Rosacea Subtypes, How are they related?


So we all know the official rosacea subtypes right  ?

  1. Erythematotelangiectatic,
  2. Papulopustular,
  3. Phymatous and
  4. Ocular rosacea

(Lets ignore neurogenic rosacea for now).

Well, are these 4 sub types related, and in what way? Will rosacea progress in severity and can your rosacea proceed between subtypes?

If we are in a question asking mood, then why not also thrown in the possibility that perhaps the 4 official rosacea subtypes are separate diseases.

Some recently published, Galderma-funded research, seeks to answer a sparsely answered question about rosacea subtypes. Just how are they related?

Research Findings

The paper seems quite solid and has surfaced some potentially interesting and useful findings. Here is a brief summary of what I see as they key results – to save you reading the paper. For more information, see the full paper via medscape.

  • a small  number of erythematotelangiectatic rosacea sufferers may progress to papulopustular and/or phymatous rosacea
  • a small number of papulopustular rosacea sufferers may develop phymatous rosacea
  • phymatous rosacea is more frequently associated with papulopustular rosacea than erythematotelangiectatic rosacea
  • the nose has more pustules in phymatous rosacea than in erythematotelangiectatic rosacea
  • the cheeks have more pustules in papulopustular rosacea
  • ocular rosacea doesn’t seem to more associated with either erythematotelangiectatic or papulopustular rosacea
  • a previous study found an association between the severity of erythematotelangiectatic rosacea and presence of ocular rosacea
  • the non transient red face of rosacea was the most bothersome feature for the participants
  • during a flushing episode papulopustular rosacea sufferers more frequently reported burning/stinging than erythematotelangiectatic sufferers
  • those with papulopustular rosacea were twice as likely to have facial burning/stinging
  • those with papulopustular rosacea were more likely to have swelling and phymas
  • the average duration of rosacea in the group was 20 years
  • majority of ocular rosacea sufferers reported cutaneous symptoms before the onset of ocular symptoms
  • of those who had both erythematotelangiectatic and papulopustular rosacea a majority reported that they developed erythematotelangiectatic rosacea first
  • of those who had both erythematotelangiectatic and phymatous rosacea a majority reported developed erythematotelangiectatic symptoms first
  • of those who had both erythematotelangiectatic and papulopustular rosacea a majority developed papulopustular symptoms first

Study Deficiencies

The study recognises that there may be selection bias based on who was in the study group. Even though the study group was large it was not a full representation of the general population.

Weaknesses of NRS Expert Committee

The paper also make some observations about the weakness of the NRS Expert Committee’s Rosacea Classification System.

  1. It is difficult to distinguish the facial redness of photodamage from erythematotelangiectatic rosacea.
  2. Flushing episodes which are important for the finding of erythematotelangiectatic rosacea, are subjective and may be inaccurately reported. The paper suggests that the removal of the requirement of flushing for a diagnosis of erythematotelangiectatic rosacea, whilst retaining persistent centro-facial erythema may give a more precise diagnosis.
  3. All all transient symptoms – papulopustules, ocular symptoms, flushing, burning/stinging ought to be measured in a specific period preceding time period, say week or month to be a useful measure.
  4. Ocular rosacea diagnosis is difficult due to the wide spectrum of ocular symptoms, so some refining of the definition is needed.

Paper Abstract

An Observational Cross-sectional Survey of Rosacea

Clinical Associations and Progression Between Subtypes

J. Tan, U. Blume-Peytavi, J.P. Ortonne, K. Wilhelm, L. Marticou, E. Baltas, M. Rivier, L. Petit, P. Martel

The British Journal of Dermatology. 2013;169(3):555-562.

Background: Few studies have evaluated differences between rosacea subtypes in epidemiological associations and clinical features. The natural history of rosacea is unknown and progression between subtypes has been implied but not formally evaluated.

Objectives: To assess associations between the four rosacea subtypes

  1. erythematotelangiectatic (ETR),
  2. papulopustular (PPR),
  3. phymatous (PHY) and
  4. ocular

including quantitative and qualitative details on primary and secondary features of rosacea. A secondary objective was to evaluate for the potential of progression between subtypes.

Methods: This cross-sectional study recruited subjects with rosacea from Northern Germany and comprised clinical evaluation by a dermatologist and a survey of demographics and onset of rosacea-associated signs and symptoms.

Results: A total of 135 subjects with rosacea were enrolled.

PHY was more frequently associated with PPR than ETR (P < 0·001).

Compared with ETR, PPR was significantly associated with facial burning/stinging (P = 0·001), phymas (P < 0·001) and oedema (P < 0·001); and during flushing episodes, was more frequently associated with burning (P = 0·018), skin tension (P = 0·005) and itching (P = 0·027).

ETR was more frequently associated with dry facial skin (P < 0·001).

Flushing was reported by 66% and the site most frequently involved was the cheeks (100%).

Papulopustules were evanescent in 42% and the sites most frequently involved were the cheeks (80%) and nose (67%).

Of those fulfilling criteria for at least two subtypes, 66% developed ETR before PPR; 92% developed ETR before PHY; 83% developed PPR before PHY; and the majority developed cutaneous rosacea-associated features before ocular signs/symptoms.

Conclusions: Significant differences exist between ETR and PPR in rosacea-associated features and in subtype associations.

A small proportion of subjects with rosacea may progress between subtypes

Funding sources: Galderma funded this study and was involved in study design.

Conflicts of interest:
J.T. has received grants and honoraria from Galderma as an advisor, speaker and trialist;

U.B.-P. has received grants and honoraria from Galderma as an advisor, speaker and trialist;

L.M. has received honoraria from Galderma as a consultant;

E.B. has received honoraria from Galderma as an advisor;

J.P.O. declares no conflict of interest;

ProDerm, of which K.W. is founder and medical director, received honoraria for performing the study;

M.R., L.P. and P.M. are employees of Galderma.

Related Articles


About the Author

About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

Follow Rosacea Support

Subscribe via RSS Feed

1 Reader Comment

  1. Paul Blythe says:

    I don’t think there is much new news here. I have or have had three of the four (all but PHY) sometimes together, eventually finding a food / no sun combination that keeps things workable and mild. I would suggest that the last thing we need now is a splintering what effort there is out there to establish causes. The biggest problem with Rosacea already is that it is pretty much in the hands of dermatologists, despite almost all the triggers except the sun being ingested or not obviously related to the skin (such as exercise). It would be better to see effort go into causes, perhaps with involvement of internists and auto-immune specialists. The work of Dr Gallo seemed to be moving off finding a better cream and towards cause but I haven’t seen anything for a while.

Leave your comment here


Subscribe to Rosacea News

Enter your email address to receive the latest news about rosacea in your inbox.