A revised and updated set of criteria and treatment recommendations establishes a phenotype approach to diagnosing and classifying rosacea. This approach marks a transition from treating rosacea patients according to subtype. Global representation may identify research needed to determine whether rosacea is a global condition.
A revised and updated set of criteria and treatment recommendations by a global panel of dermatologists and ophthalmologists establishes a new approach to diagnosing and classifying rosacea by phenotype rather than by subtype.
Dr. TanJerry Tan, M.D., panel co-chair and adjunct professor of internal medicine and dermatology, Western University, Windsor, Ontario, tells Dermatology Times that the position paper from the global ROSacea COnsensus (ROSCO) helps to clarify the diagnostic criteria for rosacea.
“The prior criteria were based on the 2002 recommendations from the National Rosacea Society. Because research has advanced over the last decade and a half, we have updated these diagnostic criteria to what is currently presented in the first ROSCO paper,” he says.
The ROSCO publication indicates that there only two specific diagnostic features, each of which can be individually diagnostic of rosacea; or major criteria, of which any two in combination can be diagnostic of rosacea.
“That’s a significant change from the prior recommendations from the National Rosacea Society. This increases the accuracy of diagnosis to focus on either centrofacial erythema or phymatous changes as diagnostic features independently,” Dr. Tan says. “In the past, any one of almost five different clinical criteria would be individually diagnostic of rosacea, which we felt needed revision.”
An aspect that was important in the National Rosacea Society 2002 recommendations was the grouping of common presentations to subtypes. For example, erythematotelangiectatic rosacea was the combination of flushing, background erythema and telangiectasia. Subtype two, called papulopustular rosacea, was the presence of centrofacial erythema with papules and pustules.
“…with those two different subtypes, there are multiple phenotypes within those subtypes-phenotypes being the actual clinical sign or symptom presenting,” Dr. Tan says. “…that has led to confusion in terms of the research that is being conducted into rosacea. Much of the research conducted in the last decade and a half is based on grouping into these common presentations, as opposed to grouping into rosacea in general, with specific phenotypic segregation.”
To illustrate the change, Dr. Tan cites the example of a patient that presents just with background centrofacial erythema and not much in the way of telangiectasia or significant episodic flushing. Technically, he says, that patient did not have subtype one rosacea – erythematotelangiectatic - because the patient did not have flushing, nor did the patient have significant telangiectasia.
“Practically, in our current phenotypic-led classification, it’s not important to be grouping into subtypes. It’s more important to be categorizing based on patients’ presentation in terms of signs and symptoms,” he says. “So, if they simply presented with centrofacial erythema that would be diagnostic of rosacea, but we wouldn’t go onto subtype. We would just leave them as is, as that predominant phenotype. Then, we would manage them based on that, with various treatment options that are indicated for background centrofacial erythema.”
In the past, dermatologists treating a patient with erythematotelangiectatic rosacea, might have used multiple treatments to address each of the three phenotypes: flushing, centrofacial erythema and telangiectasia. There is no singular treatment for the three, according to Dr. Tan.
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The new recommendation allows providers to focus on treating what patients indicate are their most bothersome rosacea symptoms, Dr. Tan says.
Interestingly, Dr. Tan says it’s an approach most of his colleagues are already using.
“We’re simply articulating what is done in practice,” he says.
Some of the 2002 rosacea recommendations by the National Rosacea Society may have led to misunderstandings in terms of grading scale, according to Dr. Tan. In a grading scale of subtype, one has to account for multiple phenotypes. Using a phenotype-led approach makes scale development and phenotype evaluation more simplified and targeted.
Another part of the old recommendations that could have been confusing was the potential for overlapping phenotypes within the subtypes. A case in point: centrofacial erythema is in both subtype one and subtype two.
“In some of the epidemiological research, one could never be sure whether patients were counted separately as subtype one, if they had centrofacial erythema; then, also counted again in patients who also had papules and pustules as a subtype two patient. There was a risk that you would be counted twice,” he says.
The ROSCO expert panel, including 17 dermatologists and three ophthalmologists, is globally representative.
“We were uncertain of how rosacea manifests in different ethnic groups and skin types and wanted to make sure that Asians were represented as well as Africans and Latinos. So, we had representation from China, Latin America, South America, India, Europe and North America,” Dr. Tan says.
The global representation will help to shed light on research needed to determine whether rosacea is, indeed, a global condition.
“We think it probably is, but it may manifest differently in patients of different skin color and skin tone,” Dr. Tan says.
Part of the problem is that centrofacial erythema presents as redness in light skin but can present as darker shades of brown or purple in darker skin types.
“One of the issues is how to move forward the research agenda of rosacea in patients who are not light photo-types, where you can’t see redness,” he says.
Dr. Tan receives honoraria from Galderma for participating in the panel. He also has been an advisor and/or speaker for Almirall, Bayer, Cipher, Galderma, Stiefel/GSK, Merz, Valeant; consultant to Galderma, Merz, Roche; and clinical investigator for Allergan, Cipher, Dermira and Galderma.
Schaller, M., Almeida, L., Bewley, A., Cribier, B., Dlova, N., Kautz, G., Mannis, M., Oon, H., Rajagopalan, M., Steinhoff, M., Thiboutot, D., Troielli, P., Webster, G., Wu, Y., van Zuuren, E. and Tan, J. (2016), Rosacea treatment update: Recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. Accepted Author Manuscript. doi:10.1111/bjd.15173
Tan J, Steinhoff M, Berg J, Del Rosso A, Layton A, Leyden J, Schauber J, Schaller M, Cribier B, Thiboutot D, Webster G, and the Rosacea International Study Group. Shortcomings in rosacea diagnosis and classification. Br J Dermatol. Perspectives. 18 Jan 2017. P 197-199.