Rosacea is a chronic inflammatory skin condition of the central face driven by immune dysregulation, genetic predisposition, epidermal barrier dysfunction, and microbial dysbiosis. Recent evidence implicates both the gut and skin microbiomes-through direct immune interactions and the gut-skin axis-in driving cutaneous inflammation and disease severity, with an increase in proinflammatory species such as Demodex folliculorum, Staphylococcus epidermidis, and Bacillus oleronius alongside a decline in protective species such as Cutibacterium acnes. Therapeutic strategies now aim to restore microbial balance using narrow-spectrum antibiotics, anthelmintics, topical and oral probiotics, and microbiome-friendly skin care to reduce inflammation, reinforce skin barrier function, and improve clinical outcomes. Future research to refine precision treatments that target specific microbial and immune pathways would be beneficial to modulate dysbiosis and improve outcomes in rosacea.