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type 3 (described later), may occur along with the primary features or appear inde- pendently. Rarely, one or more of these features is present at a peripheral site, such as the scalp, ears, neck, chest, and back. 13 Patients may actively participate in the diagnosis process by providing an assessment of the severity of the condi- tion using the 0 to 3 scale described in Table 1. 13 They may provide a global assessment, describe the physical char- acteristics of the disease, and detail the psychological, social, and occupation- al effects of rosacea on their lives. 13 Because it may be misdiagnosed as acne, photodermatitis, seborrheic dermatitis, or contact dermatitis, rosacea must be differentiated from a variety of other skin conditions that have a similar pre- sentation. 1 Rosacea can be differentiated from acne by a number of characteristics. Acne can occur over the majority of the body. Rosacea occurs almost exclusively on the nose, face, and cheeks. Those with acne generally have oily skin com- pared with the typically dry facial skin associated with rosacea. Acne lesions include cysts, whiteheads, and black- heads; rosacea has only papules. In addi- tion, the flushing/blushing characteristic of rosacea is absent in acne. Classification and Subtypes Rosacea diagnosis may include deter- mining the appropriate subtype and fur- ther classifying it as mild, moderate, or severe based on the system devel- oped by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. 13 The subtypes (Figure 1 13 ) are defined based on visible clinical features and associated symp- toms that are most commonly seen with the particular subtype 14 : Subtype 1: Erythematotelangiectatic (ETR)—characterized by flushing and persistent erythema; telangiectases are common but not required. 13 Subtype 2: Papulopustular (PPR)— characterized by persistent erythema, transient papules, and/or pustules; sting- ing and burning sensations are common but not required for diagnosis. 13 Subtype 3: Phymatous—character- ized by thickened skin, enlargement, and nodules with irregular surface; most commonly occurs on the nose (rhino- phyma) but may also be seen on the chin, forehead, cheeks, and ears; telan- giectases and enlarged pores may also be present. 13 Subtype 4: Ocular—characterized by conjunctivitis, watering, and redness of the eyes; grittiness or feeling that there is a foreign body in the eye; photosensi- tivity; and eyelid swelling. Progressive, untreated disease can damage the cor- nea, iris, and sclera, leading to visual impairment and blindness. 15 Ocular rosa- cea may occur in conjunction with other rosacea subtypes in as many as 50% of cases. 2 Complicating the ability to correctly classify rosacea is the presence of a variant type called granulomatous rosa- cea, which is characterized by reddish- brown nodules or papules. 12 In addition, patients may exhibit more than one type of rosacea concurrently. 12 For example, a patient may show symptoms of ocular rosacea along with PPR. Patients may also develop different types of rosacea in succession. If not appropriately managed, rosacea may progress over time. 12,13 Symptoms of FIGURE 1: ROSACEA SUBTYPES 13 Subtype 4, ocular rosacea, may include a watery or bloodshot appearance, telangiectasia of con- junctiva and lid margin, or lid and periocular erythema.Blepharitis, conjunctivitis, and irregularity of the eyelid margins also may occur. A, mild; B, moderate; C, severe. Reprinted from J Am Acad Dermatol, 50, Wilkin J, Dahl M, Detmar M, et al, Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea, 907-912, Copyright (2004), with permission from Elsevier. Subtype 1, erythematotelangiectatic rosacea, is characterized by flushing and persistent central facial erythema. Telangiectases are common but not essential for diagnosis. A, mild; B, moderate; C, severe. Subtype 2, papulopustular rosacea, includes persistent central facial erythema with transient pap- ules, pustules, or both in central facial distribution. A, mild; B, moderate; C, severe. Subtype 3, phymatous rosacea, may include thickening skin, irregular surface nodularities, and enlargement. Patulous, expressive follicles may appear in phymatous area, and telangiectases may be present. A, mild; B, moderate; C, severe. 112 PharmacyTimes.org December 2015 CONTINUING EDUCATION