Based on the presentation by Katerina Grafanaki, “Trigger Factors and Comorbidities,” EADV 2026, Vienna.
Rosacea can manifest in different ways, including facial redness and flushing, inflammatory lesions, burning sensations, or ocular symptoms. According to the phenotype-based approach of the international ROSCO consensus, treatment is tailored to the active manifestations of the disease and their impact on quality of life.
In her presentation, Katerina Grafanaki explores how environmental exposures, diet, sleep, and comorbid conditions may influence the course of rosacea.
Triggers Are Common, but Individual
In a National Rosacea Society survey of 1,066 patients, the most frequently reported triggers were:
| Factor | Percentage of patients reporting a reaction |
|---|---|
| Sun exposure | 81% |
| Emotional stress | 79% |
| Hot weather | 75% |
| Wind | 57% |
| Intense physical exercise | 56% |
| Alcohol | 52% |
| Hot baths | 51% |
| Cold weather | 46% |
| Spicy foods | 45% |
| Humidity | 44% |
| Indoor heat | 41% |
| Certain skincare products | 41% |
These figures reflect patients’ self-reported experiences. They indicate which reactions are commonly reported but do not mean that everyone with rosacea needs to avoid all the listed factors.
Diet: Flare-Ups and Long-Term Associations
The presentation highlights two roles of diet.
The first is triggering flushing and worsening symptoms. Hot foods and beverages, alcohol, capsaicin in hot peppers, and cinnamaldehyde may activate sensitive nerve endings and vascular responses.
The second is the association between habitual dietary patterns and the risk of developing rosacea. In a UK Biobank study involving 198,557 participants, higher scores for healthy plant-based diets were associated with a lower risk of the disease.
The more favorable dietary pattern included whole grains, vegetables, fruits, legumes, and nuts. A less favorable dietary pattern included sugary drinks, desserts, refined grains, and ultra-processed foods. The presentation also noted an association between higher meat consumption and increased risk, while greater consumption of legumes and nuts was associated with lower risk.
These are observational associations: they do not prove that a particular food causes rosacea or that changing one's diet will cure it. The speaker’s recommendation is to identify individual dietary triggers, maintain a balanced diet, and avoid restrictive elimination diets without a clear indication.
Triggers Beyond Diet
Katerina emphasizes the combined effect of environmental exposures: heat, solar radiation, humidity, and sudden temperature changes may act together. Working conditions, overheating, masks, and friction can also play a role.
The presentation also discusses evidence linking air pollution to new cases of rosacea. Poor sleep and anxiety are associated with a greater disease burden, and this relationship may be bidirectional.
Blue light is not presented as an established major trigger. The use of electronic devices and light exposure may be worth discussing if a patient notices a consistent relationship with their symptoms.
Another topic is the influence of information found online. Based on other people's recommendations, patients may change their skincare products or diet, take supplements, or start self-treatment. Therefore, useful questions during a consultation include: “What has changed? What products are you using? Where did this recommendation come from?”
Burning Sensations, Hormonal Changes, and the Microbiome
In patients experiencing pronounced burning sensations, the speaker suggests simplifying skincare and assessing whether a neurogenic component may predominate. Discomfort can be severe even when visible redness is minimal.
A history of topical corticosteroid use is important: prolonged application of these medications to the face may cause rosacea-like dermatitis. Hormonal changes, particularly during perimenopause, may also affect vascular reactivity. Evidence linking specific contraceptive methods to rosacea flare-ups remains limited and, by itself, does not justify discontinuing contraception.
Demodex density and the body's response to the mite may contribute to inflammation. The gut microbiome is also being investigated, although decisions about further testing should take gastrointestinal symptoms into account.
Which Associated Symptoms Matter?
The presentation highlights three groups of comorbidities: migraine, gastrointestinal disorders, and psychological distress.
The coexistence of these conditions does not prove that rosacea causes them. However, asking a few targeted questions may improve patient care:
- For recurrent headaches, clarify their frequency, the presence of aura, and their impact on daily life.
- For persistent gastrointestinal symptoms, take a detailed history and determine whether further investigation is warranted.
- For anxiety, low mood, sleep disturbances, or social avoidance, assess the psychological burden and identify the support needed.
The eyes also require particular attention. Dryness, a gritty sensation, and eyelid inflammation should be discussed with a healthcare professional. Eye pain, light sensitivity, or changes in vision require urgent ophthalmological assessment.
The Main Takeaway
Treat the active manifestations of rosacea while simultaneously identifying one or two of the most significant contributing factors that could be addressed to improve the course of the disease and the patient's quality of life.
This approach takes into account both the condition of the skin and the patient's actual experience, without imposing universal restrictions.