A retrospective study in a Tunis teaching hospital from 1990- 2003 included 244 rosacea cases with predominantly Fitzpatrick phototype IV–V and found a prevalence of 0.2%.4,10
Sun exposure (64%) was the most frequent trigger, followed by thermal stimuli (25%). The diagnosis of rosacea was made using symptoms and clinical features in 185 patients and histological findings in 59 patients. Erythematotelangiectatic type occurred in 12%, papulopustular rosacea in 69%, and rhinophyma in 3.7% of patients. The mean duration between the onset of rosacea symptoms and the first consultation was about 20 months.10
A study of rosacea in Korea included one hundred sixty-eight patients diagnosed with rosacea from March 2002 through February 2007.11 The global assessment with physician rating subtypes revealed 47(92.2%) males and 115(98.3%) females presented erythematotelangiectatic rosacea, and 23 (45.1%) males and 62 (53.0%) females showed papulopustular subtype.11 The study showed that sun exposure in this population correlated with erythematotelangiectatic type rosacea.11
Finally, a Colombian study showed a prevalence of rosacea of 2.85%, which was the highest reported in Latin America.17
Skin Barrier Dysfunction and SOC Rosacea Patients
Genetic and exogenous factors may trigger rosacea in predisposed patients. Upregulation and dysregulation of the innate immune system and neurovascular dysregulation are essential mechanisms involved in rosacea.2,23-26 These mechanisms start activating inflammatory cascades leading to acute and chronic inflammation and acute and chronic changes in the facial vasculature.23-26 Patients with rosacea present with an impaired skin barrier function which could be at the root of the condition or a consequence of activated and chronic inflammation.24,27
The intact skin barrier prevents excess water loss and thwarts toxins and dysbiosis. However, harsh chemicals, surfactants, exfoliants, and aggressive cleansers – especially those with a high pH - can damage the skin barrier.24,27
Rosacea mainly affects sebaceous gland-rich facial skin. Molecular analysis of permeability barrier alterations in papulopustular rosacea compared to healthy sebaceous glandrich skin showed significant alterations in the cornified envelope and intercellular lipid lamellae formation, desmosome, and tight junction organizations, barrier alarmins, and antimicrobial peptides.28 The researchers concluded that these permeability barrier alterations in papulopustular rosacea at the molecular level highlight the importance of barrier repair therapies for rosacea.28
The lesional skin of patients is characterized by significantly increased pH and transepidermal water loss and significantly decreased skin hydration levels, indicating skin barrier dysfunction.29 Inflammatory skin disease processes such as atopic dermatitis, psoriasis, and acne are associated with barrier deficiency.28,29 Conversely, exogenously initiated barrier dysfunction and dysbiosis of the cutaneous microbiota may cause or exacerbate the disease state.24-29 To which extent this applies to rosacea is unclear for various ethnic skin types and requires further research.
Rosacea Diagnosis in SOC Patients
Statement 2: A history of "skin sensitivity" (e.g., burning, stinging from many OTC skincare products) should raise suspicion for diagnosing rosacea in SOC patients.
The clinical diagnosis of rosacea is based on visual assessment and patient history, excluding other conditions, such as contact dermatitis, seborrheic dermatitis, photodamage, acne vulgaris, and cutaneous lupus, and carcinoid syndrome.2 Classification of rosacea comprises a patient-focused phenotype approach reflecting the myriad clinical presentations of rosacea patients.1,2 Rosacea commonly affects the central face with erythema and lesions prominent on the cheeks, forehead, chin, and nose.1,2 Symptoms of rosacea include facial flushing, stinging, burning, and itching.1,2 To avoid misdiagnosis of rosacea in SOC, dermatologists should consider rosacea in the differential diagnosis of any patient presenting with a history of skin sensitivity, central facial erythema, papules, and pustules.30
Patients with rosacea often complain of low tolerance to skincare. A Chinese retrospective case-control survey of 997 rosacea cases and 1012 skin-healthy controls showed a low tolerance to skincare in the past five years before the onset of rosacea.31 The chi-square test and the logistic regression analysis revealed a low tolerance of the facial skin to skincare in the rosacea group compared to the controls.31 The history of facial skin allergic reaction was related to the severity of self-reported symptoms of rosacea, including dryness, burning, stinging, and itching.31
Statement 3: To avoid underdiagnosis of rosacea in SOC, dermatologists should also have a high index of suspicion of rosacea in SOC patients presenting with facial erythema, papules, and pustules.
Challenges in diagnosis have been described in populations with SOC, which may contribute to disparities in treatment.5,8,15 The clinical presentation of rosacea across diverse ethnic skin types includes the spectrum of clinical subtypes.6,9,16 Particularly, erythema and telangiectasia may be challenging to recognize in richly pigmented skin types.15-19,22,30
Moreover, the lower index of suspicion and difficulties in
Sun exposure (64%) was the most frequent trigger, followed by thermal stimuli (25%). The diagnosis of rosacea was made using symptoms and clinical features in 185 patients and histological findings in 59 patients. Erythematotelangiectatic type occurred in 12%, papulopustular rosacea in 69%, and rhinophyma in 3.7% of patients. The mean duration between the onset of rosacea symptoms and the first consultation was about 20 months.10
A study of rosacea in Korea included one hundred sixty-eight patients diagnosed with rosacea from March 2002 through February 2007.11 The global assessment with physician rating subtypes revealed 47(92.2%) males and 115(98.3%) females presented erythematotelangiectatic rosacea, and 23 (45.1%) males and 62 (53.0%) females showed papulopustular subtype.11 The study showed that sun exposure in this population correlated with erythematotelangiectatic type rosacea.11
Finally, a Colombian study showed a prevalence of rosacea of 2.85%, which was the highest reported in Latin America.17
Skin Barrier Dysfunction and SOC Rosacea Patients
Genetic and exogenous factors may trigger rosacea in predisposed patients. Upregulation and dysregulation of the innate immune system and neurovascular dysregulation are essential mechanisms involved in rosacea.2,23-26 These mechanisms start activating inflammatory cascades leading to acute and chronic inflammation and acute and chronic changes in the facial vasculature.23-26 Patients with rosacea present with an impaired skin barrier function which could be at the root of the condition or a consequence of activated and chronic inflammation.24,27
The intact skin barrier prevents excess water loss and thwarts toxins and dysbiosis. However, harsh chemicals, surfactants, exfoliants, and aggressive cleansers – especially those with a high pH - can damage the skin barrier.24,27
Rosacea mainly affects sebaceous gland-rich facial skin. Molecular analysis of permeability barrier alterations in papulopustular rosacea compared to healthy sebaceous glandrich skin showed significant alterations in the cornified envelope and intercellular lipid lamellae formation, desmosome, and tight junction organizations, barrier alarmins, and antimicrobial peptides.28 The researchers concluded that these permeability barrier alterations in papulopustular rosacea at the molecular level highlight the importance of barrier repair therapies for rosacea.28
The lesional skin of patients is characterized by significantly increased pH and transepidermal water loss and significantly decreased skin hydration levels, indicating skin barrier dysfunction.29 Inflammatory skin disease processes such as atopic dermatitis, psoriasis, and acne are associated with barrier deficiency.28,29 Conversely, exogenously initiated barrier dysfunction and dysbiosis of the cutaneous microbiota may cause or exacerbate the disease state.24-29 To which extent this applies to rosacea is unclear for various ethnic skin types and requires further research.
Rosacea Diagnosis in SOC Patients
Statement 2: A history of "skin sensitivity" (e.g., burning, stinging from many OTC skincare products) should raise suspicion for diagnosing rosacea in SOC patients.
The clinical diagnosis of rosacea is based on visual assessment and patient history, excluding other conditions, such as contact dermatitis, seborrheic dermatitis, photodamage, acne vulgaris, and cutaneous lupus, and carcinoid syndrome.2 Classification of rosacea comprises a patient-focused phenotype approach reflecting the myriad clinical presentations of rosacea patients.1,2 Rosacea commonly affects the central face with erythema and lesions prominent on the cheeks, forehead, chin, and nose.1,2 Symptoms of rosacea include facial flushing, stinging, burning, and itching.1,2 To avoid misdiagnosis of rosacea in SOC, dermatologists should consider rosacea in the differential diagnosis of any patient presenting with a history of skin sensitivity, central facial erythema, papules, and pustules.30
Patients with rosacea often complain of low tolerance to skincare. A Chinese retrospective case-control survey of 997 rosacea cases and 1012 skin-healthy controls showed a low tolerance to skincare in the past five years before the onset of rosacea.31 The chi-square test and the logistic regression analysis revealed a low tolerance of the facial skin to skincare in the rosacea group compared to the controls.31 The history of facial skin allergic reaction was related to the severity of self-reported symptoms of rosacea, including dryness, burning, stinging, and itching.31
Statement 3: To avoid underdiagnosis of rosacea in SOC, dermatologists should also have a high index of suspicion of rosacea in SOC patients presenting with facial erythema, papules, and pustules.
Challenges in diagnosis have been described in populations with SOC, which may contribute to disparities in treatment.5,8,15 The clinical presentation of rosacea across diverse ethnic skin types includes the spectrum of clinical subtypes.6,9,16 Particularly, erythema and telangiectasia may be challenging to recognize in richly pigmented skin types.15-19,22,30
Moreover, the lower index of suspicion and difficulties in
