Grading System for Rosacea

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Rosacea is a common and chronic, relapsing skin disease that is often characterized by transient or persistent redness of the face, the prominence of blood vessels in the skin, and the presence of numerous papules and pustules. Most patients will exhibit one or more of the typical signs and symptoms of rosacea and they will often undergo a series of remissions and flare-ups throughout their lifetime. At present, there is no medical consensus on the causes of rosacea and there is no specific cure other than the control and treatment of its signs and symptoms and the proper management of potential triggers.

In order to establish a consistent framework for the clinical management of and research on rosacea, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea formulated a standard grading system to promote the uniform assessment of rosacea. The standard grading system provides a rating scale for the primary and secondary features of rosacea and a global assessment based on four sub-types of the disease based on a combination of the clinical manifestations of rosacea and the severity of its impact on the patient, including its psychological, social and occupational effects.


Primary and Secondary Features of Rosacea

Rosacea can be diagnosed based on the presence of one or more of its primary features on the central area of the face. These primary features are as follows:

  • Transient erythema – the patient has a tendency of excessive blushing or flushing
  • Non-transient erythema – the patient often experiences persistent redness in his or her facial skin
  • Papules and pustules – there are crops of red and dome-shaped papules and pustules throughout the skin
  • Telangiectasia – tiny dilated vessels can be seen on the skin


In addition, rosacea can also exhibit secondary features that can either co-exist with the primary features or occur independently. These secondary characteristics include:

  • Burning or stinging sensation, with or without scaling and dermatitis
  • Elevated red plaques
  • Rough, scaly, dry central facial skin that looks like eczema or dermatitis
  • Oedema, often accompanying or following facial erythema or flushing
  • Ocular symptoms ranging from burning or itching eyes, bloodshot eyes, eyelid inflammation, and corneal damage
  • Occurrence of rosacea at sites other than the face, such as the neck, scalp, ears and back
  • Overgrowth of sebaceous glands, open skin pores and skin thickening


Grading of Rosacea

In assessing the primary signs and symptoms of rosacea, clinicians will grade them on a four-point scale usually based on visual observation of their frequency, duration, extent and severity and their progression throughout the patient’s history, In some cases, more detailed assessments can be done using advanced technology. The rating scale consists of: absent – 0; mild – 1; moderate – 2; and severe – 3. On the other hand, the secondary features can be simply graded as either absent or present.

The clinical scorecard for assessing rosacea is provided below:





Primary Features
Flushing(transient erythema)
Non-transient erythema
Papules and pustules
Secondary Features
Burning or stinging
Dry appearance
 If present:





 If chronic:




Ocular manifestations
Peripheral locations
 If present:

List location/s

Phymatous changes
Global Assessment
Physician’s rating by sub-type
  Sub-type 1 – Erythematotelangiectatic
  Sub-type 2 – Papulopustular
  Sub-type 3 – Phymatous
  Sub-type 4 – Ocular
Patient’s global assessment


In assessing papules and pustules, the number of papules and pustules should be recorded and their severity graded using the following scale:



No. of Papules/Pustules












Global Assessment by Sub-Type

Sub-type 1: Erythematotelangiectatic rosacea –Flushing and persistent redness (erythema) of the center of the face, which may or may not be accompanied by telangiectasia (dilated vessels)

Sub-type 2: Papulopustular rosacea – Persistent facial erythema with transient papules in the center of the face

Sub-type 3: Phymatous rosacea – Thickening of the skin, with irregular and enlarged nodules on the nose, chin, forehead, cheeks or ears

Sub-type 4: Ocular rosacea – Sensation similar to having a foreign body in the eye, burning or stinging, dryness, itching, light sensitivity, blurred vision, dilated blood vessels and oedema of parts of the eye

The global assessment for each sub-type is according to should be performed with a scale of 0 to 3 based on a composite of the severity and extent of the signs and symptoms at the time of the examination. The rating should also take into consideration the duration of the signs and symptoms throughout the patient’s history. The patient’s participation and involvement in the diagnosis and treatment of rosacea are critical since the ultimate goal is to control the condition and minimize its adverse impact on the life of the patient.

Because of this, the patient is also required to provide a global assessment of the severity of their condition using a scale of 0 to 3 based on both the physical manifestations of rosacea and its impact on their quality of life, including the psychological, social and occupational effects.


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