Patient-focused Solutions in Rosacea Management: Treatment Challenges in Special Patient Groups

July 2019 | Volume 18 | Issue 7 | Original Article | 608 | Copyright © July 2019

Ahuva Cices MD, Andrew F. Alexis MD MPH

Skin of Color Center, Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY

diagnostic challenges), protective effects of melanin from ultraviolet (UV) radiation, and a lower incidence of genes conferring susceptibility in diverse populations.3,4 Recognizing diagnostic challenges posed by masking of clinical features by increased epidermal melanin are necessary to prevent delayed diagnosis, disease progression, and advanced disease, which result in greater morbidity and even disfigurement.3

Pathophysiology of rosacea is likely multifactorial, involving abnormal responses to environmental stressors in individuals with genetic predispositions leading to immune and neurovascaular dysregulation.9 Genetically predisposed individuals have an abnormal response to environmental stressors such as UV exposure, temperature changes, microbial antigens (eg, Demodex folliculorum, Heliobacter pylori), and emotional stress that results in Th1/Th17 polarization.4

Studies finding increased risk with positive family history, twin studies with high concordance, and genome association studies support the important role of genetics in rosacea.4 A cohort-based twin study evaluating the role of genetics and environmental factors in rosacea calculated the genetic contribution to rosacea development to be 46%.9 Genome-wide association studies isolated three human leukocyte antigen (HLA) alleles with known association to autoimmune disease including type I DM and celiac disease within a large population of European descent.10 Additional studies are needed to further elucidate the complex interplay of genetics and environment in rosacea.

Diagnosis and Classification
Rosacea is a clinical diagnosis based on physical exam and history that can have a wide range of presentations.5 Guidelines from the National Rosacea Society (NRS) published in 2012 pioneered criteria for rosacea diagnosis and categorization defined by the presence of one or more primary features: flushing, persistent erythema, papules, pustules, and telangiectasia with variable presence of secondary features: burning, stinging, erythematous plaques, dryness, edema, ocular manifestations, and phymatous changes.2 Furthermore, the NRS identified four rosacea subtypes: erythematotelangiectatic (ETR), papulopustular (PPR), phymatous, and ocular, with one variant: granulomatous based on presence of combinations of various primary and secondary disease features.2 Though this classification of rosacea is still currently in use and enabled the development of significant clinical and therapeutics advancements in rosacea management, it falls short in its failure to accurately address the broader scope of clinical presentations.5 Oversimplification of the disease into distinct categories overlooks the fact that often features of multiple subtypes are present simultaneously creating a more complex clinical picture and furthermore, there is often progression from one subtype to another over time.5,11 These shortcomings were addressed by the global ROSacea COncensus (ROSCO) consensus panel, which put forth the first set of guidelines for phenotype driven management, which will be further discussed in the management section of this paper.11

Overall, ETR is the most common subtype of rosacea, followed by PPR.2 Important differences in skin of color include higher reported frequency of PPR compared to ETR (likely due to difficulty recognizing features of ETR in dark skin), as well as increased prevalence of the granulomatous subtype (Figure 2).3 Phymatous changes, most often seen in older males, are frequently observed in combination with ETR or PPR.2 Ocular rosacea is frequently diagnosed when other features of rosacea are present to aid in the diagnosis, with nearly 50% of patients experiencing onset of cutaneous symptoms prior to ocular symptoms.5

Recently, there has been a shift towards a phenotype-led approach, which more accurately reflects patients seen in clinical practice and has important therapeutic implications, further discussed in the treatment portion of this review.11 This is especially significant in patients with disease not fitting the prototypical descriptions such as those with skin of color who are less likely to be identified as having predominant telangiectasia and erythematous changes in the skin. Additionally, the current classification system perpetuates the lack of evidence-based research and investigation of less prevalent, but high morbidity subtypes such as phymatous and ocular rosacea.11

Rosacea remains under recognized in skin of color, however, there are tools readily available to assist with this oftentimes-challenging diagnosis. Patient history can provide vital information that is not obtainable on exam: this can include a description of burning or stinging sensations, a family history of rosacea or mixed heritage, and even a history of acne that failed to respond to standard treatments.3 On exam, it may be difficult to appreciate features of erythema and telangiectasia due to masking by constitutive skin pigmentation, but other features such as dryness and edema may be visible on the central face or acneiform papular and pustular lesions