Results of a Patient Survey on Rosacea Redness

Rosacea is a chronic facial skin disorder that aff ects an estimated 16 million Americans.¹ Although once conventionally divided into 4 subtypes, rosacea is now classified as a single disorder with many potential clinical features, or phenotypes, that may occur in various combinations, with persistent facial erythema as the primary diagnostic sign.² Phymatous changes, such as rhinophyma, are also considered diagnostic, although less common. In addition, major signs of rosacea include papules and pustules, flushing, visible blood vessels on the face (telangiectasia), and certain ocular manifestations. The presence of any two of the major phenotypes may be considered diagnostic of rosacea. Secondary phenotypes include burning, stinging, edema, and dryness. Although these signs and symptoms may appear at different times and in varying combinations, studies indicate that they may all be manifestations of the same underlying inflammatory continuum.²

The impact of severe redness on quality of life was illustrated in a previous National Rosacea Society (NRS) burden of illness study.³ In the survey of 708 respondents, the mean score on a validated Dermatology Life Quality Index was 5.2 overall, which is comparable to scores for patients with acne. However, respondents with severe erythema scored 13.4, comparable to scores for patients with eczema and psoriasis. In another NRS survey of 1675 patients with rosacea, 82% of those who experienced erythema reported that the condition negatively impacted their general outlook on life, with the figure rising to 90% for those with moderate to severe redness.⁴

According to a new NRS survey on rosacea redness, most respondents reported experiencing persistent facial erythema and noted that it is the most frequently bothersome sign, leading to considerable psychological impact.⁵ Furthermore, two-thirds of respondents indicated they experience fl are-ups more than once a week. “The results of this survey serve as a strong reminder that persistent facial redness is the defining feature of rosacea, and one that should not be ignored when treating patients,” said Hilary Baldwin, MD, associate professor of dermatology at Rutgers Robert Wood Johnson Medical School.

New Survey Reveals Effects of Redness

In the survey of 986 patients with rosacea, 77% of respondents said they experienced persistent facial redness, whereas 61% reported having bumps and pimples and 53% had visible blood vessels on their face.⁵ Forty-six percent said they experienced burning, stinging, and itching; 43% had red, irritated, or watery eyes indicative of ocular rosacea; and 27% reported having a red, swollen nose or rough and thickened skin due to phymatous changes.

About 60% of respondents said persistent redness was the most frequently bothersome sign they experienced, compared with 38% who indicated that bumps and pimples bothered them most frequently. About 30% of respondents said they experienced flare-ups of their facial redness daily, and a further 34% had facial redness flares several times a week.

Asked how the redness of rosacea affected them, 59% of respondents said it made them feel self-conscious and that people were looking at their face, and 57% responded they were frustrated or annoyed with their appearance. Forty percent stated they stayed out of the sun or limited outdoor activities, and 38% indicated they thought the redness made them look unhealthy. Only 4% of respondents said their rosacea redness did not affect them.

Most survey respondents (80%) reported that they have discussed treatments for redness with their health care provider. Eighty percent discussed a topical prescription medication; 40%, an oral prescription medication; and 24%, treatment with a laser or light device. About two-thirds (62%) of those who were prescribed a topical medication used it daily or as directed by their health care provider, whereas 13% applied it only during a flare-up, 12% had stopped using it, and 11% used it occasionally. In comparison, 40% of those who were prescribed an oral medication took it daily or as directed, 17% had stopped taking it, 12% took it only when flaring up, and 8% took it occasionally.

Among those who stopped using a topical or oral prescription therapy, 24% said it was because the treatment stopped working; 13%, due to unpleasant side effects; 8%, due to expense; 7%, because it was not convenient; and 5%, because they ran out and did not refill their prescription.

A Fresh Approach to Treating Rosacea Erythema

Research and clinical experience show that targeting the persistent erythema of rosacea, in combination with treating all signs and symptoms individually, may not only clear its appearance but also lessen the severity of the disease itself, according to Julie Harper, MD, president and owner of the Dermatology and SkinCare Center of Birmingham. Dr Harper noted that erythema may often underlie other signs and symptoms, and even if it is not the most obvious feature to the patient, it is an important treatment target. “Background erythema is often present along with other signs,” she said. “While bumps and pimples may be bothersome to the patient, the redness is also a central part of the pathogenesis. We do not just want to fix what we see now; we want to halt the progression of the disease.”

A recent study of oxymetazoline cream, 1%, a US Food and Drug Administration-approved alpha-agonist that acts as a vasoconstrictor to narrow the blood vessels and consequently reduce the appearance of redness, showed that its consistent daily use over 52 weeks was effective and well tolerated.⁶ The medication specifically targets the enlargement of blood vessels and reduces them to normal size, Dr Harper explained, and added that the findings have had a critical influence on how she prescribes therapy. “It changed my practice,” she said. “Based on what we are learning, I am using oxymetazoline cream more. It is a shift in our thinking about rosacea. It is time to start targeting dilated vessels for treatment, as it seems to be an important part of managing what we already see and helping to control the disease long term.” Oxymetazoline cream, 1% has a specific receptor selectivity that makes it easier and safer to use without causing a worsening or rebound of redness, and it does not cause the patient’s face to appear overly blanched and ghost-like, Dr Harper remarked.

Although comprehensive treatment plans may be complex, a key to ensuring that patients gain the full benefit is education to encourage adherence to therapy, explaining why more than one medication may be necessary and exactly how the therapies should be used. The time of day, frequency, and areas of application should be clearly explained. “Medications work differently and have different targets and outcomes. Using them in combination is going to help make our patients better,” Dr Harper said. For example, a patient who applies an alpha-agonist before going to bed instead of in the morning will not see the full benefit of the treatment. The medication should also be used every day. “I had been allowing patients to use the therapy as needed, but now I am convinced we need to use it consistently,” she said. “The erythema of rosacea did not happen overnight. The vasodilation is not intermittent, and the vasonormalization should not be either.”

Dr Harper noted that complete treatment of rosacea may resemble being served a multicourse meal at a restaurant. With rosacea, the “courses” may include not only facial redness, but also bumps and pimples, telangiectasia, swelling, stinging, and dryness. Just as a diner must use a variety of utensils, such as a fork for salad or a spoon for soup, certain therapies or combinations will be more useful than others for the specific signs and symptoms that a patient is experiencing. Dr Baldwin agreed. “As dermatologists, we want patients to be healthy and happy in their skin,” she said. “With today’s increasingly sophisticated tools, it is now possible to tailor therapy to address each patient’s individual signs and symptoms, and substantially improve the quality of their lives.”