Payer Perspectives in Dermatology - Rosacea

Rosacea is a chronic skin disorder characterized by facial redness and flare-ups that can be especially troubling and distressing to affected individuals. According to the National Institutes of Health, an estimated 14 million Americans (or 5% of the US population) are affected by rosacea. The condition can vary substantially from one patient to another, and it is sometimes confused with acne. Although there is no cure for rosacea and the cause remains unclear, medical therapy can control or reverse its signs and symptoms.

Rosacea remains largely underrecognized and undertreated, which is unfortunate for the many Americans who are suffering from this debilitating condition, according to GuyF. Webster, MD, PhD, FAAD, Clinical Professor of Dermatology at Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.

Signs and Symptoms

The primary signs of rosacea are flushing, persistent redness, bumps and pimples, and visible blood vessels. Patients may also complain of eye irritation, burning or stinging, and dry appearance of the skin.

The spectrum of presentations under the heading of rosacea encompasses different subtypes. Central facial redness, the vascular subtype (erythematotelangiectatic rosacea), should be differentiated from papulopustular (inflammatory) rosacea, in which patients also develop bumps and pimples that fluctuate over time. It is important to distinguish between these 2 subtypes, because they may respond to different treatment modalities.

A bulbous nose is the hallmark of the phymatous type of rosacea, which is rare. When rosacea affects the eyes with redness or scratchiness, the condition is called ocular rosacea; by some estimates, 50% of individuals with rosacea have an ocular component. Lesser variants include granulomatous, pyoderma faciale, perioral dermatitis, and steroid rosacea.

For obvious reasons, rosacea can have a very negative impact on the patient’s self-esteem and quality of life. “Patients don’t like to have red cheeks and pimples, and flushing of the face can also be uncomfortable,” Dr Webster said. This can lead to social and psychological problems.

A study published in the British Journal of Dermatology showed that effective treatment (topical metronidazole, oral tetracycline, and oral isotretinoin) reduced the signs and symptoms of rosacea among 308 patients, and improved the Dermatology Life Quality Index scores by approximately 40% (Aksoy B, et al. Br J Dermatol. 2010;163:719-725); however, Dr Webster noted that isotretinoin is not indicated for and rarely needed for the treatment of rosacea. The proper diagnosis and treatment of this condition, therefore, is important.

Underlying Causes

The causes of rosacea are only beginning to be understood, Dr Webster said, “largely because science has only recently had the tools to explain the disease.”

It is becoming clearer that the predominant force driving rosacea is inflammation. A growing body of evidence supports the role of an abnormal innate immune response, which is upregulated in the face of certain triggers—foods, thermal stimuli, irritants, and so forth.

A number of characteristics of rosacea are related to inflammation. Vasodilation is greater and more persistent in patients with rosacea than in people without rosacea. A defective skin barrier may cause hyperirritability, such as stinging and burning from cosmetics and medications.

The predominance of inflammation as an underlying factor is also in line with another emerging concept. Although rosacea is not frequently thought of as a neurologic condition, there are “clear neurologic influences,” Dr Webster said. “It must be remembered that blushing is a neurally mediated function and that rosacea thus partly has a neurologic basis.”

Diagnostic Pitfalls

There are several misperceptions surrounding the diagnosis of rosacea. Not every “red face” is rosacea, Dr Webster cautioned. Seeing a dermatologist is therefore crucial to avoiding misdiagnosis.

Rosacea is often being confused with acne. “Patients sometimes confuse rosacea with acne vulgaris,” Dr Webster noted. “Typically, acne occurs in a younger age-group than does rosacea, and it is characterized by comedonal lesions. Patients in their 20s and 30s may have both conditions simultaneously.”

            Rosacea is also sometimes being mistakenly perceived as facial redness caused by excessive alcohol consumption, another misperception that can add to a patient’s distress. 

            Correct diagnosis is crucial to ensuring the appropriate approach to treatment. 

Diagnosis and Treatment

It is important to make this distinction to properly treat these conditions. Essentially, rosacea is diagnosed clinically by the presence of red cheeks, with or without central facial pimples, and with or without irritated eyes, according to Dr Webster.

“Rosacea can be a difficult disease to treat,” he pointed out. Topical metronidazole is the primary topical therapy and is the first-line option. It is most active on inflammatory lesions and may have some effect on erythema. Azelaic acid cream is approximately equal in efficacy to topical metronidazole, and nonirritating benzoyl peroxide is also useful in the inflammatory form. Topical erythromycin, clindamycin, and tetracycline have little effect on rosacea, but topical tretinoin can help for the long-term.

Oral therapy may be necessary for some patients. Tetracyclines are the mainstay of oral treatment—not because of their antimicrobial action, because there is no bacterial stimulus, but because of the anti-inflammatory effects of this class of agents. For the past few years, a 40-mg sustained-release anti-inflammatory formulation of doxycycline has been available and has the advantage of acting below the level of antimicrobial activity, Dr Webster noted.

“There is justifiable concern about antibiotic overuse, the spread of resistant organisms, and the possibility that long-term rosacea treatment might exacerbate resistance,” he said. “This drug is designed to be purely anti-inflammatory. Antimicrobial levels of the drug are never achieved, and there is no change in the microbial flora of the skin or in the gastrointestinal tract. Therefore, resistance cannot develop,” he added.

Refractory nodules may require isotretinoin therapy, but a lasting response is infrequently seen. Intense-pulsed light, pulsed-dye laser, and other more invasive modalities can be useful in severe cases of rosacea.

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Last modified: August 30, 2021
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