Mercedes Florez-White, MD, associate professor of dermatology, Herbert Wertheim College of Medicine, Florida International University, Miami.
Epidemiologic data indicate that fair-skinned individuals are more likely to have rosacea,1 but there is growing evidence that the disease’s prevalence among populations with skin of color (SOC) is greater than previously believed. Some sources attribute this discrepancy to misdiagnoses and underreporting of patients with SOC, owing to the difficulty in detecting common symptoms such as erythema in highly pigmented skin.1
National survey data found that, of ethnic/racial groups affected by rosacea, Hispanic or Latino populations comprised the largest portion, with 3.9% affected compared with 2% of blacks and 2.3% Asian or Pacific Islanders.2 These numbers may not be surprising given that the Hispanic or Latino population is one of the fastest-growing ethnic groups in the United States,3 and point to the need for better awareness and earlier diagnosis of rosacea in this patient population.
Mercedes Florez-White, MD, associate professor of dermatology at the Herbert Wertheim College of Medicine at the Florida International University in Miami, recently published an article outlining special considerations for patients of Latin American ancestry who are being seen or treated for acne or rosacea.4 She discussed effective screening, cultural influences, and treatment options with The Dermatologist.
Defining Skin Tone
One of the initial challenges in treating or even studying the Latino population is the terminology itself. The terms “Hispanic” and “Latino” can refer to a geographic group or an ethnic one. For the purposes of her research, Dr Florez-White focuses on individuals with Latin American ancestry, meaning they are living in the United States and were born there to parents of Latin American descent, or had been born in any Latin American country. “Within the Latin American population, you can have skin color from light to dark and everything in the middle,” said Dr Florez-White.
Identifying rosacea in lighter skin types, whether in Caucasian or Hispanic individuals, tends to be easier due to the presence of erythema and the high visibility of blood vessels and lesions. In darker skin, flushing and telangiectasia may be more difficult to spot, and lesions may appear more purple than red in color.
Dr Florez-White found that in patients of Latin American ancestry, especially those with more pigmented skin, rosacea was frequently misdiagnosed as adult acne, which is common in that population and has some similar characteristics.4
Step Up Screening
Being aware of the prevalence of rosacea in patients with SOC is only one step toward improving diagnostic accuracy, Dr Florez-White said. Dermatologists should also take note when patients with SOC do not respond to traditional acne treatments, and consider these other steps:
- Get a detailed clinical history. Look for risk factors outside of ethnicity, such as a family history of rosacea, photosensitivity, or a history of smoking cigarettes.5,6 Ask the patient about common symptoms, such as flushing, burning, or sensitive skin, and any allergies including food allergies.
- Conduct a thorough exam. Patients with SOC will have the same symptoms as patients with fair skin, but they present slightly differently in highly pigmented skin. Also be aware of common differential diagnoses, including acne. Clinically, the presence of papules and pustules but lack of comedones indicates something other than acne, said Dr Florez-White.
- Use diagnostic tools. Some sources have reported success observing highly pigmented skin against a dark blue background to better highlight redness.1 Similarly, erythema may be more easily observed when the skin is pressed with a magnifying glass or microscope slide to see if it blanches, and if any redness is evident.1 Dr Florez-White recommends using a dermatoscope to confirm the presence of telangiectasia difficult to see in patients with darker skin.
Once you have made a diagnosis, treatment can be influenced by cultural/ethnic/racial considerations as well. Patients with SOC may not believe they need to use sun protection, and sun exposure is a common trigger for rosacea. One study of Hispanic adults living in the United States found that nearly half (47.1%) reported never or rarely using sunscreen, while 16.8% said they never or rarely stayed in the shade, and 60.3% never or rarely used sun-protective clothing.7
Certain treatments for rosacea, including lasers and some medications, can increase the risk of postinflammatory hyperpigmentation in patients with SOC, said Dr Florez-White. “For dark-skinned patients, this can be one of the most important concerns for them in terms of quality of life,” she said. This may pose a challenge to treatment adherence in this patient population.
Patients with SOC tend to respond to standard rosacea therapies just as well as those with lighter skin, although further research is needed. Making a correct diagnosis and ensuring that patients of Latin American ancestry and other patients with SOC receive access to treatment without delay is key to delivering the best care to this diverse patient population.
1. Alexis AF, Callender VD, Baldwin HE, Desai SR, Rendon MI, Taylor SC. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: Review and clinical practice experience. J Am Acad Dermatol. 2019;80(6):1722–1729.e7. doi:10.1016/j.jaad.2018.08.049
2. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014; 20(10).
3. Hispanic population to reach 111 million by 2060. Census.gov website. https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html. Updated October 4, 2018. Accessed July 22, 2019.
4. Florez-White M. Acne and rosacea: special considerations in the treatment of patients with Latin American ancestry. J Drugs Dermatol. 2019;18(3suppl):s124-126.
5. Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol. 2010;24(5):565-71. doi:10.1111/j.1468-3083.2009.03472.x
6. Rosacea risk factors answer “why me?” National Rosacea Society website. https://www.rosacea.org/press/2016/march/rosacea-risk-factors-answer-why-me. Published April 1, 2015. Accessed July 22, 2019.
7. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985. doi:10.1186/1471-2458-12-985
8. Where is rosacea worst? New map shows geographic prevalence. National Rosacea Society website. https://www.rosacea.org/press/where-Rosa