With updated guidelines and new therapeutic developments, dermatologists have more tools now than ever before for the treatment of rosacea. The Dermatologist asked Dr Julie Harper to share her insights on the diagnosis and treatment of the disease.
Q. What questions can dermatologists ask to better understand a patient’s medical history in regard to rosacea?
A. Dermatologists who have practiced for a length of time may become very comfortable with patients saying things such as “You know, if you could have seen me 2 or 3 days ago, you could have seen what my face looks like.” We should ask for more details: What does your face look like? What bothers you about that? Do you have bumps when this comes up or is this more of a redness? Do you have red that you feel like is there all the time, or are there certain things that make you flush more often? So, diagnosingrosacea oftentimes comes down to really just taking a good history.
For example, history can be so critical for individuals with darker skin types. In those darker skin types, it can be harder to visually make the diagnosis. In skin of color, we need to be sure that we are listening and taking a good history because so much of the diagnosis may come from that.
A second situation to keep in mind with medical history is ocular rosacea. People will almost never offer to us that they have symptoms of ocular rosacea because they do not know that it is even a thing. Our patient may have full blown rosacea and red eyes, and they are attributing to it allergies. A comprehensive history is just so crucial in these settings, but really for all of our patients.
Q. What strategies should dermatologists consider when creating an individualized treatment plan for rosacea?
A. The movement within the rosacea space right now is to get us to identify and then precisely treat every component. If you are a prescriber who moves really fast in clinic and you’re used to diagnosing rosacea from across the room with a standard treatment, then it is time to shake that up a little bit. Instead of just labeling somebody with rosacea, you should look to see if they have redness, telangiectasia, papules and pustules, or rhinophyma.
I am going to be bold here and say the treatment plan, most of the time, is going to utilize more than one tool. We’re going to be using combinations of treatments together in order to better treat our patients’ rosacea.
As far as psychological assistance, I think that’s always appropriate. We know that rosacea is associated with depression and anxiety. It is not really that much different from a patient with psoriasis. In any of our patients who have some of those comorbidities, regardless of the underlying disease, we should work with other areas of health care to make sure our patients get the help that they need.
Q. What are the most important takeaways from the latest rosacea guidelines?
A. We should think about rosacea as a phenotype disease. Instead of looking at a person and just diagnosing rosacea in your head, we are going to separate and divide it out so that we are treating all the components. We then use targeted treatment to treat the phenotypes are present.
In the last few years, we have developed FDA-approved treatments for rosacea. For example, we now have alpha agonists, two of them in fact that each have a different receptor selectivity. We have products like that out there that are available to target specific rosacea phenotypes.
I am going to use the same analogy I have been using for a long time. It is like when you go out to a nice dinner, and you are getting ready to have multiple courses: soup, salad, steak and potatoes. The waiter then comes to you and says that you only get to choose one utensil for the evening. Well, that is impossible, because you cannot eat soup with a fork or eat your lettuce with a spoon. Yet, we have been looking at the full menu of rosacea and choosing just one tool for treatment. We cannot expect a product that is FDA approved to treat papules and pustules to also address erythema, telangiectasia, and ocular disease.
With that in mind, I think the take-home message from these updates is to get us to really break apart the different components of rosacea and then precisely target our treatment to the individual’s presentation.