Clinical Features, Diagnostic Challenges, and Therapeutic Approaches of Scalp Rosacea: A Literature Review

Scalp rosacea is an uncommon and likely underdiagnosed manifestation of extrafacial rosacea. Since its first description in 1975, scattered reports and small series have identified characteristic features, including erythema, telangiectasias, papules, pustules, and perifollicular scaling in hairless or androgenetic areas of the scalp. Trichoscopy has recently expanded diagnostic accuracy, revealing vascular polygons, arborizing vessels, follicular plugs, and peripilar scaling. Histopathology often demonstrates perifollicular and perivascular lymphocytic infiltration, sometimes associated with Demodex folliculorum. Differential diagnoses include psoriasis, seborrheic dermatitis, lichen planopilaris, dermatomyositis, and contact dermatitis. Therapeutic approaches mirror those used in facial rosacea, including oral tetracyclines, low-dose isotretinoin, adjuvant probiotics, and topical ivermectin and metronidazole. Recent studies highlight the relevance of follicular scaling and scalp involvement as potential markers of disease severity and Demodex proliferation. Despite increasing recognition, standardized diagnostic and therapeutic guidelines are lacking. Scalp rosacea deserves broader awareness to improve recognition and management, and further prospective studies are needed to clarify its pathogenesis and optimize therapeutic strategies.