Hilary Baldwin, MD briefly summarizes her lecture Diagnosing and Managing Rosacea in Patients with Skin of Color at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

Dr. Baldwin emphasizes that the lesions, treatments, and outcomes of rosacea are essentially the same across skin types — the two real differences are recognizing that the patient has rosacea in the first place and trusting that the treatment plan won't cause the inflammation or irritation that leads to iatrogenic hyperpigmentation. Because you can't readily appreciate erythema in a skin type five or six, symptoms become central to the diagnosis: itch, burning, stinging, an episodic sensation of warmth, and ocular changes. Papules, pustules, phymas, and ocular findings are the features you can "hang your hat on." Her top differential is acne, distinguished by age, gender, chest and back involvement, and the presence or absence of comedones.

On treatment, she favors the three newer topicals — ivermectin 1% cream, minocycline 1.5% foam, and microencapsulated benzoyl peroxide 5% — not just for efficacy but because local skin reactions actually decreased during their trials, which matters most in sensitive, hyperpigmentation-prone skin. She's a firm believer in avoiding full-dose antibiotics, reaching instead for modified-release doxycycline or low-dose minocycline (40 mg), which studies suggest is a non-antibiotic dose that outperformed doxycycline in phase three. She also calls isotretinoin an "unsung hero" for rosacea, effective at doses as low as 10 mg a day or even a few times a week.

  • The morphology and treatment of rosacea don't differ much by skin type — the challenge is diagnosing it once redness is invisible and avoiding iatrogenic hyperpigmentation.
  • In skin of color, lean on symptoms (itch, burn, sting, episodic warmth) and the obvious signs — papules, pustules, phymas, ocular changes — since erythema can't be appreciated.
  • Acne is the number one differential; distinguish it by age, gender, chest/back involvement, and the presence or absence of comedones.
  • Favor the three newer topicals (ivermectin 1%, minocycline 1.5% foam, microencapsulated benzoyl peroxide 5%) whose local skin reactions decreased during treatment; avoid full-dose antibiotics in favor of modified-release doxycycline or low-dose minocycline.
  • Low-dose isotretinoin (as little as 10 mg a day or a few times a week) reduces erythema, papules, and pustules and can halt phyma progression, but therapy must be continued to maintain the response.