In 2025, the journal JDDG (Journal der Deutschen Dermatologischen Gesellschaft) published a literature review on rosacea in childhood and adolescence, in which the authors systematized and analyzed available information on the epidemiology, pathogenesis, diagnosis, and treatment of this condition in pediatric practice [1].

Rosacea is traditionally perceived as a chronic inflammatory disease of adults, most commonly occurring between ages 30 and 50 and primarily affecting the central face. However, despite this common clinical image, rosacea can debut much earlier: initial manifestations of classic clinical types have been described from infancy onwards. In practice, the diagnosis is often not considered in children and adolescents, leading to underdiagnosed or misdiagnosed cases.

Prevalence: insights from the literature

The authors emphasize that precise data on the incidence and prevalence of rosacea in children and adolescents are lacking. This is a significant finding for clinicians: the actual frequency may be higher than perceived due to diagnostic gaps. It is noted that the first manifestation usually occurs between ages 4 and 8, and the path to diagnosis can take months or even years.

Predisposing factors, as in adults, include light phototypes I–II according to Fitzpatrick (especially in the papulopustular variant), as well as the use of topical or inhaled steroids (particularly in the periorificial variant) [2, 3]. The disease can also occur in children and adolescents with darker skin types. Data on gender differences are inconsistent; although an even distribution is often reported, some studies suggest more frequent and severe ocular manifestations in girls [4].

Pathogenesis: is it different in children?

According to current understanding, the pathogenesis of rosacea in children and adolescents does not differ from that in adults. It develops against a background of genetic predisposition and external triggers, involving several key components: dysregulation of the innate and adaptive immune systems, vasomotor instability, and interaction with microorganisms.

At the molecular level, cathelicidins play a vital role: released by mast cells, among others, they induce proinflammatory mediators and stimulate neovascularization. The increased presence of cathelicidins is linked to higher precursor production and protease expression; induction occurs via TLR2, which is overexpressed in rosacea. Microorganisms (e.g., Staphylococcus epidermidis and Demodex mites) may trigger the immune response through TLR2 activation.

A practical nuance for pediatrics: immunocompetent children with healthy skin generally do not show Demodex colonization, which increases during adolescence. However, successful approaches aimed at reducing Demodex colonization in children with rosacea support a pathophysiological link in this age group, although the presence of Demodex is not required for diagnosis. Triggers generally overlap with those in adults: UV radiation, heat, spicy or hot foods and drinks, topical steroids, and psychological stress [5].

Clinical presentation in children: what to watch for

Diagnosis in childhood, as in adults, is based on clinical findings. The authors note that specific variants and locations pose greater diagnostic challenges in young patients. While internationally approved diagnostic criteria for children do not yet exist, pediatric criteria have been proposed, requiring any two of the following: flushing or persistent facial erythema; facial telangiectasias; papulopustular lesions without comedones; localization on convex areas of the face; or ocular involvement (blepharitis, recurrent chalazion, conjunctivitis, keratitis) [4].

Erythematotelangiectatic Rosacea. Flushes may last longer than a few minutes or become persistent, most often involving the cheeks; they are triggered by heat or UV light. Visible telangiectasias are possible, and this variant may precede papulopustular eruptions.

Papulopustular Rosacea. This is the most frequently described variant in children and adolescents. Acne vulgaris may be present simultaneously, complicating the diagnosis. A key differential feature from acne: comedones are expected in acne, whereas rosacea is typically characterized by their absence, along with flushing, persistent erythema, or telangiectasias.

Idiopathic Facial Aseptic Granuloma (IFAG). This variant is specific to infants and children: a solitary (rarely multiple) erythematous nodule, usually located infraorbitally or on the cheeks, without peripheral signs of inflammation. The nodule typically regresses spontaneously without scarring after about one year. This phenotype is not seen in adults [2].

Ophthalmorosacea: A Key Distinction in the Pediatric Group. According to the review, ocular lesions occur in up to 60% of children and adolescents—more frequently than in adults [3, 4]. In about half of young patients, ocular symptoms may precede cutaneous signs or occur in isolation, making recognition difficult. The early and leading finding is meibomian gland dysfunction with inflammation spreading to the ocular surface. Recurrent inflammation of the eyelid margin can serve as a vital diagnostic marker for distinguishing it from acne vulgaris.

Treatment of pediatric rosacea: review recommendations (off-label)

Treatment is primarily based on adult strategies but must account for age restrictions and the fact that all therapeutic options in children are effectively used off-label [1, 5].

Basic measures (essential for almost all patients):

• Identification and avoidance of triggers (heat, UV, irritating external agents, including steroids).
• Use of mild cleansers and soothing topical agents.
• Daily UV protection.

Topical therapy for mild to moderate severity includes topical metronidazole, 15% azelaic acid (noting potential transient stinging), 1% ivermectin cream, and topical calcineurin inhibitors (pimecrolimus, tacrolimus), which are considered well-tolerated options [1, 5].

Systemic therapy for severe forms (typically for 8–12 weeks):

• Macrolides (azithromycin, erythromycin, clarithromycin): can be used before age 9 [2, 3].
• Doxycycline: possible from age 9; contraindicated in younger children due to the risk of enamel and bone defects [3, 5].
• Isotretinoin: only isolated reports for severe cases; low doses have shown a good response.

Ophthalmorosacea: Often requires a long-term regimen that includes eyelid hygiene, artificial tears, and, if necessary, topical or systemic antibiotics (macrolides or tetracyclines). Interdisciplinary management by a dermatologist and an ophthalmologist is emphasized [1, 4].

Prevention and skincare for children with rosacea focuses on long-term trigger control and supportive care: minimizing provocative factors (UV, heat, irritating agents, steroids), mild cleansing without aggressive irritants, using soothing topical agents, and regular daily sun protection. For patients with ocular manifestations, basic care includes consistent eyelid hygiene and the use of artificial tears [1, 5].

Clinical implications

Although rosacea typically starts after age 30, it can also start in childhood and may be mistaken for more common conditions. Suspicion should increase when central erythema/flushing and papulopustules without comedones are present, especially alongside signs of ocular involvement (blepharitis, recurrent chalazia), which are frequent in children and often appear before skin lesions. Therapy follows adult logic but remains almost entirely off-label, requiring careful consideration of age and an interdisciplinary approach for ocular symptoms [1].

References

1. Korsing S., Stieler K., Pleyer U. et al. Rosacea in childhood and adolescence: a review. J Dtsch Dermatol Ges 2025; 23: 684–691. https://doi.org/10.1111/ddg.15693
2. Noguera-Morel L., Hernández-Martin A., Torrelo A. Childhood rosacea and related disorders. Clin Exp Dermatol 2021; 46(3): 430–437.
3. Gonser U., Gonser C.E., Deuter C. et al. Systemic therapy of ocular and cutaneous rosacea in children. J Eur Acad Dermatol Venereol 2017; 31(10): 1732–1738.
4. Chamaillard M., Mortemousque B., Boralevi F. et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol 2008; 144(2): 167–171.
5. Clanner-Engelshofen B.M., Bernhard D., Dargatz S. et al. S2k-Leitlinie: Rosazea. J Dtsch Dermatol Ges 2022; 20(8): 1147–1167.