Rosacea is not a condition that only affects fair-skinned people. The global prevalence is approximately 5.46%, and while the classic presentation — flushed cheeks, visible blood vessels, persistent redness on a pale background — is well-described in Fitzpatrick I–III, rosacea also occurs in Fitzpatrick IV–VI skin. The difference is not in who gets it but in how it looks, how quickly it is diagnosed, and what can go wrong with treatment.
In darker skin, erythema may appear brown, violet, or dusky rather than red. Telangiectasia (visible blood vessels) may be invisible to the naked eye and require dermatoscopy to detect. Flushing may be experienced as burning or stinging without visible color change. The result is delayed diagnosis, misdiagnosis, and patients who are told they have acne, contact dermatitis, or hyperpigmentation when what they have is rosacea.
This article covers what the evidence says about rosacea in skin of color: why it is missed, how to identify it, which topical and oral treatments are appropriate, and how to choose laser and light-based devices safely when vascular treatment is indicated.
Why rosacea is missed in skin of color
The 2017 update to the rosacea classification by the National Rosacea Society Expert Committee (Gallo et al., published in the Journal of the American Academy of Dermatology) established that two features are independently diagnostic: persistent centrofacial erythema with periodic intensification, and phymatous changes. In the absence of these, diagnosis requires two or more major features: flushing, telangiectasia, inflammatory lesions (papules and pustules), and ocular manifestations.
The ROSCO (ROsacea COnsensus) 2019 panel update explicitly addressed the diagnostic challenge in skin of color, noting that "melanin can camouflage erythema and telangiectases, leading to underdiagnosis or underappreciation in skin phototypes V and VI." The panel recommended that clinicians pay greater attention to minor features — burning, stinging, dry sensation — and to patient history including facial flushing, failed acne treatments, and family history of rosacea.
A 2022 article in Drugs in Context by Maliyar and Abdulla (PMC9165629) provided specific guidance on managing rosacea in skin of colour. The authors noted that patients with darker skin tones and rosacea frequently experience misdiagnoses and delayed diagnoses, negatively impacting quality of life and disease progression. Features that should raise clinical suspicion include a history of facial stinging or burning, experiences of facial flushing, a history of acne diagnosis with failed acne treatments, and centrofacial distribution of papules and pustules.
The diagnostic blind spot is partly structural. Most dermatology training materials, clinical atlases, and published images of rosacea feature Fitzpatrick I–III skin. The AAD's public information page on rosacea notes that in darker skin tones, rosacea creates areas of darker skin or dusky brown coloring rather than the classic pink or red — but this presentation is underrepresented in the literature that clinicians train on.
What rosacea looks like in darker skin
The phenotypic presentation differs by skin tone:
| Feature | Fitzpatrick I–III | Fitzpatrick IV–VI |
|---|---|---|
| Persistent erythema | Red, pink | Brown, violet, dusky |
| Flushing | Visible redness | May be invisible; burning/stinging reported |
| Telangiectasia | Visible to naked eye | May require dermatoscopy |
| Papules/pustules | Similar | Similar, but accompanied by PIH risk |
| Phymatous changes | Similar | Similar, may be detected later |
One underrecognized cause of rosacea in skin of color is steroid-induced rosacea from the use of topical corticosteroids in skin-lightening products. Maliyar and Abdulla (2022) flagged this as a diagnostic consideration, particularly in patients who have used over-the-counter lightening creams containing unauthorized potent steroids. The resulting condition can mimic or worsen rosacea while simultaneously thinning the skin barrier.
The clinical implication is that a clinician examining a patient with Fitzpatrick V–VI skin who reports facial burning, intermittent swelling, and papules on the cheeks and nose should consider rosacea even if visible erythema is not apparent. A history of failed acne treatments is a particularly important clue — standard acne therapies (benzoyl peroxide, retinoids) can worsen rosacea by increasing irritation in an already inflamed skin barrier.
There is also emerging evidence that rosacea may be more severe when it does present in skin of color. Data presented at the 2025 AAD meeting (reported by Clinical Advisor) found that Black patients had 5.31 times higher odds of severe rosacea compared to White patients. Whether this reflects delayed diagnosis, diagnostic access, or a biological difference is not yet clear — but it reinforces the importance of early recognition.
Topical and oral treatments: what changes in skin of color
The treatment approach for rosacea in skin of color follows the same principles as in lighter skin, with modifications for PIH risk and barrier sensitivity.
Papulopustular rosacea
First-line topicals. The NRS treatment algorithm (updated 2025) recommends ivermectin 1% cream (Soolantra), metronidazole 0.75% or 1% (Metrogel, Noritate), and azelaic acid 15% gel (Finacea) as first-line topical options for papulopustular rosacea.
For skin of color specifically, azelaic acid has dual relevance: it treats the inflammatory component of rosacea and simultaneously addresses the post-inflammatory hyperpigmentation that often accompanies rosacea lesions in darker skin. Maliyar and Abdulla (2022) noted that clinicians should "beware of postinflammatory hyperpigmentation risk with irritating cosmeceuticals and topical therapies for rosacea in skin of colour." Azelaic acid's favorable PIH profile makes it a practical first choice.
Ivermectin 1% cream has anti-inflammatory and anti-Demodex activity. It takes longer to show results than metronidazole but may produce longer-lasting improvement. It is generally well-tolerated in skin of color, though the vehicle can be drying in patients with already compromised barriers.
Metronidazole is the most established topical for rosacea, with decades of safety data. It is well-tolerated across all Fitzpatrick types.
Topical minocycline foam (Zilxi) received FDA approval for moderate-to-severe papulopustular rosacea. A study by Gold et al. published in JAAD (2020;82:1166-1173) supported its efficacy. The foam formulation is less irritating than some gel vehicles, which is relevant for barrier-sensitive darker skin.
Oral therapy. Subantimicrobial-dose doxycycline (40 mg modified-release, Oracea) is the standard oral treatment for moderate-to-severe papulopustular rosacea. It provides anti-inflammatory activity without antibiotic effects at this dose. Extended-release minocycline (Emrosi) is a newer oral option, FDA-approved in November 2024 for inflammatory lesions of rosacea. Phase 3 trials (MVOR-1 and MVOR-2) demonstrated superiority over both doxycycline 40 mg (Oracea) and placebo for IGA success and inflammatory lesion count reduction.
For refractory papulopustular rosacea, low-dose isotretinoin may be considered, with the same monitoring requirements and teratogenicity precautions as in acne treatment.
Persistent erythema
Brimonidine gel 0.33% (Mirvaso) and oxymetazoline cream 1.0% (Rhofade) are alpha-adrenergic agonists that constrict blood vessels, temporarily reducing erythema for up to 12 hours. The AAD notes that daily use for a year or longer may help reduce overall erythema intensity over time.
For skin of color, the utility of these agents is nuanced. The erythema they target may be less visible in darker skin, and the benefit may be more about symptom relief (reduced warmth, burning) than cosmetic improvement. Maliyar and Abdulla noted that redness-reducing topical therapies are "most appropriate in Fitzpatrick skin phototypes III and IV," suggesting diminishing visible benefit in Fitzpatrick V–VI.
A practical consideration: some patients experience rebound erythema with brimonidine — paradoxical worsening when the vasoconstriction wears off. This effect has been reported more frequently with brimonidine than with oxymetazoline.
Laser and light-based devices for vascular rosacea
When topical and oral therapy do not adequately control the vascular component — persistent erythema and telangiectasia — laser and light-based devices become relevant. The choice of device and settings is critical in skin of color.
PDL (pulsed dye laser): the evidence base, applied cautiously
PDL at 595 nm targets oxyhemoglobin and is the most studied vascular laser for rosacea. The FDA approved PDL for vascular disorders in 1986. A meta-analysis by Zhai et al. (2024, Journal of Cosmetic Dermatology, PMC11626304) analyzed the efficacy of IPL and PDL in rosacea management and confirmed that PDL is effective for reducing erythema and telangiectasia.
Standard rosacea parameters for PDL include a 10-mm spot size, 6-ms pulse duration, and 7 J/cm² with cryogen cooling — a protocol published in the Indian Journal of Dermatology, Venereology and Leprology (IJDVL) guidelines for vascular laser treatment.
For darker skin, PDL requires modification:
- Extended pulse durations reduce purpura and lower the peak power delivered to the epidermis.
- Aggressive epidermal cooling (cryogen spray) is essential to protect melanin-rich skin from thermal injury.
- Lower fluence starting points and conservative titration.
- Test spots before full-face treatment.
The IJDVL guidelines note that darker-skinned patients may experience epidermal sloughing after PDL and recommend waiting 3–6 months between sessions to allow any PIH to resolve. This extended interval means the treatment course is longer for darker skin.
Purpura (bruising) lasting 7–14 days is common with PDL at purpuric settings. Subpurpuric settings avoid bruising but require more sessions for equivalent results. The IJDVL guidelines cite that purpura-free long-pulsed PDL is effective in 75% of cases for rosacea-associated telangiectasia at subpurpuric thresholds.
Nd:YAG 1064 nm: the safer wavelength for darker skin
The 1064 nm Nd:YAG wavelength has lower absolute melanin absorption than 585 nm or 595 nm, meaning less energy is absorbed by the epidermis and more reaches the deeper vascular targets. The IJDVL guidelines describe 1064 nm as "very safe for type V skin" in the context of vascular treatment.
Eremia and Li reported 75% clearance of facial telangiectasia at 1 month in 97% of sites treated with 1064 nm Nd:YAG. The wavelength's deeper penetration (5–6 mm coagulation depth) also allows treatment of broader-caliber vessels that PDL may not reach.
The Excel V platform (Cutera) offers both 532 nm (KTP) and 1064 nm wavelengths, allowing the provider to select the safer 1064 nm wavelength for darker-skinned patients while reserving 532 nm for lighter skin or specific vascular indications.
IPL: elevated risk in darker skin
IPL (500–1200 nm broadband) can be effective for rosacea in lighter skin. Schroeter et al. demonstrated 78% response rate with less than 1% recurrence over 3-year follow-up. Taub reported 83% reduced redness, 75% reduced flushing, and 64% fewer acneiform breakouts after 1–7 IPL sessions.
For skin of color, however, IPL is generally not recommended as first-line for rosacea. The broadband output includes significant energy at wavelengths absorbed by epidermal melanin, and the risk of PIH, hypopigmentation, and burns increases with melanin density. The IJDVL guidelines note that IPL is safest for Fitzpatrick I–III. Competing melanin chromophores can shield the targeted hemoglobin, reducing efficacy while increasing risk.
If IPL is used in Fitzpatrick IV skin, longer pulse durations, lower fluence, aggressive cooling, and test spots are mandatory. IPL for rosacea in Fitzpatrick V–VI should be avoided by most providers.
Fractional non-ablative lasers (1550 nm): targeting water, not melanin
Fractional photothermolysis at 1550 nm targets tissue water rather than melanin or hemoglobin. The IJDVL guidelines describe this wavelength as "especially beneficial for Fitzpatrick skin type IV–VI" because non-specific thermal injury to melanin-rich epidermis is unlikely. The fractionated delivery avoids bulk heating.
This approach does not directly target the vascular component of rosacea, but the collagen remodeling and barrier improvement may help with the inflammatory component. It is an adjunctive option rather than a primary vascular treatment.
A staged approach for skin of color
For a patient with Fitzpatrick IV–VI skin and rosacea, a reasonable treatment sequence:
Stage 1: Diagnosis and medical management. Confirm the diagnosis. Start appropriate topical therapy (azelaic acid or ivermectin as first-line, given azelaic acid's dual benefit for PIH). Add subantimicrobial doxycycline if topical alone is insufficient. Optimize barrier care and trigger avoidance.
Stage 2: Erythema management. If persistent erythema is a significant concern, consider oxymetazoline or brimonidine for temporary relief. Be aware of the rebound risk with brimonidine.
Stage 3: Vascular device therapy, if needed. If topical and oral therapy have not adequately controlled erythema and telangiectasia, and the patient wants device-based treatment:
- First choice for Fitzpatrick IV–VI: 1064 nm Nd:YAG. Lower melanin absorption, deeper vessel penetration, established safety in darker skin.
- Second choice: PDL 595 nm with modified settings (subpurpuric, extended pulse duration, aggressive cooling, test spots first).
- Avoid as first-line in Fitzpatrick V–VI: IPL.
Stage 4: Maintenance. Rosacea is chronic. Device treatments reduce visible vessels but do not cure the underlying condition. Maintenance sessions every 6–12 months are typical. Continue topical therapy throughout.
Cost and practical considerations
U.S. cost ranges per session (2025–2026 data):
| Treatment | Cost per session | Sessions typically needed |
|---|---|---|
| PDL (Vbeam) | $400–800 | 2–4 |
| Nd:YAG vascular | $400–800 | 2–4 |
| IPL for rosacea | $300–600 | 3–5 |
| Combination laser + IPL | $500–1,000 | 3–6 |
Insurance generally does not cover laser treatment for rosacea, as it is classified as cosmetic. Topical prescriptions (metronidazole, azelaic acid, ivermectin) may be covered.
Questions to ask
- Could my symptoms be rosacea even though I don't look red? In darker skin, yes. Burning, stinging, papules, and flushing without classic redness are consistent with rosacea.
- Does my provider have experience diagnosing rosacea in skin of color? If rosacea was not considered in the differential diagnosis despite compatible symptoms, this is a gap.
- If laser treatment is recommended, which wavelength will be used? For Fitzpatrick IV–VI, the answer should favor 1064 nm Nd:YAG or PDL with modified settings over IPL.
- Will test spots be performed? For darker skin, test spots are standard practice before full-face vascular laser treatment.
- What happens if PIH develops after laser treatment? The provider should have a specific protocol that includes topical intervention and adjusted treatment intervals.
Sources
- Gallo RL, et al. Standard Classification and Pathophysiology of Rosacea: The 2017 Update by the NRS Expert Committee. JAAD, 2018;78(1):148-155.
- Thiboutot D, et al. Standard Management Options for Rosacea: The 2019 Update by the NRS Expert Committee. JAAD, 2020;82:1501-1510.
- Maliyar K, Abdulla SJ. Dermatology: How to Manage Rosacea in Skin of Colour. Drugs in Context, 2022;11:2021-11-1. PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC9165629/
- Nguyen C, et al. Rosacea: Practical Guidance and Challenges for Clinical Management. Clinical, Cosmetic and Investigational Dermatology, 2024;17:175-190. PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC10821660/
- Zhai Q, et al. Meta-Analysis of the Efficacy of IPL and PDL Therapy in the Management of Rosacea. Journal of Cosmetic Dermatology, 2024;23(12):e16549. PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC11626304/
- Piccolo D, et al. Effective Treatment of Rosacea and Other Vascular Lesions Using IPL. Journal of Clinical Medicine, 2024;13(6):1646. PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC10970793/
- Srinivas CR, Kumaresan M. Lasers for Vascular Lesions: Standard Guidelines of Care. Indian J Dermatol Venereol Leprol, 2011;77:349-368. https://ijdvl.com/lasers-for-vascular-lesions-standard-guidelines-of-care/
- National Rosacea Society. Rosacea Treatment Algorithms, 2025. https://www.rosacea.org/physicians/rosacea-treatment-algorithms
- AAD. Rosacea: Diagnosis and Treatment. https://www.aad.org/public/diseases/rosacea/treatment/diagnosis-treat
- Alexis AF, et al. Global Epidemiology and Clinical Spectrum of Rosacea, Highlighting Skin of Color. JAAD, 2019;80(6):1722-1729.
