Rosacea: Diagnosis and Treatment

Julie Harper, MD, presented the session, “Rosacea: Diagnosis and Treatment,” at Dermatology Week 2022, with a review of the new diagnostic classification of rosacea and its pathogenesis, along with a discussion on developing treatment strategies to target rosacea’s clinical phenotypes.

She began by saying, “We realized that if we tried too hard to push someone into one of [the rosacea] subtypes, we may be leaving some of their rosacea largely untreated… So, we’re getting away from subtyping people and now we’re really talking about phenotypes of rosacea. In a nutshell, what that means is when your rosacea patient is sitting in front of you, you want to identify, diagnose, and document every feature of rosacea that they have and once you’ve done that, then you can come up with your treatment plan.”

Based on the clinical phenotypes, a new diagnostic classification of rosacea has been created. Two of the phenotypes are now considered diagnostic for rosacea: fixed centrofacial erythema and phymatous changes. In the absence of these, at least two of the major phenotypes of rosacea are needed for a diagnosis: flushing, papules and pustules, telangiectasia, and ocular manifestations. Secondary phenotypes include burning, stinging, edema, and dryness.

“Treat everything you see. Different signs of rosacea will require multiple modes of treatment,” Dr Harper noted.

She shared the STOP mnemonic that she uses for patients with rosacea during their first visit, which stands for:

• Identify signs and symptoms of rosacea.
• Discuss triggers.
• Agree on an outcome.
• Develop a plan.

Dr Harper suggested, “I want you to think of [the phenotypes of rosacea] as a menu of features. Does my patient have telangiectasia, or ocular disease, or papules, or redness? And then what tool am I going to use to treat them?”

“We have forks, spoon, and knives to treat rosacea. The forks are those products indicated for papules and pustules. The spoons are FDA approved for persistent background erythema. And then we have our knives, which are the device-based treatments,” she continued. The “forks” include modified-release doxycycline 40 mg, minocycline 1.5% foam, and 5% microencapsulated benzoyl peroxide cream (not yet FDA approved). The “spoons” include brimonidine 0.33% gel and oxymetazoline 1% cream. And the “knives” include pulsed dye laser, KTP, intense pulsed light, and electrosurgery.

Combination treatments should be considered. “The goals of combination therapy are to not just get people better; we want to get them clear. We want to get them clear faster. And then we want to maximize remission periods. We want them to spend more of their life in the clear state than they do in the not clear state. When we do that, I think we minimize the burden of disease,” Dr Harper explained.

She concluded, “A real take-home here is that targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema. Sometimes you need to use another tool. Don’t tie your hands, give your patients the results they want, which is to get them as close to clear as we can possibly get them.”

Reference

Harper JC. Rosacea: diagnosis and treatment. Presented at: Dermatology Week 2022; May 11–14, 2022; Virtual.