NEW YORK — There is a consensus that rosacea is unusual in anyone who does not have a light skin type and Northern European ancestry, but one expert maintains this a persistent misimpression reinforced by missed cases.

Textbooks “tell us that rosacea is concentrated in women, those 40 years of age or older, and in those with White skin,” but this is “not totally true,” said Hilary Baldwin, MD, who is affiliated with the Rutgers Robert Wood Johnson Medical Center, New Brunswick, New Jersey, and is the medical director of the Acne Treatment and Research Center, Brooklyn, New York.

Although rosacea may be less common in people with darker skin types, she said that the challenges to diagnosis make it hard to judge how much less common it is in these patients.

“Patients with darker skin tones are rarely diagnosed with rosacea even when there are symptoms consistent with the diagnosis,” she said, observing that rosacea in Black people or others with darker skin “is by no means rare.”

Two Issues Explain Low Rates of Rosacea in Black Individuals

The problem is twofold, according to Baldwin, who spoke at the Skin of Color Update (SOCU) 2026.

The first is that the classic signs of phymatous skin and erythema concentrated in the midface are difficult to see in patients with darker skin types. The second is the accepted premise that rosacea is unusual in darker skin creates a bias that impedes recognition.

Baldwin suggested a work around. Rather than discounting the possibility of rosacea in a patient with a darker skin type, “think instead in terms of symptoms,” she said. Avoiding the bias that rosacea is uncommon in darker skin types, a focus on symptoms can be useful for including rosacea in the differential diagnosis regardless of skin color.

For a practical strategy in darker skin types, Baldwin offered the acronym ALTER as a mnemonic for both rosacea diagnosis and management. These letters stand for Ask questions, Look for nonclassic signs, use Tools for diagnosis, Educate patients on skin care, and Recommend sunscreen.

Even if the classic signs of rosacea are more difficult to see on dark skin, the symptoms are generally similar across skin types.

The questions that help the clinician stay focused on symptoms rather than skin appearance include: Do you feel a sense of warmth come and go? Does your skin itch, sting, or burn? Do your eyes itch or burn? Do you associate your symptoms with triggers, such as skin products or other skin exposures that cause irritation?

Positive answers to these questions should bring rosacea to mind, according to Baldwin. When inspecting the skin, she suggested not only looking for papules, pustules, and phymatous changes that are typical of rosacea, but also to consider signs that are not always needed to diagnose rosacea in lighter skin, such as edema, dry skin, and conjunctival involvement.

Erythema Does Not Always Mean Red Skin

The difficulty of seeing erythema, a hallmark symptom of rosacea, in darker relative to lighter skin types is well known, but the term erythema does not exclude colors other than pink or red, according to textbooks. Other types of discoloration, including purple or brown hues in dark skin, are often the manifestation of erythema in darker skin tones.

These types of discoloration are identifiable to those who are looking for them, but Baldwin suggested further aids to help increase confidence. Dermoscopy, for example, is effective for visualizing the characteristic telangiectasias of rosacea in dark skin types. She also suggested diascopy, which involves pressing a clear pane of glass, such as a microscope slide, against the skin to look for blanching indicative of erythema.

There are plausible reasons to support the idea that rosacea is less common in patients with darker skin types, even if it is not rare, according to Baldwin. Noting that the pathophysiology of rosacea includes a diminished skin barrier function, she cited evidence that skin in Black people has lower ceramide levels, which is a surrogate for barrier function, compared with either White or Asian people. In addition, darker skin is less reactive to ultraviolet light, a known trigger of rosacea. A lower genetic predisposition to rosacea in individuals with dark skin has also been suggested.

If these factors reduce the risk for rosacea, however, there is plenty of evidence that racial differences or skin melanin content does not eliminate risk. Baldwin said that epidemiologic data in textbooks generally place the risk for rosacea at about 2% in patients with darker skin types relative to 10% in the overall population. In some countries, such as Ireland, rosacea rates approach 15%.

But, again, the difficulty of recognizing rosacea in darker skin types and the likelihood that clinicians do not consider this diagnosis outside of skin types in which it seems most common makes these estimates suspect, Baldwin noted.

Rosacea in Black Skin Is Undertreated

This is highly consistent with a series of studies on rosacea in patients with skin of color led by Andrew Alexis, MD, MPH, professor of clinical dermatology at Weill Cornell Medical Center in New York City. In a review paper published in 2019, he and his coauthors also argued that rosacea is not rare in patients with skin of color but is likely commonly overlooked leading to diagnostic delays and undertreatment.

“There is a great deal of evidence that rosacea is reported less often in patients with darker skin because the diagnosis is missed,” Alexis told Medscape Medical News. “The biggest problem is that it just does not come to mind in skin-of-color patients.”

The ways to treat and reduce risk for rosacea, such as using anti-inflammatory antibiotics and sunscreens, do not differ by skin type in general, although both Baldwin and Alexis cautioned that there is a greater risk for iatrogenic hyperpigmentation in Black than White individuals caused by irritating therapies.

However, Alexis led a 2012 study showing that oral doxycycline was similarly effective and well tolerated for rosacea in Fitzpatrick skin types IV to VI relative to types I to III. Treatment success defined as an investigator global assessment score of 0 or 1 was achieved in 74.6% and 74.3% of patients with these lighter and darker skin types, respectively.

To improve the diminished barrier function associated with rosacea, Baldwin recommended frequent use of moisturizers in patients with light or darker skin, but she highlighted ivermectin 1% cream, minocycline 1.5% foam, and microencapsulated benzoyl peroxide 5% as topicals to considers specifically in Black patients for their low irritating properties.

“To avoid hyperpigmentation, I like to use topical products that offer the best efficacy and tolerability,” she said, explaining these choices. She called traditional products, such as metronidazole and azelaic acid, “not terribly effective and quite irritating.”

Baldwin reported having financial relationships with Beiersdorf, Galderma, Kenvue, La Roche-Posay, L’Oreal, Ortho Dermatologics, and Sun Pharmaceuticals. Alexis reported having financial relationships with AbbVie, Allergan Almirall, Alphyn Biologics, Alumis, Amgen, Apogee, Arcutis, Boehringer Ingelheim, Botanix, Bristol-Myers Squibb, Canfield, Castle Biosciences, Dermavant, Genentech, HairDays, Incyte, Johnson & Johnson, LEO Pharma, Elli Lilly, L’Oreal, Novartis, Ortho Dermatologics, Oruka, Pfizer, Sanofi-Regeneron, Swiss American, Symrise, UCB, Veradermics, and VisualDx.

Ted Bosworth, a career medical writer based in New York City, has been covering advances in clinical medicine, including dermatology and oncology, for several decades.