The exposomal imprint on rosacea: More than skin deep

Rosacea is a chronic, inflammatory dermatosis driven by a complex interplay of genetic, environmental and lifestyle factors, collectively known as the exposome. This review explores how intrinsic contributors such as genetic susceptibility, immune dysregulation, microbiome alterations, hormonal influences and psychosocial stress intersect with extrinsic triggers like ultraviolet radiation (UVR), air pollution, dietary factors, and climate variability to shape rosacea pathogenesis. Recent advances in single-cell transcriptomics have identified fibroblasts as key components of inflammatory and vascular pathways in rosacea. Concurrently, discoveries in non-coding RNAs and RNA modifications reveal subtype-specific molecular signatures and novel biomarkers. Mendelian randomization (MR) studies further reveal causal links between rosacea and autoimmune, metabolic and gastrointestinal comorbidities-that rosacea is more than skin deep. The role of the gut-skin axis, particularly involving small intestinal bacterial overgrowth (SIBO) and Helicobacter pylori infection, reflects the importance of microbial and neuroimmune crosstalk. Disparities in diagnosis and management persist, particularly among individuals with skin of colour (SOC) and those with limited healthcare access. By integrating an exposomal framework, this review advocates for a paradigm shift in rosacea management: from reactive treatment to proactive, exposome-informed intervention. Personalized skincare, microbiome-targeted strategies, dietary modulation and psychosocial support represent emerging pillars in a holistic, precision medicine framework. Future research should prioritize exposome-informed prevention, inclusive care models, and the development of personalized interventiouns that address both cutaneous and systemic facets of rosacea.