Rosacea in skin of colour

Rosacea can affect all skin tones. Kezia Parkins explores how the condition affects skin of colour and the importance of representation in dermatology

In recent years, dermatology has been called out for underrepresenting and sometimes misrepresenting skin conditions in Black skin and skin of colour. While efforts are being made to repair these holes in professional and public knowledge, engrained beliefs and lack of education means misdiagnosis persists and there is no better example of that than rosacea.

Rosacea is a long-term inflammatory skin condition usually occurring on the face and which affects one in 10 people in the UK, with most in the 30-to-50-year-old age group, or with fair skin, according to research from Bupa. But, as one of the most common inflammatory skin conditions out there, it’s often underdiagnosed in Black people and people of colour.

Epidemiological studies suggest that the prevalence of rosacea is much lower in people with darker skin (Fitzpatrick phototypes IV–VI) compared to fair-skinned individuals (Fitzpatrick skin phenotypes I or II). However, it’s unclear if this is because of genuine differences in prevalence or the disparities in diagnosis.

According to a 2018 study published in the Journal of the American Academy of Dermatology, up to 40 million people of colour struggle with rosacea. That’s a big market but lack of information and understanding could mean therapists, clinics and brands are missing out on treating this group or targeting them with representation in advertising.

“It is generally underdiagnosed, especially in skin of colour,” explains Dr Ginni Mansberg, a GP and the co-founder and medical director at ESK Skincare. “Because it’s so often missed, getting great data about how common rosacea is in skin of colour is really tough. But studies find it affects anywhere up to 22% of us with recent studies finding that in skin of colour, rosacea is present in 10%, or even 15%, of people.”

Understanding rosacea

Rosacea is a chronic skin condition with numerous subtypes but is most commonly characterised by erythema (redness) flushing, pimples or pustules and sometimes burning sensations. “Rosacea tends to have a waxing and waning course with times of skin flaring and other times it can be quiet,” says aesthetic doctor Ifeoma Ekijeme, founder and medical director of Adonia Medical Clinic in London.

“The exact pathophysiology of rosacea is unknown but genetic factors, the body’s immune system, microbial exposure, food/ alcohol and UV exposure can negatively impact its symptoms,” adds oculoplastic surgeon and facial aesthetics doctor Maryam Zamani, who runs The Clinic by Dr Maryam Zamani in London.

It mostly affects the centre of the face, especially around the cheeks and nose. It can also affect the neck, chest and scalp as well as the eyes. There are four main types of rosacea but whether it’s erythematotelangiectatic rosacea which causes flushing and redness, or papulopustular rosacea which causes pimples and pustules, the driver of these are largely unknown.

“Because of the LACK of typical VISIBLE REDNESS, people with rosacea and skin of colour tend to get DIAGNOSED LATER and have MORE PUSTULES and PIMPLES„

“We still don’t know exactly what causes rosacea,” says Dr Mansberg. “We know genes play a role as does a tiny mite called the Demodex, which exists in higher numbers on the skin of people with rosacea. Scientists are also looking at the role the gut microbiome may play as well.”

Rosacea on dark skin

Rosacea can present differently on dark skin compared to light skin. On light skin, rosacea typically appears as redness across the cheeks, nose, forehead and chin. It can also cause visible blood vessels and acne-like bumps. It makes sense that such symptoms as redness, flushing and broken vessels would be a lot more visible in paler-skinned individuals but assuming that this doesn’t occur in darker-skinned people does not.

The issue is reminiscent of the trope that Black people don’t blush. They do. Blushing is a human physiological reaction to emotional stressors that causes blood vessels to dilate and affects everyone, but the darker the skin, the harder that is to see.

“Redness and flushing is super easy to see on pale skin, but harder to see on skin of colour. The result is that rosacea isn’t top of mind so we see this real delay in diagnosis. In my experience, lots of my patients feel gaslit and dismissed because doctors don’t take their skin symptoms seriously,” says Dr Mansberg.

“Because of the lack of typical visible redness, people with rosacea and skin of colour tend to get diagnosed later and have more pustules and pimples. They are also likely to mention burning and stinging of their skin, often for very long periods of time, that has been disregarded.”

Dr Ejikeme adds that instead of the classic redness, rosacea may manifest as brown or purple discolouration, making it less noticeable or mistaken for other conditions. “The history of flushing, however, is universal and a diagnosis can be made based on the history,” she adds.

Misdiagnosis or underdiagnosis is common, as Dr Zamani explains: “Facial flushing and telangiectasia may be more difficult to see and may appear more like pigmentation issues. Similarly, rosacea in skin of colour can often be mistaken for acne.” It is also often misdiagnosed in skin of colour for eczema or an allergic reaction, hence why taking a detailed history is crucial.

“In darker skin, the redness associated with rosacea may be less noticeable but can still manifest as hyperpigmentation or dark spots,” says Mojisola Johnson, an aesthetician specialising in Black skin. “Swelling and inflammation may also be present, leading to a persistent or recurrent pattern of skin sensitivity and discomfort.”

Equity in rosacea understanding

“Rosacea is more common in skin of colour than previously described and there should be a higher index of suspicion when patients describe skin sensitivities to common triggers,” says Dr Zamani.

“Representation of conditions in all skin colours is important so we can better diagnose dermatosis and offer better treatment protocols.”

Dr Ejikeme adds, “Representation of skin conditions across all skin types is vital for ensuring equitable access to healthcare and accurate diagnosis. It raises awareness about the diverse ways skin conditions can manifest, reducing misdiagnosis and improving treatment outcomes.”

Dr Mansberg says it’s about fairness: “We can’t treat what we don’t diagnose and we can’t diagnose rosacea if we aren’t listening to our patients. It’s important for us as clinicians to have an open mind about rosacea. Just because someone is not white, it doesn’t mean they don’t have rosacea.

“I’m just hoping people will keep an open mind because successfully treating rosacea is life-changing for sufferers. And our sisters and brothers of colour deserve that skin improvement, too.”

“Representation of skin conditions in all skin types is crucial for raising awareness, improving understanding, and ensuring that individuals from diverse backgrounds receive proper care and treatment,” adds Johnson. “It helps to address disparities in healthcare and promote inclusivity in medical education and research.”

Treating rosacea in skin of colour

“Rosacea isn’t always easy to treat, but it definitely won’t respond to no treatment,” says Mansberg. “The treatment of rosacea is the same regardless of skin colour. But, the most important thing is to get the diagnosis so we can start treatment. That means at least thinking about rosacea if the skin is burning and sensitive and there are pimples and pustules, especially in the mid face.”

Dr Zamani says that rosacea should be on the differential when patients present with acne lesions without comodones or if they are not responding to therapy. “Erythema may not always be visible but a history for triggers and flushing sensation is key,” she adds. “Sun protection is vital, and we need to be aware of proinflammatory hyperpigmentation risk with treatment.”

The best treatments for rosacea in dark skin include gentle skincare routines with non-irritating products. Ingredients like niacinamide, azelaic acid, liquorice extract and green tea extract can help reduce redness and inflammation without causing hyperpigmentation as well as standardised medical treatments such as those defined in NICE guidelines.

As literature is increasingly suggesting that lifestyle, diet and the microbiome play a part in rosacea, Dr Mansberg says to advise clients to keep a diary to try and figure out their triggers which typically includes sunlight, spicy food and alcohol. Recent rosacea research has confirmed that sufferers should only use a cleanser once a day and avoid any cleanser that is alkaline. Allowing skin to dry fully before applying skincare is also thought to be important as stinging is more likely if you put skincare onto wet rosacea skin.

“When rosacea occurs we always recommend discussing this with a GP and getting a referral to dermatology as this is a condition which is eligible for management within the NHS,” adds Dr Ejikeme.