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 affects one in 10 people in the UK, with most in the 30-to-50-year-old age group, or who have 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 color.
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). But, 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 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 (SOC) 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!”
What is rosacea and what causes it?
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,” Dr Ifeoma Ekijeme says.
“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 Dr Maryam Zamani.
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 erythematotelangiectatic rosacea which causes flushing/redness or papulopustular rosacea which causes pimples and pustules - the driver of these are largely unknown.
“We still don’t know exactly what causes rosacea,” says Dr Mansberg.
“We know our 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 might play as well.”
How does rosacea show up 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 doesn’t occur in darker-skinned people doesn’t.
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.”
“Instead of the classic redness, rosacea may manifest as brown or purple discolouration, making it less noticeable or mistaken for other conditions,” says Dr Ejikeme.
“The history of flushing however is universal and a diagnosis can be made effectively based on the history.”
“Misdiagnosis or underdiagnosis is common because facial flushing and telangiectasia may be more difficult to see and may appear more like pigmentation issues,” says Zamani. “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 Dr Ejikeme adds.
"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."
The importance of 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.”
“Representation of skin conditions across all skin types is vital for ensuring equitable access to healthcare and accurate diagnosis,” says Dr Ejikeme. “It helps raise awareness about the diverse ways skin conditions can manifest, reducing misdiagnosis and improving treatment outcomes.”
“It’s about fairness,” says Dr Mansberg. “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 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."
How to treat rosacea in skin of colour
“Rosacea isn’t always easy to treat, but it definitely won’t respond to no treatment,” Mansberg continues. “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.”
“Rosacea should be on the differential when patients present with acne lesion 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. Sun protection is key! And we need to be aware of proinflammatory hyperpigmentation risk with treatment,” adds Dr Zamani.
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.
As for ingredients Dr Mansberg says:
- Prescription vitamin A is effective but often irritating, so gentler forms of Vitamin A, particularly Retinal, is often touted as a tool for Rosacea management. There is a small study which showed retinal (Tretinoin’s gentle precursor) combats redness and telangiectasia or broken capillaries in rosacea. Retinol has not been studied specifically for rosacea.
- Niacinamide (vitamin B3) has been found in studies to reduce trans epidermal water loss so as to improve the skin’s hydration and combat sensitivity. It’s also very well tolerated, and a couple of tiny trials have found benefits specifically for rosacea skin. That’s why many doctors suggest it is used in a 4-5% concentration for rosacea.
- No good studies of panthenol for rosacea have been done and yet a consensus statement from Asian dermatologists recommended panthenol as an important skincare ingredient to manage sensitivity and dryness in people with rosacea.
Dr Mansberg says that if no improvement is seen with these ingredients, it is worth advising clients to visit their GP.
“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,” adss Dr Ejikeme.