Rosacea's Textbook Redness May Hide Cases in Patients of Color

Rosacea's textbook look—flushed cheeks laced with visible blood vessels—may be exactly why it goes unrecognized in patients whose skin does not redden the same way. A systematic review of 222 studies covering 32,442 patients found that rosacea's subtype mix varies by race and ethnicity, and that erythema-based diagnostic criteria may under-recognize presentations more common in patients with darker skin.¹

Rosacea Diagnosis Has Long Skewed Away From Patients of Color

Patients of color have long received a rosacea diagnosis far less often than White patients, even when they report symptoms consistent with the disease. An analysis of national ambulatory care survey data from 1993 to 2010 found that Black and Asian or Pacific Islander patients made up just 2.0% and 2.3% of rosacea diagnoses, respectively, and that Black patients who presented with “other diseases of the skin” consistent with rosacea received that diagnosis far less often than White patients with the same complaint (8.3% vs 2.2%, respectively).²

That gap has persisted alongside a diagnostic framework built in 2002 by the National Rosacea Society, which centers visible erythema and telangiectasia. Those vascular signs are harder to see against melanin-rich skin, so clinicians trained on that framework may be looking for the wrong signs in patients who are not White, the authors suggested.

The present review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251116235).¹ They searched Embase, MEDLINE, and PubMed from inception through August 10, 2025, for studies reporting rosacea by race or ethnicity, or in populations more than 90% monoethnic. From 3721 screened records, 222 studies met inclusion criteria, covering 32,442 patients.

The included literature skewed heavily toward East Asian cohorts: Korean patients accounted for 46.6% of the sample and Chinese patients for 40.1%, while Black (0.10%) and South Asian (0.04%) patients were barely represented. Fitzpatrick phototype, the scale used to classify skin's reaction to sun exposure, was reported for just 17.5% of patients, leaving most of the evidence base without a direct measure of skin tone.

Subtype Mix Varied Sharply by Race and Ethnicity

Erythematotelangiectatic rosacea, marked by persistent facial redness and visible vessels, was the most common subtype overall (54.8%). It appeared even more often in Japanese (87.1%), Middle Eastern (74.3%), and Korean (65.2%) cohorts than in Caucasian patients (50.4%; all P < .001). Phymatous rosacea, which thickens skin and tissue rather than reddening it, showed the opposite pattern: it was reported in 100.0% of South Asian patients, 58.3% of Black patients, and 29.0% of Chinese patients, compared with 12.1% of Caucasian patients. Ocular rosacea was most frequent in Black (50.0%) and Middle Eastern (15.2%) patients, papules and pustules predominated in Black patients (79.2%), and flushing was rarely reported in Black or South Asian cohorts.

The subtype mix also shifted by publication era, tracking which classification system was in use at the time: phymatous rosacea predominated in studies published before 2002 (50.0%), papulopustular rosacea predominated from 2002 to 2016 (52.5%), and erythematotelangiectatic rosacea predominated from 2017 to 2025 (56.1%).

The authors tied the racial and ethnic skew to visibility rather than necessarily to underlying biology. Vascular signs central to the 2002 framework “can be masked by epidermal melanin,” they wrote, which could make erythema-independent features like phymatous change or ocular involvement appear more common in darker-skinned groups simply because they are easier to document.

“Our findings support the transition toward the 2017 ROSCO [Rosacea COnsensus] phenotype-based framework,” the researchers wrote, pointing to a model that scores individual features—papules, phymatous change, ocular signs—independently rather than anchoring diagnosis to a single, erythema-dependent subtype label.

Study Relied on an Imbalanced, Outdated Classification

The authors acknowledged that their sample was markedly imbalanced, with Korean and Chinese cohorts vastly overrepresented and Black and South Asian patients barely present, limiting how confidently the subtype differences generalize. Most included studies also relied on the outdated 2002 subtype system rather than the newer ROSCO phenotype model, and study quality varied across the 222 included reports.

Race and ethnicity reporting was inconsistent from study to study, and Fitzpatrick phototype was documented in only a minority of cases, making it difficult to separate true population differences in rosacea presentation from gaps in how studies recorded their patients. The authors called for large, prospective studies that intentionally recruit underrepresented populations and standardize phenotype reporting going forward.

What It Means for Diagnosis and Access

For clinicians, the findings argue for assessing rosacea's individual features—ocular irritation, papules, skin thickening—individually instead of waiting for visible flushing to prompt the diagnosis, particularly in patients with darker skin tones. A visit built solely around visible redness risks missing phymatous or ocular disease already in front of the clinician.

The equity gap carries stakes beyond the exam room. A rosacea diagnosis that arrives late, or not at all, delays symptom-targeted treatment and specialist referral. The authors’ call for routine Fitzpatrick phototype documentation points to a fix that managed care and research infrastructure could standardize before the next review has to ask the same question.

Reference

1. Levy R, Fremont S, Rodney A, Perlmutter JW, Moshkovich M, Mukovozov I. Rosacea presentation across race and ethnicity: a systematic review. J Cutan Med Surg. Published online September 15, 2026. doi:10.1177/12034754261484192

2. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014;20(10). PMID:25526008