**Background:** Rosacea is a common chronic dermatosis with a global prevalence of approximately 5.46%, affecting middle-aged adults equally across sexes, with a predominance in Northern European populations. The condition presents with centrofacial erythema, telangiectasias, papules, and pustules. The 2017 classification shifted from a subtype-based system to a phenotype-based approach, grouping pathognomonic centrofacial erythema with major criteria (papules, pustules, flushing, telangiectasia, ocular involvement) and secondary phenotypes (burning, stinging, edema, dry appearance). Pathophysiology involves multifactorial components: dysregulation of innate and adaptive immunity, aberrant cathelicidin expression (LL-37), Toll-like receptor 2 (TLR2) activation, matrix metalloproteases (MMP2, MMP9), mast cells, and environmental triggers (UV light, alcohol, stress). Demodex folliculorum infestation is strongly associated (pooled prevalence 70.4% in rosacea vs 31.8% in controls; OR 9.04, 95% CI 4.83–16.93). Comorbidities include inflammatory bowel disease, depression, migraine, and cardiovascular conditions.
**Methods:** This is a narrative review summarizing current literature on rosacea management. It covers epidemiology, pathophysiology, histopathology, and therapeutic strategies including topical, systemic, laser/light, and combination therapies. The review draws on clinical trials, meta-analyses, and expert committee guidelines (e.g., National Rosacea Society).
**Key Results:** Topical therapies are the mainstay: FDA-approved agents include azelaic acid 15% gel, brimonidine tartrate 0.33% gel, ivermectin 1% cream, metronidazole (0.75% gel/cream/lotion, 1% cream/gel), oxymetazoline hydrochloride 1% cream, sodium sulfacetamide 10%/sulfur 5%, and calcineurin inhibitors. For papulopustular rosacea, ivermectin 1% cream cleared 38.4% and 40.1% of subjects vs 11.6% and 18.8% for vehicle (both P < 0.001). Azelaic acid 15% gel was significantly superior to placebo (P = 0.005) and more effective than metronidazole 0.75% gel. Brimonidine tartrate 0.5% gel showed significant improvement at 30 minutes, with 58.3% vs 32.0% efficacy at day 29 (P < 0.001). Oxymetazoline 1% cream achieved ≥2-grade improvement in Clinician Erythema Assessment (CEA) in 36.7% of patients after 52 weeks. Sodium sulfacetamide/sulfur reduced papulopustular lesions by 65% vs 44% (P = 0.002) and erythema by 66% vs 33% (P = 0.005) compared to vehicle. Systemic therapies: subantimicrobial-dose doxycycline (SDD) 40 mg is the only FDA-approved systemic therapy for inflammatory lesions, significantly reducing relapse rate and lesion count vs placebo (P < 0.05). Isotretinoin (0.25 mg/kg/day for 4 months) improves refractory papulopustular rosacea. Combination therapies show superior efficacy: topical metronidazole 1% plus doxycycline 40 mg reduced lesion count by 13.86 vs 8.47 (P = 0.002) at week 12. Topical ivermectin 1% plus doxycycline 40 mg reduced lesions by –80.3% vs –73.6% (P = 0.032) and achieved 100% lesion reduction in 17.8% vs 7.2% (P = 0.006) at week 12. Laser/light therapies (PDL, IPL, Nd:YAG, KTP, CO2) are effective for telangiectasias and phymatous changes; CO2 laser achieved good-to-excellent improvement in 95% of rhinophyma patients.
**Clinical Implications:** Management should be phenotype-driven, targeting specific features (erythema, papules/pustules, phymatous changes, ocular involvement). Combination therapies are often more effective than monotherapy, especially for moderate-to-severe disease. Patient education on trigger avoidance (alcohol, spicy foods, sun, stress) and gentle skin care is foundational. Quality of life is significantly impacted, with higher rates of anxiety and depression; effective treatment improves Dermatology Life Quality Index (DLQI) scores. Emerging therapies (e.g., secukinumab, hydroxychloroquine, botulinum toxin) require further validation. Continued research into pathophysiology and novel treatments is needed to refine management.