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Stages of Rosacea


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First off what are 'stages' of rosacea?  Usually in past literature on rosacea, stages refer to the 'subtypes' of rosacea that are progressive as though a rosacea sufferer 'steps' through each 'stage' of a subtype or diagnostic features of rosacea usually from mild to worse.  

Stages of Rosacea a Myth that has been Debunked

In many reports on rosacea, especially those written in the past, rosacea is spoken of as progressing in stages and that the progression leads to rhinophyma (Phenotype 5). For example, note this report from Better Medicine, Heathgrades, discussing the 'stages of rosacea" from mild to moderate to severe to rhinophyma rosacea, implying that rosacea progresses in stages. [1] A CNN Health Report on the Stages of Rosacea in 2017 continues this myth. You may find similar reports that imply or state that rosacea progresses into stages. Harvard Medical School continues to refer to the four stages of rosacea. [6] The term 'stages' of rosacea has been used extensively in rosacea papers in the past and continues to be used to describe an implied progression from mild to worse skin conditions. [7]

However, current thought on this subject is far from this idea and simply isn't proven to be true. This is an example of the 'butterfly effect in rosacea" due to 'initial conditions' of a false myth.

Papers that Debunk This False Myth

“The notion that the erythematotelangiectatic stage generally transforms into the papulo-pustular, inflammatory stage is simply wrong and grossly misleading. Firstly, the papulo-pustular stage mainly occurs in males in whom rosacea is a more serious disease at all stages. The papulo-pustular stage is actually uncommon in females.” [2]

“Rosacea is often divided into four stages, according to the progressive nature of the condition. However, the progression is not absolute. For unknown reasons, certain patients may skip a stage. Others experience ocular symptoms as the first manifestation of the condition.” [3]

One report concluded that "A small proportion of rosacea subjects may progress between subtypes." [4]

"Although rosacea findings may change over time, no proven natural progression exists.[5]

Phenotype Classification vs Subtype Classification

Also, there is controversy on the classification of rosacea into subtypes and variants which is related to this subject. Current types are now considered to be phenotypes, so the subtype classification is not the current classification. The Phenotype classification is superior to the subtype classification. There is no data suggesting that you move progressively through the six phenotypes of rosacea. While you may have more than one phenotype at the same time, there is nothing indicating you will progress in stages through each one. How does the phenotype classification work?


While any rosacea sufferer may indeed have a case of rosacea that gets worse, it does not mean that every rosacea sufferer progresses from a mild stage of rosacea into stages that get worse. The consensus is that if you fail to treat rosacea it may get worse, but not necessarily in 'stages' which is usually referring to the former subtypes and now is considered the phenotypes of rosacea. However, the consensus is that a rosacea sufferer does not necessarily move from one 'stage' into a more progressively worse 'stage' or that every rosacea suffer does this, furthermore, only a small percentage progresses from one 'stage' into another 'stage.' 

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End Notes

[1] "In the early stage, rosacea causes redness that comes and goes on the cheeks, nose, forehead, or chin....As rosacea gets worse, the facial redness grows more noticeable and long-lasting...In the most advanced stage of rosacea, the skin is a deep shade of red....In advanced rosacea, the nose sometimes grows red, swollen, and bumpy, a condition called rhinophyma.

The Stages of Rosacea, Better Medicine, Heathgrades

Other papers and sites that refer to the stages of rosacea:

"It progresses in stages known as pre-rosacea, mild rosacea, moderate rosacea and severe rosacea and has periods of exacerbation and remission."  The Four Stages of Rosacea, Pulse Light Clinic, 31 March 2015, Rosacea Nutritional Advice

"Several classifications of the disease exist. In France, Edouard Grosshans described four stages…German schools described only 3 stages, like experts from the National Rosacea Society (NRS), who described four subtypes…" 
Ann Dermatol Venereol. 2014 Sep;141 Suppl 2:S151-7.  doi: 10.1016/S0151-9638(14)70152-8.
[Signs and symptoms of rosacea]
J-L Schmutz  

"4 progressive stages of rosacea and symptoms may vary depending on the stage."
Rosacea, SummitMD Dermatology 

[2] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman , M.D., Ph.D.
Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.
The William J. Cunliffe Lectureship 2003—Manuscript

[3] Consult Your Pharmacist
Differentiating Between Rosacea and Acne
W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD candidate :U.S. Pharmacist

[4] Br J Dermatol. 2013 Apr 21. doi: 10.1111/bjd.12385. [Epub ahead of print]
An observational cross-sectional survey of rosacea: Clinical associations and progression between subtypes.
Tan J, Blume-Peytavi U, Ortonne JP, Wilhelm K, Marticou L, Baltas E, Rivier M, Petit L, Martel P.
Department of Medicine, University of Western Ontario, London, Ontario and Windsor Clinical Research Inc., Windsor, Ontario, Canada.

[5] Am Fam Physician. 2015 Aug 1;92(3):187-196.
Rosacea: Diagnosis and Treatment

[6] Rosacea, Harvard Health Publishing, Harvard Medical School 

[7] United European Gastroenterol J. 2015 Feb; 3(1): 17–24 refers to the 'four stages of rosacea' in its article on H pylori with the following statement: 

There are four stages of rosacea:

I: frequent flushing, irritation caused by topical preparations

II: facial erythema that becomes more persistent, slight telangiectasias, increased skin sensitivity

III: persistent, spreading erythema, oedema, papules, pustules, enlarged pores, ocular changes

IV: tissue hyperplasia, fibroplasias, rhinophyma) and connective-sebaceous hypertrophy may occur with possible deformation of the affected skin in the late stages.

Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea
AG Gravina, A Federico, E Ruocco, A Lo Schiavo, M Masarone, C Tuccillo, F Peccerillo, A Miranda, L Romano, C de Sio, I de Sio,1 M Persico, V Ruocco, G Riegler, C Loguercio, and M Romano

Edited  by Guide

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