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

the absence of comedones or acneiform lesions on the body (Figure 3).³ Furthermore, strategies to further assess erythema and telangiectasia in darker skin include use of dermoscopy, diascopy to test for blanching, and photography against a dark blue background.³

Diagnosis of rosacea requires exclusion of differential diagnoses that may present with centrofacial erythema and must be excluded on a case-by-case basis including seborrheic dermatitis, malar rash of acute cutaneous lupus or systemic lupus erythematosus, chronic photodamage, contact dermatitis, carcinoid syndrome, and niacin ingestion.^3,5 Given the high prevalence of systemic lupus erythematosus and sarcoidosis in individuals of African descent, black patients presenting with central facial erythema sparing the nasolabial folds or edematous plaques should undergo appropriate work up in order to rule out these conditions including serological evaluation (eg, antinuclear antibody or angiotensin converting enzyme, respectively), punch biopsy, and referral to rheumatology or pulmonology colleagues if indicated.¹²

Quality of Life
Rosacea has significant adverse effects on quality of life (QOL). Physical discomfort due to symptoms such as irritation, itching, burning, or stinging understandably affect an individual’s well-being.¹³ Psychosocial affects related to skin changes of rosacea that are typically highly visible and have a substantial effect on physical appearance have been shown to cause shame, embarrassment, low self-esteem, low self-confidence, negative body image, and anxiety.^14,15 Physical appearance has been shown to have a significant impact on a wide variety of social outcomes from personal relationships and mate selection to workplace success.¹⁴ A German study using willingness to pay as a correlate for disease burden found women and those with more extensive facial involvement willing to pay more, and likely to experience greater negative QOL due to their rosacea than their counterparts who are of male gender or have less facial involvement.¹⁶ The associated stigmatization and frustration experienced by patients are well documented, as are increased rates of psychiatric comorbidities such as social anxiety, depression, and social phobia.¹⁴ Notably, males are more susceptible to stigmatization in setting of rosacea, possibly due to more severe phenotypes such as rhinophyma.¹⁴ Increased stigmatization from rosacea has also been associated with higher rates of depression and social avoidance behaviors.

The psychosocial impact on QOL is often underestimated by physicians, likely in part due to the fact that the objective disease severity does not correlate with the magnitude of effect on QOL, with the exception of depression.^13,14 A web-based cross-sectional study of 600 adults with ETR and PPR cohorts, respectively, found that 45 and 53 percent disagreed that they were satisfied with their appearance due to rosacea, 42 and 27 percent agreed that they “worry how people will react when they see my rosacea,” and 43 and 59 percent strongly agreed that they feel their rosacea is unattractive to others despite more than 90% of both cohorts self-identifying as having mild to moderate disease.¹⁵ Another important finding in the literature is the reversal of psychological symptoms with therapy; though the number of studies evaluating this outcome are limited future studies will likely continue to evaluate these changes as important measures of treatment success.¹⁶

Management
Diagnosis of rosacea should promptly be followed by education regarding the chronicity and relapsing nature of the disease as well as the importance of gentle skin care, regular photo-protection with sun protection factor 30 or greater, and trigger avoidance.^4,5,11 Identification of patient-specific triggers is essential to preventing disease flares.¹⁷ Use of gentle skin cleansers, frequent use of emollients, and avoiding exacerbating factors such as sunlight, temperature changes, and emotional stress, are primary interventions for managing secondary features namely dry, itchy, painful, burning skin.¹¹ Counseling should be provided in a culturally sensitive manner, taking into account that recommendations may differ significantly from traditional cultural practices in non-white populations such as regular consumption of spicy foods, aggressive exfoliation, or regular use of abrasive skin brightening and lightening products.³ Many darker skinned individuals report not using sunscreen out of unfamiliarity or cultural discordance and may struggle to find a cosmetically suitable product.¹⁸

Evidence-based guidelines for rosacea are limited by the fact