-three patients with moderate-to-severe PPR were enrolled. Ten patients received ivermectin 10 mg/g cream and 13 received metronidazole 1% gel (non-randomized, based on physician preference), applied once daily for 8 weeks. Inflammatory lesion counts and key clinical/dermoscopic features were assessed at baseline and after 8 weeks by two independent, blinded physicians. Post-treatment clinical outcomes (optimal response: >75% lesion reduction; partial response: 50-75% reduction) were correlated with baseline features. Results: Both treatments significantly reduced inflammatory lesion counts (p<0.001 for both). Any response (optimal or partial) occurred in 7/10 (70%) ivermectin-treated and 8/13 (62%) metronidazole-treated patients. Optimal response occurred in 5/10 (50%) ivermectin-treated and 4/13 (31%) metronidazole-treated patients. In the ivermectin group, all patients who achieved optimal response had baseline protruding follicular plugs (PFPs) (5/5, 100%) in dermoscopy, which are indicators of Demodex tails. Those with partial or minimal/no response in the ivermectin group did not have baseline PFPs (0/5). Baseline PFPs were significantly associated with optimal response to ivermectin (p=0.004). In the metronidazole group, all 4 optimal responders did not have baseline PFPs. All the 4 patients in the metronidazole group with baseline PFPs showed minimal/no response, though this was not statistically significant (p=0.176). No other baseline features significantly predicted response in either treatment group. Conclusion: PFPs in dermoscopy of moderate-to-severe PPR serve as positive predictors for optimal response to topical ivermectin, but not metronidazole. This observation warrants validation in larger controlled trials.

Detection of Demodex in rosacea: standardized skin surface biopsy versus ultraviolet dermoscopy.

Ünal E, Yücel MB, Yiğit M, et al. Clin Exp Dermatol. 2026 Feb 25:llag100. DOI: 10.1093/ced/llag100. Epub ahead of print. PMID: 41739824.

Introduction: Demodex mites are believed to contribute to the pathogenesis of both rosacea and demodicosis. While standardized skin surface biopsy (SSSB) remains the gold standard for detecting Demodex density, it is invasive and time-consuming. Ultraviolet (UV) dermoscopy, a non-invasive technique that visualizes fluorescent structures, may offer a rapid alternative for identifying Demodex proliferation. To investigate the relationship between Demodex folliculorum (D. folliculorum) and Demodex brevis (D. brevis) counts obtained by SSSB and fluorescent dots detected under UV dermoscopy, and to evaluate the diagnostic value of these findings in rosacea and demodicosis. Methods: Fifty-four patients with rosacea or demodicosis were evaluated using both UV dermoscopy and SSSB from the same facial region. Orange and bright blue fluorescent dots were recorded dermoscopically, and mite density and species were quantified via SSSB. Correlation analyses and ROC curve analysis were performed to assess diagnostic performance. Results: A significant positive correlation was found between total Demodex count and bright blue fluorescent dots (r = 0.343, p = 0.013), but not with orange dots (r = -0.065, p = 0.649). Only D. folliculorum showed significant correlation with blue and total fluorescent dots. ROC analysis identified >11 bright blue dots as the optimal threshold for predicting Demodex positivity, with a sensitivity of 82.1% and specificity of 71.4% (AUC = 0.793, p = 0.003). Conclusion: Bright blue fluorescent dots observed under UV dermoscopy significantly correlate with Demodex density, particularly D. folliculorum. A threshold of >11 blue dots demonstrated good diagnostic accuracy and may serve as a practical, non-invasive alternative or adjunct to SSSB in clinical settings. Orange fluorescence was not associated with Demodex density and likely reflects unrelated sebaceous or microbial activity.

Botulinum toxin vascular effectiveness: low or high doses?

Nazari S, Sadeghi MS, Pourani MR, et al. Aesthetic Plast Surg. 2026 Feb 9. Epub ahead of print. DOI: 10.1007/s00266-026-05685-7. PMID: 41661263.

Introduction: Botulinum toxin (BoNT) is increasingly recognized for vascular effects beyond its established neuromuscular use. Evidence indicates a dose-dependent mechanism in which BoNT either promotes vasodilation and perfusion or inhibits cholinergic vasodilatory activity, making it relevant for ischemic, vasospastic, and inflammatory conditions. This review evaluates current data on the dose-dependent vascular actions of BoNT and outlines its therapeutic relevance in aesthetic and reconstructive medicine. Materials and methods: A narrative review was performed using PubMed, MEDLINE, Embase, and Google Scholar, focusing on studies published from 2000 to 2025. Search terms combined "botulinum toxin" with "vasodilation," "ischemia," "flap survival," "angiogenesis," and related concepts. Eligible publications included clinical trials, animal studies, in vitro models, and systematic reviews assessing vascular outcomes after BoNT exposure. Of 163 records identified, 57 met inclusion criteria and were analyzed. Results: BoNT demonstrates dual vascular mechanisms. At higher doses, it enhances perfusion and promotes angiogenesis through vascular endothelial growth factor and nitric oxide pathways, supporting applications in ischemic flaps and Raynaud's phenomenon. At lower doses, it reduces excessive cholinergic vasodilation and neurogenic inflammation, offering benefits in conditions such as rosacea and hyperhidrosis. These effects are dose-dependent and tissue-specific, with variability across experimental models. Concentrations above 20 IU/ml may be considered high-dose, whereas lower levels represent low-dose BoNT. Conclusion: BoNT exhibits versatile vascular activity. Higher doses support vascular regeneration and angiogenesis, while lower doses modulate hyperreactive vascular responses. Further research is needed to clarify mechanisms, refine dose-response guidelines, and assess long-term safety across clinical indications to optimize its vascular applications.

Clinical outcomes and predictive factors of combination treatment with oral doxycycline, topical calcineurin inhibitor, and pulsed dye laser in erythematotelangiectatic rosacea.

Kim M, Kim BR, Choi CW, Youn SW. Lasers Surg Med. 2026 Feb 10. Epub ahead of print. DOI: 10.1002/lsm.70109. PMID: 41668549.

Objective: Given that the therapeutic evidence for doxycycline in rosacea has predominantly been derived from studies on papulopustular rosacea (PPR), this study aimed to evaluate the efficacy and safety of combined oral doxycycline, topical calcineurin inhibitor (TCI), and pulsed dye laser (PDL) therapy in erythematotelangiectatic rosacea (ETR) and to identify clinical predictors of treatment response. Materials and methods: Medical photographs of patients with ETR treated with oral doxycycline, TCI, and two subsequent PDL sessions were retrospectively reviewed. Erythema on the right cheek was quantitatively measured using computer-aided image analysis. Results: Of the 79 included patients, 47 had the ETR subtype and 32 had the mixed ETR/PPR subtype. Erythema significantly improved after oral doxycycline and TCI treatment (p < 0.001) and further PDL treatment (p < 0.001). Particularly, in patients with moderate-to-severe ETR, background erythema improved to a level comparable to that observed in patients with mild ETR after treatment (p = 0.307). Post-treatment erythema did not differ by age (p = 0.963) or Fitzpatrick skin type (p = 0.277); however, it was significantly lower among males (p = 0.008) and in patients without prior steroid treatment (p = 0.046). No serious adverse events, including photosensitivity, were observed. Conclusion: Combined oral doxycycline, TCI, and PDL therapy is effective and safe for ETR, especially in patients with higher severity. Prompt diagnosis and avoidance of steroid misuse may improve treatment responses.

Measurement properties of PROMIS measures relevant to chronic skin diseases.

Nock MR, Ershadi S, Sánchez-Feliciano A, et al. JAMA Dermatol. 2026 Feb 1;162(2):157-165. DOI: 10.1001/jamadermatol.2025.5163. PMID: 41432938; PMCID: PMC12728729.

Importance: Patient-Reported Outcomes Measurement Information System (PROMIS) is a generalized set of patient-reported outcome measures (PROMs) that can be readily integrated into the dermatologic clinic setting, but the measurement properties of these PROMs among patients with a range of chronic skin diseases have yet to be established. Objective: To evaluate the structural validity, internal consistency, construct validity, and responsiveness of PROMIS short-form measures for anxiety, depression, social satisfaction, and social isolation as well as the construct validity and responsiveness of single-item pain and itch intensity measures. Design, setting, and participants: In this cohort study, adults 18 years and older with a self-reported chronic skin disease (eg, atopic dermatitis, acne, psoriasis) were recruited in February 2025 from across the US via an online survey platform. Enrolled participants completed a baseline survey of PROMIS and several other relevant measures and then a follow-up survey 3 months later. Main outcomes and measures: Measures collected include the PROMIS measures, Dermatology Life Quality Index, Skindex-29, a baseline patient global assessment, and a change in skin disease anchor question at follow-up. Structural validity, internal consistency, construct validity, and responsiveness were evaluated for the short-form measures. Construct validity and responsiveness were assessed for the single-item measures. Results: Of 549 included participants with chronic skin diseases, 287 (52.3%) were female, 262 (47.7%) were male, and the median (IQR) age was 36 (30-45) years. A total of 249 patients (45.1%) had atopic dermatitis, 246 (44.8%) had acne, and 113 (20.6%) had psoriasis. The anxiety, depression, social satisfaction, and social isolation short-form measures demonstrated adequate structural validity (ie, all with comparative fit index and/or Tucker-Lewis index values greater than 0.95; standardized root mean residual values less than 0.08) and internal consistency (Cronbach α values greater than 0.90). All measures showed sufficient construct validity on known-groups and convergent validity testing (eg, magnitude of Pearson correlations between measures evaluating similar underlying constructs with values of 0.30 or greater). When comparing responsiveness based on standardized response means (SRMs), the pain (SRM, 0.41) and itch intensity (SRM range, 0.32-0.44) measures showed similar responsiveness as the Skindex-29 symptoms domain (SRM, 0.47), and the social satisfaction (SRM, -0.20) and isolation (SRM, 0.27) measures showed similar responsiveness to the Skindex-29 functioning domain (SRM, 0.25). Responsiveness of the anxiety (SRM, 0.11) and depression (SRM, 0.16) measures were lower than the Skindex-29 emotions domain (SRM, 0.43). Conclusions and relevance: In this study, PROMIS measures were valid for assessing the physical, emotional, and social effects of chronic skin diseases, and measures for physical and social impact tracked improvements with treatment.

Case Reports

Rosacea scleritis and sclero-uveitis; under recognised and over treated.

Richards J. J Ophthalmic Inflamm Infect. 2026 Feb 12. DOI: 10.1186/s12348-025-00546-x. Epub ahead of print. PMID: 41680375.

Background: Rosacea episcleritis, scleritis and uveitis may be missed when clinicians focus on the eye without appraising the adnexae and facial skin. Addressing rosacea can reduce treatment failures and avoid systemic complications of less effective or more toxic drugs. Case series and narrative review: This series presents four cases with scleritis and / or sclero-uveitis in the setting of facial or ocular rosacea. Where relevant, negative systemic scleritis work up is included. Common features were incomplete resolution or poor response to one or more of topical and systemic steroid, systemic non-steroidal anti-inflammatory, systemic immunomodulatory and topical antibiotic treatment. All cases responded promptly to treatment with oral doxycycline, allowing withdrawal of other treatment. A review of the literature is presented, updating understanding of immunogenetics and inflammatory pathways relevant to ophthalmic management of these cases. Important considerations include the role of steroids, vitamin D, microbes, toll like receptors and their influence on the cathelicidin (Ll-17) pathway in rosacea inflammation. Conclusion: Making a correct rosacea diagnosis and managing with doxycycline or related medication can result in rapid remission, minimising disease complications and side effects of less targeted drugs.

Facial swelling in a young adult with type 1 diabetes: morbihan disease as a scleroderma mimic.

Shammas R, Gudino-Rosales S, Kneiber D, et al. Cureus. 2026 Jan 15;18(1):e101635. DOI: 10.7759/cureus.101635. PMID: 41694889; PMCID: PMC12906367.

Scleredema diabeticorum and Morbihan disease (solid facial edema) can mimic scleroderma, creating diagnostic challenges for rheumatologists. We report a 19-year-old male with poorly controlled type 1 diabetes (glycated hemoglobin (HbA1c) >9%) presenting with progressive facial swelling. Extensive workup excluded superior vena cava syndrome and connective tissue diseases. Histopathological examination of the skin fragment was suggestive of scleredema diabeticorum or Morbihan disease secondary to rosacea. Key differentiating features included sparing of hands/feet, absence of Raynaud's phenomenon, and non-specific low-titer anti-nuclear antibody (ANA). This case emphasizes recognizing scleroderma mimics to ensure appropriate therapy.

News

Rosacea Awareness Month to Highlight Wide Range of Management Options

Rosacea.org

The 1 in 20 Americans who suffer from rosacea have more treatment options than ever before — but most patients don't take advantage of the full range of ever-increasing therapy options, experts say. The National Rosacea Society (NRS) has designated April as Rosacea Awareness Month to educate the public about this chronic facial skin disorder and encourage those who suspect they may have it to see a dermatologist for diagnosis, effective treatment and guidance on gentle skin care.

AI for Rosacea Diagnosis Shows Both Promise and Shortcomings

Rosacea.org

According to the company OpenAI, over 230 million people ask ChatGPT about health problems each week. Several recent studies have investigated whether publicly available large language models (LLMs), including ChatGPT, can aid in the detection and diagnosis of dermatological conditions like rosacea, with varying results. The studies used a variety of methods to prompt AI models for diagnosis, including pulling photographs from online dermatological databases, taking patient photographs in a clinical setting, and using text descriptions copied from online forums.

Here's Why Your Face Gets Red After Working Out—and How to Prevent It

Real Simple

There's nothing quite like the feeling of being all hot and sweaty after you just dominated a HIIT workout, and the cherry on top is supposed to be that coveted post-workout glow. But for some people, their reward is a brilliantly beet-red complexion, which can make a person feel self-conscious after hitting the gym.

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