Rosacea is not just skin deep; there are significant inflammatory responses in motion that involve the barrier, microbiome, and the relationship with the gut. Even more than just flushing and redness, there are many pathways of inflammation that involve neurovascular events, cascades of cathelicidin activations and different cell lines, and new understandings of the role of triggers. Antibiotics including topical applications have significant impact on the process but have potential consequences in the GI tract when doses are not appropriate for inflammation instead of an infection. The discussion of approaches to treatment goes beyond therapies to include non-prescription treatments, diet modification, and avoidance of triggers: all difficult initiatives for today’s rosacea patients.