Update on Facial Erythema in Rosacea

August 2021 | Volume 20 | Issue 8 | Original Article | 861 | Copyright © August 2021


Published online July 19, 2021

Richard L. Gallo PhDa, Hilary Baldwin MDb, Linda Stein Gold MDc, Julie Harper MDd

aDepartment of Dermatology, University of California – San Diego, CA
bDepartment of Dermatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
cDepartment of Dermatology Clinical Research, Henry Ford Health System, Detroit, MI
dDermatology and Skin Care Center of Birmingham, AL

Abstract
Dermatologists are cognizant of the multiple clinical manifestations of rosacea, particularly persistent facial erythema, which has been deemed to be the most prevalent diagnostic feature and often poses a significant negative impact on quality of life. To address the need to recognize rosacea as a single disease with multiple potential phenotypes, a new classification system has been developed by 28 clinical and scientific experts worldwide.

INTRODUCTION

Dermatologists are cognizant of the multiple clinical manifestations of rosacea, particularly persistent facial erythema, which has been deemed to be the most prevalent diagnostic feature and often poses a significant negative impact on quality of life. To address the need to recognize rosacea as a single disease with multiple potential phenotypes, a new classification system has been developed by 28 clinical and scientific experts worldwide. This is a paradigm shift in the way the disorder is assessed and seeks to improve how rosacea is treated by physicians. Therapies focusing on erythema are often used in combination with treatments for other manifestations of the disorder, and optimal outcomes are achieved when treatments target specific phenotypes while partnering with the patient to determine expectations and improve proper and regular medication use.

The National Rosacea Society (NRS) recently organized a roundtable discussion of thought leaders in rosacea to discuss facial erythema in light of the new standard classification system, recent burden-of-illness studies, the new standard management options and significant advances in medical therapy and patient care. The main discussion points are summarized in this article.

Recent developments in rosacea call for clinicians to place greater emphasis on persistent facial erythema, one of the most common and troublesome features of the disorder, now designated as its most prevalent diagnostic phenotype. New therapies, often used in combinations, are increasingly addressing this manifestation, and are most successfully employed when collaborating with the patient to identify expectations, ensure effective application, and achieve optimal outcomes.

Clinicians should now consider rosacea as a single disease with multiple potential phenotypes. Drawing from current scientific knowledge as well as clinical experience, the recently updated standard classification of rosacea has shifted away from subtypes and identifies the various phenotypes that may occur in many possible combinations in individual patients (Table 1).1 Persistent facial erythema is a diagnostic phenotype, and phymatous changes, although less common, are also diagnostic. Major signs include papules and pustules, flushing, telangiectasia, and certain ocular manifestations. The presence of any two of the major phenotypes also may be considered diagnostic, and secondary phenotypes include burning, stinging, edema, and dryness. Rosacea therefore encompasses a multitude of possible combinations of signs and symptoms.

An important advantage for physicians in using the new classification system is its emphasis on a diverse collection of individual signs and symptoms, as well as their potential interrelationship. Notably, recent studies have shown that rosacea’s features, from erythema to papules and pustules to phymatous changes, appear to be part of a consistent continuum of inflammation.2-5 Although rosacea’s various phenotypes may appear in different combinations and at different times, research suggests that they all may be manifestations of this underlying inflammatory process, and that rosacea may evolve