When should I consider referring a patient with rosacea to a dermatologist for further evaluation or treatment?

Consider referring a patient with rosacea to a dermatologist for further evaluation or treatment in the following situations:

• If the patient has severe papules and/or pustules that have not responded to combination therapy in primary care, including oral tetracyclines, as they may require specialist treatment such as oral isotretinoin.
• If there is diagnostic uncertainty, for example in people with darker skin phototypes where erythema and telangiectasia are difficult to detect, and a skin biopsy or dermatoscopy may be needed to confirm diagnosis.
• If moderate-to-severe papules and/or pustules show little or no improvement after initial treatment in primary care.
• If there is severe telangiectasia that has not responded to self-management advice.
• If there is prominent non-inflamed phymatous disease that may require referral to plastic surgery or specialist dermatological interventions.
• If ocular rosacea symptoms are severe, do not respond to optimal primary care management, or if serious eye complications such as keratitis or anterior uveitis are suspected, referral to ophthalmology is indicated.
• For persistent erythema and/or telangiectasia that may benefit from specialist treatments such as laser therapy or electrodessication.

Referral decisions should be based on clinical judgement and local referral guidelines, considering the severity, response to treatment, and diagnostic clarity of the rosacea presentation.

These recommendations are based on the ROSacea COnsensus (ROSCO) international consensus publications, the Dutch clinical guideline, the US National Rosacea Society expert committee publications, and expert opinion in review articles ¹.