Between phase 3 clinical trials testing the efficacy of new treatment modalities for the market, studies on the impacts on quality of life with the condition, and focuses on patient demographics, 2019 was an active year for research in rosacea. The Dermatologist compiled some of the industry’s top research from the past year that could help shape future upcoming studies and reviews on rosacea diagnosis, treatment, and management.
Examining Patient Quality of Life
It is no secret that rosacea can have a significant negative effect on patient quality of life. In fact, 76% of patients reported feeling at least a small impact on quality of life in a multinational online survey.1 Rosacea can cause loss of confidence in one in three people, and 19% of people report making more than seven adaptions to their lifestyle to accommodate their condition.1 These changes include avoiding sun exposure, not consuming alcohol as well as spicy or hot foods, staying away from extreme temperature climates, and missing social activities.
For some patients, however, rosacea can have a very or extremely large impact as based on their Dermatology Life Quality Index score. Tan et al2 highlighted several factors that could help clinicians identify high-burden patients, defined as patients scoring positively in three of four categories:
- Impact of rosacea on quality of life (score >5, where 0=no impact and 10=very high);
- Level of behavior adaptation (score >6, where 0=not adapted and 10=extremely);
- Willingness to pay for a cure (score >20% of monthly income); and
- Time trade-off for a cure (score >6 months).
Compared with nonhigh-burden patients, the high-burden group tended to be younger (39.5±11.8 vs 45.9±14.0; P<.01), male (45.6% vs 31.0%; P<.01), employed (83.5% vs 69.4%; P<.01), urban dwelling (63.9% vs 42.9%; P<.01), and reporting a higher number of symptoms in the past 12 months (mean number, 5.0±3.5 vs 4.4±2.7; P<.05).2 In addition, high-burden patients were more likely to experience itching, burning, swelling, pain than their counterparts.
Similarly, a survey of 1044 people with rosacea conducted by the National Rosacea Society found that successful treatment can have a significant impact on patient quality of life.3 In the survey results, 76% of participants reported at least some improvement in their skin after treatment; of this group, 40% reported improvements in their psychological well-being, 35% for social well-being, and 31% in occupational well-being.
Furthermore, improvements in quality of life were substantial when the symptoms of rosacea where nearly or completely eliminated by treatment. With almost clear or fully clear skin, 81%, 71%, and 62% of participants reported improvements in their psychological well-being, social lives, and workplace, respectively.3 These responses are in stark contrast to when only slight to moderate improvements in skin were noted, which saw only 24%, 21%, and 19% of respondents noting improvements in the same respective categories.
Results from a cross-sectional survey published in the Journal of Dermatology Research and Therapy detailed the psychosocial impact of rosacea on 19 female patients.4 The majority of participants commonly reported using makeup as cosmetic camouflage all of the time (42%) or often (26%), and zero reported to never or rarely using makeup to cover their rosacea. A small majority (53%) reported feeling frustration all of the time and an additional 32% reported feeling frustration often as a result of rosacea, and, similarly, 74% felt embarrassed by the condition all of the time or often. These results indicate that patients are constantly worried about their rosacea and how others perceive the condition.
Each of these three studies2-4 stresses the importance of a multifaceted treatment and management plan for patients with rosacea. Additional resources, such as adjunct therapies to address severity or mental health referrals, may benefit all patients with rosacea.
Identifying Rosacea in Skin of Color
In its June 2019 issue, the Journal of the American Academy of Dermatology published a comprehensive review on the global epidemiology and clinical spectrum of rosacea with particular interest to presentation in skin of color.5 Notably, the article states that rosacea is often underdiagnosed or misdiagnosed in patients with skin of color. The condition’s characteristic persistent facial erythema is reported less frequently than papules and pustules, likely due to the difficulty of recognizing erythema in darker Fitzpatrick skin types as well as the potential for hyperpigmentation to mask redness.6,7
When diagnosing rosacea in patients with skin of color, the authors5 recommended several components to consider. First, a thorough examination of patient history should be conducted. This includes querying the patient for self-reported observations and history, asking questions such as:
- Have you ever experienced a warm sensation or flushing over your face?;
- Has your skin appeared more red than normal?;
- Do your symptoms develop or get worse following certain triggers, eg, heat, spicy food, stress?; and
- Do you have a family history of rosacea or, if no diagnosis was made, a history of signs and symptoms?
Second, the authors5 recommended dermatologists familiarize themselves with the other clinical signs and symptoms of rosacea. These include noting the signs concentrated in the central face as well as dry appearance, edema, and hyperpigmentation. In particular, clinicians should observe the presence of acneiform papules and pustules, which will lack comedones (thus differentiating rosacea from acne). Additionally, ocular symptoms (itching, irritation) and thickening of the nasal and medial cheek skin can also be present.
Third, erythema and telangiectasia can be identified with a number of other methods outside of seeing with the naked eye. One example discussed was using a magnifying glass or microscope slide; when the glass/slide is pressed against the skin and the skin pales, erythema is present. Another example reviewed was photographing patients against a dark blue background with adequate lighting to help distinguish erythema and telangiectasia more readily.
As for treatment, patients with skin of color should follow similar approaches to that of lighter Fitzpatrick skin types. However, dermatologists should be careful to address postinflammatory hyperpigmentation as well as avoid further pigmentary complications. Also, dermatologists should stress the importance of appropriate skin care with patients. This includes use of a gentle, nonalkaline, fragrance-free emollient cleanser; a silicone-based moisturizer; light, water-based cosmetics; and, most importantly, use of sunscreen/physical sunblock. Patients should also be counseled on rosacea triggers.