From Red-Cheeked Baby to Bulbous Nose: Rosacea, Start to Finish

At Maui Derm NP+PA Summer 2026 in Colorado Springs, Hilary Baldwin, MD, medical director of the Acne Treatment & Research Center at Atlantic Health and associate professor of dermatology at SUNY Downstate Medical Center, used a single theoretical patient to trace rosacea from infancy through old age, illustrating how the disease's presentation and treatment shift at each stage of life.¹

Rather than presenting isolated cases, Baldwin built 1 composite patient who developed nearly every rosacea subtype in sequence: pediatric erythema, background erythema and telangiectasias, flushing, papulopustular disease, and finally phymatous and ocular disease as an older adult. The format let her walk clinicians through the full differential of facial redness and match each subtype to its appropriate treatment.

Pediatric Rosacea Is Easy to Miss

Baldwin noted that pediatric rosacea occurs in an estimated 4% or fewer of children and often goes unrecognized because red cheeks can appear benign, even endearing.

“Rosacea is not something that's talked about very much and usually doesn't require treatment because the red cheeks are sort of cute, but they can get papules, and the ocular disease requires treatment because it can become serious,” Baldwin told HCPLive.

She added that many children with rosacea continue to have the disease into adulthood. Published pediatric data remain sparse; one review found initial manifestations typically appear between ages 4 and 8, with underdiagnosis common because of overlap with acne vulgaris.²

Not All Redness Is the Same Redness

A central theme of the case was distinguishing between types of facial erythema, since each responds to a different treatment approach. Background erythema, “the hallmark of rosacea,” according to Baldwin, typically responds to the alpha agonists brimonidine or oxymetazoline.

Flushing, defined as intermittent redness with normal skin in between episodes, is harder to treat and was managed in this case with carvedilol. Randomized data support this approach: a controlled trial found oral carvedilol produced greater reduction in erythema and flushing than topical brimonidine, with parallel improvement in anxiety and depression scores.³ Botulinum toxin is an alternative but carries cost barriers, limited insurance coverage, and a risk of facial muscle paralysis, Baldwin said.

Erythema tied directly to active papules tends to resolve once the papules are treated. By contrast, telangiectasias, do not respond to topical or oral therapy and require energy-based treatment.

A Counseling Pearl On Alpha Agonists

Baldwin highlighted a common source of patient confusion: telangiectasias can appear more prominent once background erythema is treated with an alpha agonist. She explained that the vessels are not actually worsening, but they stand out more once the surrounding redness fades. She recommended pointing out any telangiectasias before starting alpha agonist therapy so patients do not attribute their appearance to the medication.

Papulopustular Disease Remains The Most Treatable

Baldwin described papules and pustules as the easiest rosacea subtype to manage. Among 5 available topical options, she favors ivermectin, topical minocycline, and microencapsulated benzoyl peroxide. The 2 oral options, modified-release doxycycline and a newer long-acting low-dose minocycline (Emrosi), are dosed below antimicrobial thresholds, allowing clinicians to treat effectively while supporting antibiotic stewardship. The minocycline option, approved by the FDA in November 2024, demonstrated superiority over both placebo and modified-release doxycycline for inflammatory lesion reduction across 2 phase 3 trials.⁴

Late-Stage Disease: Phyma And Ocular Involvement

The case closed with the patient as an older adult with rhinophyma and ocular rosacea. Baldwin cited a prevalence of roughly 50% for ocular involvement among patients with rosacea, though the prevalence has a reported range from 10% to 50%.5

Ocular disease generally responds to tetracyclines. She also pointed to evidence supporting ivermectin applied to the face and eyelids as a treatment option for ocular symptoms. A small pilot study of patients with combined cutaneous and ocular rosacea found significant improvement in dry eye symptoms and clinical signs after once-daily topical ivermectin 1% cream.⁶

“We shouldn't ignore red-cheeked babies and red-cheeked young children, because they may indeed have rosacea that requires treatment in response to the same kind of treatment as adult rosacea,” Baldwin said.

Editor’s note: Reported disclosures for Baldwin include Galderma Laboratories, L.P, Ortho Dermatologics, a division of Bausch Health US, LLC, SUN PHARMACEUTICAL INDUSTRIES INC., LNHC, Inc, GENZYME CORPORATION, Journey Medical Corporation, and Novartis Pharmaceuticals Corporation.

References

1. Baldwin H. Acne and Rosacea Update 2026. Session presented at the Maui Derm NP+PA Summer 2026 meeting in Colorado Springs.

2. Korsing S, Stieler K, Pleyer U, Blume-Peytavi U, Vogt A. Rosacea in childhood and adolescence: A review. J Dtsch Dermatol Ges. 2025;23(6):684-691. doi:10.1111/ddg.15693

3. Li L, et al. Carvedilol ameliorates persistent erythema of erythematotelangiectatic rosacea by regulating the status of anxiety/depression. J Dermatol. 2022. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/1346-8138.16525

4. Journey Medical Corporation Announces U.S. FDA Approval of Emrosi (Minocycline Hydrochloride Extended Release Capsules, 40 mg) for the Treatment of Rosacea. November 4, 2024. Available at: https://ir.journeymedicalcorp.com/new-events/press-releases/detail/75/journey-medical-corporation-announces-u-s-fda-approval-of

5. Mohamed-Noriega K, Loya-Garcia D, Vera-Duarte GR, et al. Ocular Rosacea: An Updated Review. Cornea. 2025;44(4):525-537. doi:10.1097/ICO.0000000000003785

6. Sobolewska B, Doycheva D, Deuter CM, Schaller M, Zierhut M. Efficacy of Topical Ivermectin for the Treatment of Cutaneous and Ocular Rosacea. Ocul Immunol Inflamm. 2021;29(6):1137-1141. doi:10.1080/09273948.2020.1727531