Diagnosing Rosacea in Patients With Skin of Color

Rosacea is estimated to affect 5.46% of the global population.¹ In a recent study, it was estimated that rosacea affected 2% of Black individuals, 2.3% of Asian or Pacific Islander individuals, and 3.9% of Hispanic or Latino individuals of any race.² However, rosacea is often underdiagnosed among patients with skin of color.³ 

While the symptoms of rosacea are similar across all Fitzpatrick skin types, the characteristic erythema and telangiectasia are more difficult to visualize on darker phototypes.³ To address these disparities, Alexis et al³ developed a paradigm on the diagnosis and treatment of rosacea. Symptoms and signs are similar to those with lighter skin types, which include flushing, burning and stinging, long-standing symptoms, typical triggers of rosacea (such as heat), and failed improvements with acne therapies. These symptoms are concentrated in the central face. For patients with darker phototypes, Alexis et al³ recommend blanching the skin or photographing the patient with a blue background to help identify erythema. A dermatoscope can be used to help visualize telangiectasia. Patient characteristics, such as family history and mixed heritage, are also important for diagnosing rosacea among patients with skin of color.³

The treatment of rosacea among patients with darker Fitzpatrick phototypes is the same as those with lighter phototypes.³

In an interview with The Dermatologist, Susan C. Taylor, MD, shared her clinical pearls for diagnosing rosacea and her thoughts on areas of future research and education that are needed to improve the diagnosis of this condition among patients with skin of color. Dr Taylor is the Sandra J. Lazarus Professor of Dermatology, vice chair for Diversity, Equity, and Inclusion, and associate professor of dermatology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, as well as the vice president of the American Academy of Dermatology and founder of the Skin of Color Society. 

Q. What are some of the challenges of diagnosing rosacea in patients with skin of color, particularly among those with darker phototypes?
A. Patients with darker phototypes do display the most common sign of rosacea, which is erythema. The main issue, though, is that not all physicians are able to discern the redness in darker skin types. There are a couple of maneuvers that one can do to better appreciate this sign of rosacea. 

One tip that I commonly recommend to students, residents, and dermatologists is to take a microscope slide and apply it to the skin and push to blanch the skin. When removed, the provider can better appreciate any redness in the skin. There are some people who photograph the patient on a blue background, which can also highlight any redness.

My final tip is to ask the patient. A patient will know if their face is red. They will also report any burning and stinging, and if they experience blushing or flushing. Also, ask the patient if they are particularly sensitive to various cleansers or moisturizers, for example. If they are, it can be a clue to help diagnosis rosacea.

In addition, discerning telangiectasias can be difficult. Using a dermatoscope can help identify this sign of rosacea in patients with darker skin tones.

Q. What are the common pitfalls that dermatologists make when evaluating patients for rosacea, and how can we fix them?
A. The biggest concern is that many physicians do not think about rosacea in patients with darker skin tones. They think of acne quite commonly, and sometimes those patients do have papules. However, they do not think of rosacea. 

That is why dermatologists need to become detectives. We need to look for the redness. We need to find out about sensitivity to products. We need to find out about breakouts, etc. I think the real problem is we do not think about the diagnosis of rosacea.

Q. The treatments for rosacea are the same, but have any been investigated among patients with skin of color specifically?
A. That’s correct that treatment of rosacea is basically the same for all patients, regardless of phototype. A few of them have been assessed among patients with darker skin tones. One study evaluated oral subantimicrobial-dose doxycycline and found similar efficacy and safety between patients with Fitzpatrick skin types I through III and IV through VI.⁴ Another investigated oxymetazoline cream and showed similar efficacy between patients with Fitzpatrick skin types I through III and IV through VI as well.³

If there are newer therapies developed, of course we would want patients with skin of color involved in the trials.

Q. How should dermatology focus on improving our understanding of rosacea in patients with skin of color?
A. There is a need for more education that people with darker skin tones do develop rosacea. Once there is that awareness, then we need to teach dermatologists and residents how to identify redness, which would position them to be able to make that diagnosis. Once one’s index of suspicion is raised and they think about it, then they are more likely to make that diagnosis.

Q. Are there any other key takeaways you would like to leave with our audience?
A. Sun can aggravate rosacea, so it is important to ensure patients with skin of color use sunscreens and photoprotection.

And, again, think about rosacea in patients with darker skin tones, query the patient about symptoms, and treat them similarly to ones with lighter skin tones where rosacea is more easily discernible.

References
1. Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018;179(2):282-289. doi:10.1111/bjd.16481
2. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014;20(10):13030/qt1mv9r0ss.
3. Alexis AF, Callender VD, Baldwin HE, Desai SR, Rendon MI, Taylor SC. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and clinical practice experience. J Am Acad Dermatol. 2019;80(6):1722-1729.e7. doi:10.1016/j.jaad.2018.08.049
4. Sanchez J, Somolinos AL, Almodóvar PI, Webster G, Bradshaw M, Powala C. A randomized, double-blind, placebo-controlled trial of the combined effect of doxycycline hyclate 20-mg tablets and metronidazole 0.75% topical lotion in the treatment of rosacea. J Am Acad Dermatol. 2005;53(5):791-797. doi:10.1016/j.jaad.2005.04.069