Current Clinical Perspectives on Rosacea Management: Insights From a Korean Multicenter Expert Opinion Survey

Abstract

Background

Rosacea is a chronic inflammatory skin disorder characterized by erythema, papules, ocular symptoms, and heightened sensitivity. Patients with neurogenic symptoms such as burning or stinging remain particularly difficult to manage. Current guidelines often underrepresent energy-based devices (EBDs), pigmentary sequelae, psychosocial burden, and ocular comorbidities.

Objective

To examine Korean dermatologists’ expert perspectives on rosacea management, focusing on skin sensitivity, neurogenic symptoms, pigmentary changes, psychosocial impact, ocular involvement, and EBD use.

Methods

A web-based, 29-item survey was administered to 25 board-certified Korean dermatologists (May–June 2025). Quantitative and qualitative responses were analyzed.

Results

Erythematotelangiectatic and papulopustular phenotypes with sensitivity skin predominated. EBDs (pulsed dye laser, intense pulsed light) were frequently used but limited by cost and sensitivity issues. Neurogenic symptoms were recognized but rarely treated with neuromodulators. Post-inflammatory hyperpigmentation was infrequent, yet monitoring was inconsistent. Psychosocial and ocular aspects were acknowledged but seldomly systematically addressed. Respondents expressed interest in emerging adjunctive treatments such as cold plasma, skin boosters, and holistic care approaches.

Conclusion

Korean dermatologists adopt individualized strategies for rosacea, yet practice gaps remain regarding neurogenic symptoms, pigmentary complications, and psychosocial and ocular comorbidities. Findings support the need for updated multidisciplinary, phenotype-driven guidelines aligned with real-world practice.

INTRODUCTION

Rosacea is a chronic inflammatory condition presenting with overlapping features such as erythema, flushing, telangiectasia, papules, pustules, ocular disease, phymatous changes, and heightened skin sensitivity. Global prevalence ranges from 2% to 18%, with variation across ethnicity and skin types¹,².

Recent shifts from subtype-based to phenotype-based classification emphasize individualized, symptom-directed care³,⁴,⁵,⁶,⁷. Yet, implementation remains limited, especially for underrecognized phenotypes such as neurogenic rosacea-marked by burning, stinging, or dysesthesia and often refractory to conventional vascular or anti-inflammatory therapy⁸,⁹,¹⁰.

Additional clinical challenges—energy-based device (EBD) selection, psychosocial burden, ocular involvement, and pigmentary sequelae—are insufficiently addressed in guidelines, leaving clinicians reliant on empirical practice⁶,⁷. Although post-inflammatory hyperpigmentation (PIH) is not part of the formal diagnostic criteria for rosacea, it represents a clinically relevant concern in Asian patients, particularly following EBD treatment, where pigmentary complications may influence therapeutic choices and patient counseling¹¹.

To address these gaps, we conducted a multicenter survey of Korean dermatologists with extensive experience in rosacea and EBDs. The study aimed to characterize diagnostic and therapeutic practices, with emphasis on sensitive skin, neurogenic symptoms, pigmentary concerns, and psychosocial and ocular comorbidities.

MATERIALS AND METHODS

Study design and participants

A cross-sectional web-based survey (May to June 2025) targeted board-certified Korean dermatologists with ≥5 years of clinical experience and active involvement rosacea care, including EBD use. Twenty-five dermatologists participated.

Survey instrument

The 29-item questionnaire, developed by the Korean Society for Dermatologic Laser Surgery Scientific Committee, addressed 9 domains: demographics, diagnosis, skin sensitivity/PIH, psychosocial factors, ocular symptoms, treatment strategies, EBD use, overall perspectives, and free-text comments. A 5-point Likert scale (1=not important at all; 5=very important) assessed perceived importance. The full questionnaire is in Supplementary Data 1.

Data collection and analysis

Surveys were administered via Google Forms. Participation was voluntary and anonymous. Quantitative data were analyzed descriptively; qualitative responses were thematically grouped.

Ethical considerations

This study adhered to the principles of the Declaration of Helsinki. As no patient data were collected and participant risk was minimal, formal ethical review was waived.

RESULTS

Respondent characteristics

Of 25 respondents, 56% were male and 44% female, aged 36–61 years. Most (92%) had >11 years of clinical experience; nearly half had >20 years. Practice settings included academia (44%), private clinics (44%), and hospital-based practice (12%) (Table 1).

Table 1. Demographic and professional characteristics of survey respondents (n=25).

Characteristics		No. (%)
Sex
	Male	14 (56.0)
	Female	11 (44.0)
Age group
	<40 yr	5 (20.0)
	40–49 yr	7 (28.0)
	≥50 yr	13 (52.0)
Years in dermatology practice
	5–10 yr	2 (8.0)
	11–20 yr	11 (44.0)
	>20 yr	12 (48.0)
Practice setting
	Academic institution	11 (44.0)
	Private clinic	11 (44.0)
	Hospital-based practice	3 (12.0)

Diagnosis and clinical assessment

Rosacea was commonly diagnosed (68% daily; 32% weekly). Erythematotelangiectatic and papulopustular phenotypes were most frequent (96% each), followed by neurogenic (44%), phymatous (24%), and ocular (12%). Diagnosis relied primarily on clinical exam (100%) and symptom history (88%), with minimal adjunctive testing (Table 2).

Table 2. Summary of responses to the rosacea expert survey (n=25).

Domain	Survey item		Values
Diagnosis & evaluation	Commonly encountered subtypes*
		ETR	24 (96.0)
		PPR	24 (96.0)
		Neurogenic	11 (44.0)
		Phymatous	6 (24.0)
		Ocular	3 (12.0)
	Diagnostic approach*
		Clinical features	25 (100.0)
		Patient-reported symptoms	22 (88.0)
		Imaging tools including dermoscopy	7 (28.0)
		Mite smear	6 (24.0)
		Skin biopsy	2 (8.0)
		Blood test for differential diagnosis (e.g., SLE)	1 (4.0)
Skin sensitivity & PIH	Experience of patients with skin sensitivity
		Frequently	22 (88.0)
		Occasionally	3 (12.0)
	Frequency of PIH development
		Occasionally	11 (44.0)
		Rarely	10 (40.0)
		Frequently	3 (12.0)
		Never	1 (4.0)
	Actively monitor PIH during treatment
		No	15 (60.0)
		Yes	14 (56.0)
Psychosocial aspects	Psychological burden in rosacea patients
		Frequently	19 (76.0)
		Occasionally	6 (24.0)
	Routinely screen for mental health impact
		No	10 (40.0)
		Only when prompted by patient behavior	8 (32.0)
		Yes	7 (28.0)
	Referred to psychologist/psychiatrist
		No	16 (64.0)
		Yes	9 (36.0)
Ocular symptoms	Encounter ocular rosacea symptoms
		Rarely	12 (48.0)
		Occasionally	11 (44.0)
		Frequently	1 (4.0)
		Never	1 (4.0)
	Routinely screen for ocular involvement
		Yes	9 (36.0)
		Only by patient’s request	9 (36.0)
		No	7 (28.0)
	Referral to ophthalmologist
		Yes	15 (60.0)
		No	10 (40.0)
Treatment approaches	Prescription of neuromodulators or antidepressants
		Rarely	11 (44.0)
		Occasionally	7 (28.0)
		Never	4 (16.0)
		Frequently	3 (12.0)
EBD use	Indications for EBD use*
		Telangiectasia	25 (100.0)
		Persistent erythema	22 (88.0)
		Flushing	12 (48.0)
		Refractory papules/pustules	11 (44.0)
		Patient preference	6 (24.0)
	Main barrier to EBD use*
		Cost	17 (68.0)
		Skin sensitivity	16 (64.0)
		Patient fear	10 (40.0)
		Insufficient evidence	3 (12.0)
		None	1 (4.0)
		Risk of PIH	1 (4.0)
		Lack of access	1 (4.0)
	Recommendation for RF/HIFU in rosacea
		Generally safe	11 (44.0)
		Case-by-case	10 (40.0)
		After erythema control	3 (12.0)
		Not recommended	1 (4.0)
	Number of sessions recommended for initial EBD treatment		18 (72.0)
		4–6 sessions	17 (68.0)
		1–3 sessions	5 (20.0)
		>6 sessions	2 (8.0)
		Other (e.g., CAP >10 sessions)	1 (4.0)
	Typical interval between EBD sessions
		4 wk	15 (60.0)
		2 wk	5 (20.0)
		>8 wk	3 (12.0)
		8 wk	1 (4.0)
		Other (e.g., every 1–2 weeks for CAP)	1 (4.0)
	Maintenance treatment using EBD
		Yes, as-needed	14 (56.0)
		Yes, regularly	6 (24.0)
		Rarely	3 (12.0)
		No	2 (8.0)
Overall perspectives (5-point Likert scale)	Importance of managing skin sensitivity		4.52±0.82
	Importance of PIH prevention		2.52±0.96
	Importance of addressing psychosocial burden		3.56±0.92
	Importance of incorporating EBDs		3.60±0.87

Values are presented as number (%) or mean ± standard deviation.

ETR: erythematotelangiectatic rosacea, PPR: papulopustular rosacea, SLE: systemic lupus erythematosus, PIH: post-inflammatory hyperpigmentation, EBD: energy-based device, RF: radiofrequency, HIFU: high-intensity focused ultrasound, CAP: cold atmospheric plasma.

^*Multiple responses were allowed for select items.

Skin sensitivity and pigmentary concerns

Skin sensitivity was highly prevalent (88% frequently observed). PIH was uncommon (12% frequently, 40% occasional), and only 40% routinely monitored it (Table 2).

Psychosocial and ocular aspects

Psychological distress was reported by 76% of dermatologists, yet only 28% screened routinely, and 36% had ever referred patients to mental health care. Ocular rosacea was reported occasionally (44%) or rarely (48%); 36% screened regularly, and 60% referred to ophthalmology, usually reactively (Table 2).

Treatment approaches and EBD use

Topical ivermectin and oral antibiotics were universal (100%), followed by lifestyle measures (76%) and topical calcineurin inhibitors (68%) (Fig. 1A). EBDs (excluding light-emitting diodes [LEDs]), topical metronidazole, and low-irritation cosmetics were also commonly prescribed¹²,¹³.

Fig. 1. Expert perspectives on rosacea management (n=25).

(A) Commonly adopted treatment modalities. (B) Treatment modalities avoided in patients with sensitive skin. (C) Types of EBDs used in clinical practice. (D) EBDs considered most effective for persistent erythema. Multiple responses were allowed for (A-C); single choice for (D).

EBD: energy-based device, LED: light-emitting diode, LLLT: low-level light therapy, PDL: pulsed dye laser, IPL: intense pulsed light.

Among patients with sensitive skin, the most avoided treatment was low-dose isotretinoin (36%), followed by topical calcineurin inhibitors (32%), EBDs (28%), and botulinum toxin or skin boosters (28%). Notably, 32% of respondents reported no specific treatment restrictions (Fig. 1B).

Neuromodulators agents such as gabapentin or duloxetine were prescribed by only 16% of respondents for patients with neurogenic symptoms, indicating limited integration of these therapies into routine practice (Table 2).

With respect to EBDs, pulsed dye laser (PDL, 595 nm) was the most frequently used device (72%), followed by intense pulsed light (IPL, 60%) and LED/low-level light therapy (48%) (Fig. 1C). PDL was also most often regarded as the most effective modality for managing persistent erythema (64%) (Fig. 1D). All respondents reported using EBDs to treat telangiectasia, and 88% for persistent erythema. Some also applied them to refractory flushing or treatment-resistant papules and pustules. The most cited barriers to EBD use were cost (68%), skin sensitivity (64%), and patient apprehension (40%).

Popular skin rejuvenation devices such as radiofrequency (RF) and high-intensity focused ultrasound were considered safe for rosacea patients by 44% of respondents, while 40% recommended their use only on a case-by-case basis depending on severity. The most common initial EBD regimen consisted of 4–6 sessions (68%), typically delivered at 4-week intervals (60%). For maintenance, 56% provided treatment as needed during flare-ups, whereas 24% recommended regular maintenance therapy (Table 2).

Overall perspectives and clinical priorities

On a 5-point Likert scale, dermatologists rated management of skin sensitivity as the highest clinical priority (mean 4.52±0.82), followed by use of EBDs (3.60±0.87), addressing psychosocial burden rosacea (3.56±0.92), and prevention of PIH (2.52±0.96) (Table 2).

Only 32% of respondents felt that current rosacea guidelines adequately address EBD use or the management of ocular and psychosocial comorbidities. The most frequently cited shortcomings were lack of clear guidance on EBD selection and treatment protocols (33%), insufficient focus on non-pharmacologic counseling (24%), and inadequate coverage of psychosocial (16%) and ocular aspects (16%). One respondent additionally highlighted the importance of considering systemic contributors, such as small intestinal bacterial overgrowth, nutritional status, and sleep disturbances¹⁴,¹⁵,¹⁶.

Free-text responses emphasized the need for phenotype-based treatment strategies tailored to individual symptom profiles (e.g., stinging vs. burning, anxiety vs. stable mood), with corresponding selection of drugs and devices. Blue and red light therapies were proposed as potential options for papulopustular rosacea¹⁷. Newer modalities—including skin boosters, cold atmospheric plasma (CAP), and microneedle RF (particularly those incorporating polynucleotides or hyaluronic acid)—were also recommended for patients with sensitive skin¹⁸,¹⁹,²⁰,²¹.

Additional suggestions included recognizing recurrent chalazion as a diagnostic clue for ocular rosacea and incorporating baseline laboratory testing to enhance diagnostic accuracy. Collectively, these insights highlight the need for structured, practical, and multidisciplinary guidelines that align with real-world dermatologic practice.

DISCUSSION

This expert survey highlights current Korean practices in rosacea management. Diagnosis is clinical, with limited use of ancillary tools. While skin sensitivity is frequently recognized, PIH is seldom monitored. Despite awareness of psychosocial and ocular comorbidities, structured screening and referrals remain uncommon.

Treatment is multimodal, integrating topical/oral therapies, EBDs, and lifestyle interventions. Barriers to EBD use include cost, sensitivity, and a lack of protocols. Respondents emphasized gaps in guidelines, especially regarding neurogenic and ocular phenotypes, EBD protocols, and holistic care.

Neurogenic rosacea remains a particularly challenging entity. First described in 2011, this phenotype is characterized by marked neurovascular dysregulation and poor responsiveness to conventional therapies²². Although neuromodulators such as gabapentin, pregabalin, paroxetine, or carvedilol have been proposed as potentially effective in previous studies, their use was infrequent in this survey (16%)⁸,⁹,²³,²⁴,²⁵. Several factors likely contribute to this underutilization: 1) The current evidence base is limited primarily to small case reports and retrospective case-control studies, with no standardized treatment protocols; 2) Concerns regarding tolerability and adverse effects; patient reluctance to initiate psychiatric or neurologic medications; 3) Lack of insurance coverage in Korea, which imposes additional financial burden; and 4) A prevailing preference for alternative or symptomatic strategies, including EBDs or topical treatments. Collectively, these findings underscore the need for further clinical research and practical guidance on the role of neuromodulators in rosacea management.

Although PIH was infrequent, it remains clinically important in Asian patients, where pigmentary sequelae are usually secondary to EBDs rather than rosacea itself. Incidence rates vary from 2% to 15% depending on wavelength, fluence, and device parameters¹¹. PDL and IPL, the most commonly used devices in this survey, pose greater pigmentation risks in darker skin due to melanin absorption at shorter wavelengths¹¹,²⁶. Strategies such as longer pulse durations, lower fluence, and adequate epidermal cooling are recommended to mitigate these risks¹¹,²⁷, yet fewer than half of respondents reported routine monitoring for PIH, revealing a gap between awareness and practice.

Psychological distress was frequently observed, with 76% of dermatologists reporting symptoms such as anxiety or social withdrawal in their patients. This aligns with prior studies linking rosacea to depression, anxiety, and reduced quality of life²,²⁸. Despite high awareness, few clinicians routinely screened or referred patients for mental health support, highlighting the need for more holistic, patient-centered care models.

Ocular rosacea was often under-recognized despite estimated prevalence rates of 25%–50%²⁹. Inadequate screening may lead to complications such as blepharitis, conjunctivitis, corneal scarring, and in severe cases, vision loss³⁰. While 60% of respondents had referred patients to ophthalmology, only 36% performed routine screening for ocular involvement, and such referrals were largely symptom-driven. These findings emphasize the need for greater clinical vigilance and interdisciplinary collaboration⁷.

PDL and IPL were the most widely used EBDs and perceived as effective, consistent with prior meta-analyses²⁶. Despite their utility, EBD use was hindered by practical concerns, and treatment decisions remained largely experience-based due to a lack of comparative studies and standardized protocols²⁶.

Respondents also expressed interest in newer modalities—such as CAP, microneedle RF, and skin boosters containing polynucleotides or hyaluronic acid—particularly for sensitive or treatment-refractory cases. Blue and red-light therapies were also noted for potential use in papulopustular rosacea¹⁷,¹⁸,¹⁹,²⁰,²¹. Many emphasized patient education on gentle skincare and highlighted systemic factors—nutrition, sleep, stress, and gut health—as important components of holistic rosacea care¹²,¹³,¹⁶.

Several limitations should be acknowledged. First, the relatively small sample size (n=25) restricts statistical power and generalizability, as participation was confined to a select group of dermatologists. Future research should expand participation through multi-institutional or nationwide surveys to improve external validity. Second, the survey relied on self-reported practices and broad response formats, which may not fully capture the nuances of clinical decision-making, including thresholds for therapeutic escalation or treatment intensity. Incorporating case-based scenarios, ranking tasks, or refined Likert scales in future studies would allow for more granular and actionable insights. Third, the absence of universally accepted definitions for emerging phenotypes such as neurogenic, phymatous, and ocular rosacea may have introduced variability in interpretation, underscoring the need for consensus-driven refinements in classification.

Despite these limitations, our study has notable strengths. The short survey period (May to June 2025) was intentionally chosen to minimize recall bias and ensure contemporaneous reporting. Participants were highly experienced dermatologists—over 90% with >11 years of clinical practice—lending credibility despite the limited window. In addition, free-text responses enriched the dataset by capturing nuanced, practice-based perspectives beyond structured survey items, mitigating the limitations of broad question types.

In conclusion, this expert survey highlights the clinical diversity and management complexity of rosacea in Korea. While adoption of phenotype-based assessment and multimodal strategies is growing, gaps persist in addressing neurogenic and ocular subtypes, psychosocial burden, and pigmentary complications- particularly in patients with skin of color. These findings support the urgent need for updated, multidisciplinary, and phenotype-driven guidelines that reflect real-world dermatologic practice and promote more comprehensive, patient-centered care.

SUPPLEMENTARY MATERIAL

Supplementary Data 1

Full survey questionnaire