Rosacea is widely underdiagnosed in patients with skin of color, largely because traditional diagnostic frameworks rely heavily on visible redness that can be masked by skin pigmentation. Experts argue that shifting toward phenotype-based assessments can help clinicians catch missed cases of phymatous and ocular disease.
Why Traditional Rosacea Criteria Miss Patients of Color
Rosacea is frequently missed in patients with skin of color not because the condition itself is rare, but because diagnostic models traditionally depend on signs that are difficult to see on pigmented skin. Vascular symptoms central to older classification systems can be masked by epidermal melanin,
according to medical researchers writing in a systematic review published on September 15, 2026.
This reliance on transient flushing and persistent facial redness creates a significant equity gap in dermatology. When clinical suspicion remains low and visible erythema is obscured, physicians often fail to recognize underlying disease activity during routine examinations. Hilary Baldwin, MD, medical director of the Acne Treatment & Research Center in Brooklyn, New York, and clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical School, highlighted these diagnostic hurdles at the Skin of Color Update 2026 event held in New York, New York.
Subtype Shifts Across Demographics and Publication Eras
Erythematotelangiectatic rosacea, which is characterized by visible vessels and persistent redness, appeared as the most common subtype overall at 54.8%. However, its recorded frequency jumped significantly in Japanese, Middle Eastern, and Korean cohorts compared to Caucasian patients.
Conversely, phymatous rosacea—a presentation marked by skin and tissue thickening rather than flushing—showed an entirely different distribution across populations.
| Rosacea Subtype | Most Frequently Reported Demographics | Key Clinical Characteristic |
|---|---|---|
| Erythematotelangiectatic | Japanese (87.1%), Middle Eastern (74.3%), Korean (65.2%) | Persistent redness and visible vessels |
| Phymatous | South Asian (100.0%), Black (58.3%) | Skin and tissue thickening |
| Ocular | Black (50.0%), Middle Eastern (15.2%) | Eye involvement and irritation |
| Papulopustular | Black cohorts (79.2%) | Papules and pustules |
Phymatous rosacea predominated in studies published prior to 2002, while papulopustular presentations led the literature from 2002 to 2016. Studies published between 2017 and 2025 saw erythematotelangiectatic rosacea take the majority share at 56.1%.
Moving Toward Phenotype-Based Frameworks
The mismatch in how rosacea manifests across different populations points to a need for updated diagnostic standards. Researchers noted that focusing exclusively on vascular redness causes clinicians to miss non-erythematous signs like tissue thickening or ocular involvement, which may be more readily documented in darker skin tones simply because they are easier to spot.
Our findings support the transition toward the 2017 ROSCO [Rosacea COnsensus] phenotype-based framework.
Researchers, Systematic Review on Rosacea Presentation
Adopting this framework allows clinicians to evaluate individual features—such as papules, phymatous changes, and ocular signs—independently, rather than requiring a single subtype label anchored to visible flushing. Yet obstacles remain in the existing research base. The authors acknowledged that their analyzed cohorts featured varying representations, including South Asian, Black, Chinese, Japanese, Middle Eastern, and Caucasian patients. Furthermore, inconsistent reporting of race, ethnicity, and Fitzpatrick phototypes across historical literature continues to obscure the line between true epidemiological differences and recording gaps.