Rosacea Likely Underdiagnosed in Patients With Skin of Color

Rosacea is likely underdiagnosed in patients with skin of color not because they are at lower risk, but because clinicians don’t think to look for it and struggle to recognize it when they do. That was the argument from Hilary Baldwin, MD, medical director of the Acne Treatment & Research Center in Brooklyn, New York, and clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical School, at the Skin of Color Update 2026 in New York, New York.¹

Re-Evaluating Who is Impacted by Rosacea

Roughly 10% of the US population, about 16 million people, has rosacea, Baldwin said, though she acknowledged that prevalence estimates are imprecise. Textbooks describe the typical patient as a woman older than 40 years of Northern European descent, a profile Baldwin said does not hold up. “I always say that since I practice in the heart of Brooklyn, if it were only people of Northern European descent, I never would have seen this condition,” she said.

The disease is more common in lighter skin, but it is not rare in patients of color, and recent data point to a diagnostic gap. In a 2025 cross-sectional study of 109,866 primary care patients in San Francisco, 1.7% of White patients had a documented rosacea diagnosis, compared with 0.9% of patients with skin of color and 0.1% of Black patients. Patients of color who were diagnosed were more likely to receive oral therapy (34.4% vs 23.8%), which the authors noted may loosely reflect more severe disease.² A twin study conducted at a festival in Twinsburg, Ohio, estimated the genetic contribution to rosacea at about 46%, Baldwin said.¹

She noted that darker skin may experience less UV-related damage, including less matrix metalloproteinase production, collagen denaturation, and hypervascularity, and may have lower transepidermal water loss. Even so, Baldwin said a low index of suspicion and poor recognition are the main reasons patients of color go undiagnosed.

Current diagnostic criteria rely on fixed centrofacial erythema and phymas. Flushing, papules and pustules, telangiectasias, ocular findings, and symptoms serve as supporting features. When redness is hard to see in richly pigmented skin, clinicians are left with far fewer clues. Baldwin also noted that photographs labeled as rosacea in 2 recent expert review articles appeared to show acne, scarring, or hyperpigmentation instead.

The ALTER Approach

To change how clinicians see the disease, Baldwin proposed the ALTER framework: ask questions, look for nonclassical signs, use tools, educate patients, and recommend sunscreen. Clinicians should ask whether the skin or eyes itch, burn, or sting, and whether skin care products cause irritation. They should also ask whether patients feel facial warmth that comes and goes, which may signal flushing patients can feel but clinicians cannot see.

Nonclassical signs include edema, phymatous changes, eyelid margin redness, and markedly dry skin. Dermoscopy can reveal telangiectasias, and diascopy with a glass slide can confirm erythema. Patients should wash once daily with a gentle cleanser, avoid exfoliation, moisturize regularly, and use sunscreen.

Choosing Well-Tolerated Treatment for Rosacea

The priority is avoiding iatrogenic hyperpigmentation. For that reason, Baldwin favors the 3 newer topicals, ivermectin, minocycline foam, and microencapsulated benzoyl peroxide, which she said showed low irritation in phase 3 trials. When insurers require metronidazole or azelaic acid, she first repairs the barrier with gentle cleansers and moisturizers for 1 to 2 weeks or moves to oral therapy sooner. Tetracyclines work in rosacea through anti-inflammatory rather than antibacterial effects. Modified-release doxycycline and minocycline do not appear to alter the microbiome, Baldwin said. If cost is a barrier, immediate-release doxycycline 20 mg can be taken twice daily, but not as a single 40-mg dose.

When full-dose antibiotics are needed, Baldwin pointed to data showing that sarecycline matches doxycycline and minocycline against Cutibacterium acnes, with 16- to 32-fold less activity against gram-negative gut bacteria. That supports antibiotic stewardship in a chronic disease.

“We can’t keep treating these patients for 30 years with an oral antibiotic,” Baldwin said.

References

1. Baldwin H. Rosacea in skin of color: disease state update. Presented at: Skin of Color Update 2026; October 9-11, 2026; New York, NY.
2. Gomez-Lara AR, Zakaria A, Sanchez-Anguiano ME, Amerson EH. Rosacea prevalence, severity, and phenotype by race, ethnicity, and gender: a cross-sectional study of a diverse patient cohort within a primary care population. JAAD Int. 2025;24:338-341. doi:10.1016/j.jdin.2025.11.016