Go to AAD Home

Refocusing on rosacea

Experts reexamine the disease's classification

Dermatology World abstract illustration of binoculars

Refocusing on rosacea

Experts reexamine the disease's classification

Dermatology World abstract illustration of binoculars

By Emily Margosian, assistant editor

‘Tis the season for rosy cheeks. However, for patients with rosacea, a St. Nicholas-worthy flush can be a major source of distress. While treatment and understanding of rosacea remains ongoing, recent insights into the pathogenesis and pathophysiology of the disease have produced a new classification system — the first update in 15 years. This month, Dermatology World speaks with rosacea experts to discuss the implications of this new classification system, updates in available treatment, and the true patient burden of rosacea.

Classification breakdown

A lot can change in 15 years. According to Diane Thiboutot, MD, professor of dermatology at Pennsylvania State University, time — and increased understanding of rosacea’s pathophysiology — warranted an update to 2002’s initial classification system. “I think one of the challenges with the previous subtype classification was that it was difficult to put patients in any one niche, because many patients had signs and symptoms that crossed over more than one subtype,” explained Dr. Thiboutot, who helped co-author the updated classification system along with five other dermatologists and one ophthalmologist.

The original standard classification of rosacea consisted of four subtypes:

  1. Erythematotelangiectatic
  2. Papulopustular
  3. Phymatous
  4. Ocular

The new system is comprised of a more flexible set of criteria, “based on phenotypes...to provide the necessary means of assessing and treating rosacea in a manner that is consistent with each individual patient’s experience.” (J Am Acad Dermatol. 2017;78(1): 148-155.) The revised classification recommends that a diagnosis of rosacea requires:

  • 1 diagnostic phenotype
    or
  • 2 major phenotypes

Diagnostic phenotypes include:

  • Fixed centrofacial erythema in a characteristic pattern that may periodically intensify — persistent redness in facial skin.
  • Phymatous changes — including patulous follicles, skin thickening or fibrosis, glandular hyperplasia, and bulbous appearance of the nose.

Major phenotypes include:

  • Papules and pustules
  • Flushing
  • Telangiectasia
  • Ocular manifestations

The updated guidelines also include secondary phenotypes, which may appear with one or more diagnostic or major phenotypes, which include:

  • Burning or stinging
  • Edema
  • Dryness

These new criteria recognize the common presence of more than one subtype in rosacea patients, and new research suggests that all subtypes may actually be manifestations of the same inflammatory continuum — leading to rosacea progressing not only in severity, but to also include additional phenotypes if untreated over time (J Am Acad Dermatol. 2017;78(1): 148-155).

New treatments on the horizon

“Now is an exciting time in the treatment of rosacea,” said Linda Stein Gold, MD, director of clinical research at Henry Ford Hospital.

Encouraging new studies have shown promising treatment findings with interesting implications about how dermatologists should approach the disease going forward. “When we treat a rosacea patient they often have several components to their disease, they may have bumps on their face — papules and pustules — but will also have significant background erythema or redness. We generally approach the papules in one way and the background erythema in another way,” explained Dr. Stein Gold. “Traditionally, or at least the way I practice, is I feel that I have to get the papules and pustules under control first, and then go after the background erythema.”

However, new findings published in a 2017 Journal of Drugs in Dermatology article may challenge this status quo (16(9): 909-916). “This was a study that questioned that. We looked at starting ivermectin — which treats the papules and pustules first — for a month, and then adding brimonidine onto that treatment regimen and compared that to starting both drugs at the same time,” said Dr. Stein Gold. “What we found was that it did appear that by starting the drugs at the same time — and we’re not exactly sure why — you got a better and faster overall effect in clearing both the papules and pustules as well as the background erythema. This changes the way we think about treating rosacea patients.”

According to Dr. Stein Gold, another study examining rosacea patient relapse rates suggests that more aggressive treatment goals (i.e., shooting for “clear” as opposed to “almost clear”) may actually lead to extended remission periods (J Dermatolog Treat. 2017;28(5): 469-474). “It is something that I think is attainable, especially now that we have some of the better drugs,” she says. “What we find is that if you actually get the patient to completely clear, their durability of remission is significantly greater — by five months — than if they get to almost clear. Getting a patient to completely clear really does significantly improve their quality of life and gives them the possibility of a disease-free remission that could be long-term.”

Ongoing clinical trials have also yielded promising possibilities regarding the future of rosacea treatment. “There is a topical minocycline foam that’s in long-term studies right now; they’ve done phase 3, and they’re completing year-long studies looking at safety and efficacy. There is also a minocycline gel in trials — that’s very exciting for rosacea,” said Dr. Stein Gold. “There are also some new studies that are looking at a benzoyl peroxide that’s been formulated to be much less irritating. Benzoyl peroxide is not something that we generally think of for rosacea, but this is a new formulation that shows promise.”

IMPLICATIONS

“The following updates have been developed by the committee and reviewed by a panel of 21 rosacea experts worldwide and are intended to be useful to clinicians and researchers by providing clearer and more meaningful parameters to conduct new investigations, as well as to build on existing findings while offering a more meaningful guide to diagnosis and treatment,” advised the study (J Am Acad Dermatol. 2017;78(1): 148-155). 

rosacea-quote.pngHowever, what does it mean for dermatologists and their patients? “I think that the new classification may be more helpful in making treatment choices, because if you’re able to identify the features of rosacea that a patient has, there are certain therapies that target those features better than others,” said Dr. Thiboutot. “To be honest, there’s still a lot out there that we don’t know. The main driver for changes in the classification system was from new insight into the pathogenesis. We know more about neurovascular regulation in rosacea, and the role of cathelicidin peptides in rosacea and inflammation, but there’s still a lot more to learn.” 

New insight into the disease may be found thanks to a better understanding of the associated co-morbidities, said Joshua Zeichner, MD, director of cosmetics and clinical research in dermatology at Mount Sinai Hospital. “Rosacea is extremely common, but in many ways, still poorly understood. However, we do have some new data,” he said. “A recent study done through an insurance claims database looked at about 100,000 rosacea patients and had some different findings regarding co-morbidities and risk factors contrary to what we previously thought to be associated with rosacea.” According to Dr. Zeichner, a positive association was found in patients with gastroesophageal reflux disease, frequent migraines, and high cholesterol levels. “There were also certain medications that were found to be associated, including laxatives, medications that treat reflux disease, as well as some psychiatric medications like benzodiazepines,” he said. “We’re just starting to understand rosacea a bit more, and I think this is the first step in really identifying underlying associating factors. I think as dermatologists we need to be increasingly aware of just how common rosacea is, and not to ignore facial redness when we see it in the office, especially in patients who have these comorbidities.”