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Rosacea classification system can improve

Dermatology TimesDermatology Times, January 2020 (Vol. 41, No. 1)
Volume 41
Issue 1

There is still room for improvement to the National Rosacea Society Expert Committee's updated classification schema for rosacea, according to William James, M.D.

Headshot of William James, M.D.

Dr. James

There is still room for improvement to the National Rosacea Society (NRS) Expert Committee's updated classification schema for rosacea, according to William James, M.D., a professor of dermatology at the University of Pennsylvania in Philadelphia.

READ MORE: Global panel updates rosacea recommendations

The new guidelines, published in 2018, have abandoned the four main subtypes (erythematolelangiectatic [ETR], papulopustular, phymatous and ocular), replacing them with a phenotype system based upon mostly observable findings.

“Shifting from a subtype focus to individual clinical findings or a phenotype classification allows both for better selection of treatment modalities and improved ability to conduct research,” says Dr. James, co-author of a recent clinical review that evaluates the new rosacea classification and its controversies.1

“By subtyping, there was unnecessary division of interrelated disease into individual disorders; an individual’s clinical presentation might fall along a spectrum rather than within a discrete box,” the authors write.

“Each manifestation is now approached individually, which allows for more exibility and better care,” Dr. James tells Dermatology Times. However, he believes refinements should be made in some of the definitions of the clinical characteristics of rosacea, “not only specifying more precisely the features which comprise the diagnostic findings, but also expanding the list of diseases that need to be excluded when making the diagnosis of rosacea. For instance, providing timelines to fixed erythema and ushing, including periocular sparing in the list of characteristic features, and aiding in assessing how chronic solar damage may be differentiated would be helpful.”

The list of exclusions to the diagnosis has been altered in the new NRS classification system. It lists lupus erythematosus and steroid- and drug-induced rosacea; however, listing seborrheic eczema is confusing, he says. 

READ MORE: Erythema severity mirrors quality-of-life impact in rosacea

Dr. James believes the intent is to exclude seborrheic dermatitis, but not atopic or other forms of eczema. Mastocystosis, carcinoid, polycythemia vera and dermatomyositis are also not listed.

“The potential for error, due to a lack of specific detail in defining the individual manifestations and inclusion of non-rosacea disease, still persists,” he says.

Dr. James believes the new phenotype classification system fails to improve on the separation of the polar ends of the rosacea spectrum. More emphasis about the characteristics of those patients at the phymatous pole needs to be emphasized, he says. Recognizing these differences in the basic skin types will allow for better patient education about their prognosis.

“For example, I believe a smooth-skinned, bright red-faced woman will not eventuate into a patient with a large phymatous nose and large pustules and nodules,” he says. “I have not seen evidence that the inflammatory cascades now being recognized as abnormal in such a patient, referred to in the NRS paper as subclinical neuroin ammation, leads to phymatous change. Because most patients with this manifestation are men, I wonder if it is not more in uenced by androgens than in ammation.”

Despite Dr. James’ reservations about the NRS Expert Committee’s update, “there are some excellent changes,” he says. “I applaud that the committee has worked to improve the prior classification system, which I also criticized. While I still would like to see more specificity, the old system was much too general.”

READ MORE: Subclinical mite proliferation linked with rosacea subtype

Dr. James believes most dermatologists will embrace the update. “An update was long overdue. I am hopeful that with the pace of progress of new knowledge and new therapeutics that the updates will be more frequent.”


Dr. James reports no relevant fi nancial disclosures


1. Wang YA, James WD. “Update on rosacea classification and its controversies,” Cutis. 2019 Jul;104(1):70-73.

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