Persistent facial erythema in acne vulgaris and rosacea: differential diagnosis, clinical assessment, and phenotype-oriented management — a narrative review in pediatric and adult dermatology

Objective — to synthesize evidence on the differential diagnosis, assessment, and phenotype-oriented management of persistent facial erythema in acne vulgaris and rosacea in pediatric and adult dermatology. Materials and methods. PubMed/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar were searched for English-language publications from 2016 to 2026. Clinical guidelines, consensus statements, original studies, and systematic and narrative reviews were analysed. Evidence was synthesized narratively according to the principal clinical phenotypes and their key implications for management. Results and discussion. Erythema surrounding palpable inflammatory lesions in the presence of comedones supports active acne, whereas flat macules at sites of previous lesions indicate acne-induced macular erythema. Symmetrical centrofacial redness with flushing, telangiectasia, burning, or stinging favours rosacea. Diffuse erythema accompanied by dryness, scaling, or discomfort suggests treatment-related irritation or epidermal barrier dysfunction. Standardized photography, dermoscopy, colour analysis, and barrier measurements may support monitoring but cannot replace clinical evaluation. Assessment should consider lesion morphology, distribution, treatment exposure, and skin phototype. Overlapping phenotypes should be documented separately to guide individualized treatment decisions. Management in adolescents and adults should target the dominant phenotype through acne control, barrier restoration, rosacea-directed therapy, or selected laser- and light-based procedures. Conclusions. Persistent facial erythema comprises distinct clinical phenotypes requiring separate assessment and individualized management. No energy-based modality has demonstrated universal superiority.