Treating Rosacea Today
Rosacea treatment continues to evolve with an updated classification system and new research in development.
Figure 1. Patient with the diagnostic phenotype of erythema as well as papules and pustules.
Rosacea is a common chronic cutaneous disorder of the central face that is estimated to affect more than 16 million Americans.1 Rosacea is a recurrent disease consisting of various combinations of potential signs and symptoms, including flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and rhinophyma. In addition, burning and stinging sensations and ocular symptoms of foreign-body sensation and dryness may also occur. Rosacea typically first presents between 30 and 60 years of age.
The disorder has significant financial, physical, and psychological impacts.2-12 Many recent studies have found associations between rosacea and increased risk for a number of potentially serious systemic disorders, including cardiovascular disease, gastrointestinal (GI) disease, neurological and autoimmune diseases, and certain cancers. Causal relationships have not been determined at this time.13
Multiple patient surveys have documented rosacea’s substantial adverse psychosocial impact. In surveys conducted by the National Rosacea Society (NRS), more than 90% of rosacea patients said the disorder had lowered their self-confidence and self-esteem, and 41% reported that it had caused them to avoid public contact or cancel social engagements. Among rosacea patients with severe symptoms, 88% said the disorder had adversely affected their professional interactions and 51% said they had even missed work because of their condition.14
Recent survey findings from Zeichner and colleagues15 also show that rosacea negatively impacts self-perceptions, emotional, social, and overall well-being, and disease-related quality of life. The web-based survey included 600 US adults who had been diagnosed with erythematotelangiectatic rosacea (ETR) or papulopustular rosacea. Overall, 45% of participants with ETR and 53% of participants with papulopustular rosacea noted they were dissatisfied with their appearance due to rosacea, worried about how people will react when they see their rosacea, and felt their condition made them unattractive to others. (For more on this, see page 7.)
Another recent study demonstrated that patients with severe rosacea experience higher disease burden and lower quality of life.16 For the cross-sectional web-based survey, 409 participants with ETR answered questions on rosacea’s impact. Participants also completed the 21-item rosacea-specific quality of life questionnaire (RosaQoL) and the 36-item Short Form Health Survey (SF-36).
Mild erythema was reported by 63.6% of participants, moderate erythema was reported by 32% of participants, and severe erythema was reported by 4.4% of participants. Blushing/flushing and bumps/pustules were the most bothersome symptoms.
All participants reported coping skills such as using makeup and managing stress and anxiety, and attempting to prevent flares by avoiding sun exposure, certain skin care products, and other triggers. Changes in self-perception were associated with the severity of erythema. Likewise, erythema severity was associated with increases in RosaQoL emotional domain scores. However, SF-36 scores did not differ significantly between severity subgroups.
Figure 2. Patient with ocular rosacea
Although a number of topical, oral, and systemic treatments are available, treatment for rosacea remains difficult. The multifactorial nature of the disease combined with an incomplete understanding of the pathophysiology is challenging for providers and patients.2
The publication of the updated Standard Classification and Pathophysiology13,14 reflects the advances in scientific knowledge of the rosacea disease state.¹ It provides standard criteria essential for performing research, analyzing results, and comparing data from different sources, as well as to serve as a diagnostic reference in clinical practice. The system also provides common terminology for improved communication among researchers, clinicians, and health officials.
The original standard classification of rosacea identified the most common presentations morphologically as subtypes. The updated Standard Classification and Pathophysiology focuses on the individual characteristics, called phenotypes, that may result from this consistent disease process. Observing the respective phenotypes in clinical practice encourages consideration of the full range of potential signs and symptoms and the assessment of severity and selection of treatment may also be tailored to each patient, according to the consensus committee. (For more, see pages 8 and 9.)
Julie C. Harper, MD, clinical associate professor of dermatology at the University of Alabama-Birmingham, noted that the rosacea can present in clinics in a variety of ways. “Some patients have just persistent facial erythema, while other patients seem to exhibit every rosacea phenotype at one time. This new classification reminds us to recognize and treat the phenotypes that we see even when 3 or 4 overlap in one patient. Instead of trying to pick one subtype to label our rosacea patients, we now observe and document and treat all of the phenotypic lesions that they have,” she said.
“The best way to make our patients better is to treat all of the phenotypes that we observe in one patient. Combinations of therapies (ie, oral and/or topical medications that address papules and pustules, vasoconstrictors that address background erythema, and lasers that address telangiectasis) offer our patients the potential for the best outcomes,” she said. (For more with Dr Harper, see page 12.)
Figure 3. Patient with both diagnostic phenotypes, persistent erythema, and phymatous changes.
“The most exciting developments in rosacea involve the new scientific understandings regarding the etiology of rosacea. Innate immunity with abnormal antimicrobial peptides, cathelicidins, and neurovascular interactions are shedding new light on rosacea’s molecular biology and the promise of better treatments to prevent and/or treat rosacea,” said Harvey H. Jay, MD, dermatologist and rosacea specialist in practice in New York, NY.
Rosacea research continues. Recently published studies include those on quality of life, rosacea linked to multiple systemic disorders, and studies on new medications and laser treatments, among others (see page 15). Most recently, NRS awarded funding for 3 new studies,17 in addition to continuing support for 3 ongoing studies, as part of its research grants program to increase knowledge and understanding of the causes and other key aspects of rosacea that may lead to improvements in its management, prevention, or potential cure.
The new research projects include:
- A study to develop an open-source, freely available computer software program for a rosacea scoring system that will identify and count rosacea lesions and measure redness to provide reliably reproducible scores for physicians and patients;
- A study on how the skin and lipids are altered in individuals with cutaneous and ocular rosacea; and
- A retrospective study of the association of rosacea with GI disease over a 5-year period, as well as the possible impact of medications in the relationship between rosacea and GI disease, including malabsorption, celiac disease, irritable bowel syndrome, Helicobacter pylori infection, and others.
The NRS also continues to fund:
- Studies investigating cathelicidin antimicrobial peptides and the nervous system;
- Another study looking at the DNA of rosacea; and
- An investigation into how hormone use and hormone levels associated with menopause and pregnancy may affect the risk of developing rosacea.
1. Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors. J Am Acad Dermatol. 2015;72(5):749-758.
2. Sahni DR, Feldman SR, Taylor SL. Ivermectin 1% (CD5024) for the treatment of rosacea. Expert Opin Pharmacother. 2018;19(5):511-516.
3. Halioua B, Cribier B, Frey M, Tan J. Feelings of stigmatization in patients with rosacea. J Eur Acad Dermatol Venereol. 2017;31(1):163-168.
4. Moustafa F, Lewallen RS, Feldman SR. The psychological impact of rosacea and the influence of current management options. J Am Acad Dermatol. 2014;71(5):973-980.
5. Huynh TT. Burden of disease: the psychosocial impact of rosacea on a patient’s quality of life. Am Health Drug Benefits. 2013;6(6):348-354.
6. Red alert: Rosacea awareness month highlights potential increased health risks. National Rosacea Society website. https://www.rosacea.org/press/red-alert-rosacea-awareness-month-highlights-potential-increased-health-risks. Published April 1, 2016. Accessed April 3, 2018.
7. Hua TC, Chung PI, Chen YJ, et al. Cardiovascular comorbidities in patients with rosacea: a nationwide case-control study from Taiwan. J Am Acad Dermatol. 2015;73(2):249-254.
8. Li WQ, Zhang M, Danby FW, Han J, Qureshi AA. Personal history of rosacea and risk of incident cancer among women in the US. Br J Cancer. 2015;113(3):520-523.
9. Rainer BM, Fischer AH, Luz Felipe da Silva DL, Kang S, Chien AL. Rosacea is associated with chronic systemic diseases in a skin severity dependent manner: results of a case-control study. J Am Acad Dermatol. 2015;73(4):604-608.
10. Spoendlin J, Karatas G, Furlano RI, Jick SS, Meier CR. Rosacea in patients with ulcerative colitis and Crohn’s disease: a population-based case-control study. Inflamm Bowel Dis. 2016;22(3):680-687.
11. Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Association of rosacea with risk for glioma in a Danish nationwide cohort study. JAMA Dermatol. 2016;152(5):541-545.
12. Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Patients with rosacea have increased risk of depression and anxiety disorders: a Danish nationwide cohort study. Dermatology. 2016;232(2):208-213.
13. Gallo RL, Granstein RD, Kang S, et al. Rosacea comorbidities and future research: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):167-170.
14. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148-155.
15. Zeichner JA, Eichenfield LF, Feldman SR, Kasteler JS, Ferrusi IL. Quality of life in individuals with erythematotelangiectatic and papulopustular rosacea: findings from a web-based survey. J Clin Aesthet Dermatol. 2018;11(2):47-52.
16. Harper J, Del Rosso JQ, Ferrusi IL. Cross-sectional survey of the burden of illness of rosacea by erythema severity. J Drugs Dermatol. 2018;17(2):150-158.
17. National rosacea society awards additional grants for research. The Dermatologist. 2017;25(11):8.