National Rosacea Society Expert Committee Research Articles

Clinical features and treatment of rosacea

Background: Rosacea is a common facial dermatological disease characterized by central erythema and flushing. It is more common in females than males, with a prevalence of approximately 5.5% in the global population and 2.4% among all dermatological outpatients. In 2002, the National Rosacea Society Expert Committee suggested a subtype-based standardized classification system. The most common subtype of rosacea is erythematotelangiectatic rosacea (ETR), followed by papulopustular rosacea (PPR), phymatous rosacea, and ocular rosacea.Current Concepts: Rosacea is characterized by hyperactive innate and neurovascular immune reactions, which lead to altered adaptive immune reactions and hyperreactive inflammation. In 2017, the National Rosacea Society Expert Committee developed a phenotype-based classification system. The diagnostic features include persistent centrofacial erythema and phymatous changes. ETR is associated with sensitive skin and may have a debilitating psychological impact, often leading to psychological conditions such as depression and anxiety. Doxycycline and minocycline are considered the gold-standard oral treatments for rosacea. Topical ivermectin and metronidazole are commonly used to treat PPR. Low-dose isotretinoin is an alternative to avoid long-term chronic antibiotic use. Carvedilol and propranolol are off-label medications used to reduce persistent facial flushing and erythema in rosacea. Some alpha-adrenergic receptor agonists have also been approved for the treatment of persistent erythema in rosacea.Discussion and Conclusion: Rosacea exhibits multiple phenotypic manifestations. The treatment approach is individualized for each patient through the customization of multimodal treatments, including the avoidance of trigger factors and the assessment of comorbid diseases.

Rosacea in acne vulgaris patients: Subtype distribution and triggers assessment-A cross-sectional study.

Recent studies have reported that the incidence of acne combined with rosacea is increasing. However, the clinical feature and inducing factor of these two diseases co-occurrence is remain unclear. This study aims to investigate the classification and severity of female patients combining with acne and rosacea. Female patients with facial acne combined with rosacea, 15-50years old, were included from dermatology outpatient department from January 2019 to December 2019. The severity of acne was classified according to the Pillsbury grading system. Rosacea was diagnosed and classified according to the Standard issued by National Rosacea Society Expert Committee. Questionnaire was designed to collect the information of rosacea triggers from each patient. 563 vulgaris acne combined with rosacea patients (mean age 23.2±43), included 70.33% severe acne (n=396), 15.81% moderate acne(n=89), and 13.85% mild acne(n=78), had finished the study. In severe acne group, 72.47% combine with erythematotelangiectatic rosacea (ETR), 22.47% combined with papulopustular rosacea (PPR), and 5.05% combine with phymatous rosacea (PHR). In moderate acne group, 53.93% combine with ETR, 43.82% combined with papulopustular rosacea (PPR), and 2.24% combine with PHR. All patients in moderate acne subject group was combined with ETR (100%). Patients that did not use skin care produces presented 12.79 times higher rate to combine with ETR than that frequently using skin care products (P=.014). Erythema telangiectasia rosacea is the most common rosacea type in female acne patients. There is a need to be vigilant about the combination of sever/moderate acne and papulopustular rosacea. Rational daily use of skin care products can reduce the incidence of rosacea in acne patients. For acne patients without family history of rosacea, dermatologists should also not ignore the healthy education to avoid potential triggers of rosacea.

A predictive model for differential diagnosis between rosacea and sensitive skin: a cross-sectional study.

A predictive model for differential diagnosis between rosacea and sensitive skin: a cross-sectional study.

Ocular rosacea.

To revisit ocular rosacea as an underappreciated condition which can cause permanent blindness if inadequately treated, and to review data supporting improved diagnostic and treatment strategies. Ocular rosacea has an underrecognized prevalence in children and individuals with darker skin tone. Rosacea has several associations with other significant systemic diseases. Variations in local and systemic microbiome, including demodex infestation, may play a role in pathogenesis, severity, and in explaining the different phenotypes of rosacea. The National Rosacea Society Expert Committee established an updated classification system of rosacea in 2017. New treatment algorithms based on these clinical subtypes are suggested. With continued advancements in the understanding of the epidemiology and pathogenesis of rosacea, randomized controlled trials specific for ocular rosacea remain lacking. There is overall consensus that rosacea and ocular rosacea require chronic maintenance treatment strategies involving combination topical and systemic therapies.

Challenges and Advances in Rosacea Management

Rosacea is a common chronic inflammatory disorder characterized by symptoms of facial flushing and spectrums of clinical signs, including erythema, dry skin, and an inflammatory papulopustular eruption with periods of exacerbation. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Individual subtypes are likely a result of different pathogenic factors and respond best to different therapeutic regimens. Before initiation of therapy, the triggering factors should be identified and avoided. Daily applied sunscreen is a must. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Traditional therapies include topical metronidazole or azelaic acid also oral therapy as tetracyclines or isotretinoin. Emerging therapies perhaps are more promising as topical ivermectin 1% cream which is proved to be safe and effective for the treatment of inflammatory lesions from papulopustular rosacea, Brimonidine tartrate and oxymetazoline are novel therapies to treat the erythema associated with rosacea. Other treatments as pimecrolimus 1% cream, clindamycin phosphate 1.2% + tretinoin 0.025% gel, pulsed dye laser and intense pulsed light can also be used. With the advent of novel therapeutic options for the treatment of rosacea such as subantimicrobial anti-inflammatory dose doxycycline, ivermectin and Brimonidine tartrate, there is renewed interest in the study of this disease which was once regarded as a debilitating disorder and now has become a well-known and manageable entity in the setting of these emerging therapeutic options. Herein, we describe the treatments currently available as well as the emerging and combination therapies.

Update on the Management of Rosacea.

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Is the effect of smoking on rosacea still somewhat of a mystery?

Context: Rosacea is an inflammatory skin disease with a chronic course. In the past, the association between rosacea and smoking was examined only in a few studies.Objective: The objective of this study is to investigate the prevalence and the influence of smoking in rosacea patients.Materials and methods: This prospective cross-sectional study includes 200 rosacea patients and 200 age- and gender-matched rosacea-free controls. Using National Rosacea Society Expert Committee classification, we divided patients into three subgroups as having erythematotelangiectatic (ETR), papulopustular (PPR), and phymatous rosacea (PhR). Demographic data, risk factors, and smoking habits were recorded.Results: In multivariate analysis, the prevalence of smoking was significantly higher (66%) among patients compared with controls. ETR subtype (43.5%) was found to be significantly higher among active smokers (p < 0.001). Considering the risk factors, caffeine intake and alcohol consumption could not be evaluated because of their never or rarely intake. Whereas rates of photosensitive skin type and positive family history were significantly prominent in ETR patients (p < 0.001). While PhR was mostly detected in men who are very old, a significant tendency was found to develop ETR in women.Conclusion: While a significantly increased risk of developing rosacea among smokers was observed in this study, ETR seems to be the disease of active smokers. Further studies are required for better understanding of the association between rosacea and smoking.

Update on the management of rosacea.

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Distribution and Expression of Non-Neuronal Transient Receptor Potential (TRPV) Ion Channels in Rosacea

Rosacea is a frequent chronic inflammatory skin disease of unknown etiology. Because early rosacea reveals all characteristics of neurogenic inflammation, a central role of sensory nerves in its pathophysiology has been discussed. Neuroinflammatory mediators and their receptors involved in rosacea are poorly defined. Good candidates may be transient receptor potential (TRP) ion channels of vanilloid type (TRPV), which can be activated by many trigger factors of rosacea. Interestingly, TRPV2, TRPV3, and TRPV4 are expressed by both neuronal and non-neuronal cells. Here, we analyzed the expression and distribution of TRPV receptors in the various subtypes of rosacea on non-neuronal cells using immunohistochemistry, morphometry, double immunoflourescence, and quantitative real-time PCR (qRT-PCR) as compared with healthy skin and lupus erythematosus. Our results show that dermal immunolabeling of TRPV2 and TRPV3 and gene expression of TRPV1 is significantly increased in erythematotelangiectatic rosacea (ETR). Papulopustular rosacea (PPR) displayed an enhanced immunoreactivity for TRPV2, TRPV4, and also of TRPV2 gene expression. In phymatous rosacea (PhR)-affected skin, dermal immunostaining of TRPV3 and TRPV4 and gene expression of TRPV1 and TRPV3 was enhanced, whereas epidermal TRPV2 staining was decreased. Thus, dysregulation of TRPV channels also expressed by non-neuronal cells may be critically involved in the initiation and/or development of rosacea. TRP ion channels may be targets for the treatment of rosacea.

Rosacea: advances in understanding pathogenesis and treatment

Rosacea is a common, chronic inflammatory skin disease that primarily affects the face. There is a wide range of clinical features in rosacea including persistent erythema, facial flushing, telangiectasia, inflammatory papules and phymas. The National Rosacea Society Expert Committee has identified four major subtypes of rosacea based on groups of these symptoms: erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea and ocular rosacea. The pathophysiology of rosacea has not been completely elucidated; however, recent research into this disorder has identified several potential etiologic agents and processes that contribute to the disease. The synthesis of this research allows us to begin to understand how our current therapies work and provides us potential targets for future therapies. This article will review our current theories of rosacea pathogenesis, outline treatment options and discuss avenues for future research.

Prevalence of Rosacea in an Estonian Working Population Using a Standard Classification

Data about the prevalence of rosacea are scarce. The aim of this study was to evaluate the prevalence rate of rosacea according to the American National Rosacea Society Expert Committee (NRSEC) classification. A cross-sectional study of 348 subjects randomly selected from a working population >or= 30 years of age was performed. All subjects completed a questionnaire. Skin status was examined according to NRSEC criteria. Of the 348 subjects, 78 (22%) had one or more primary features of rosacea. The most common features were erythema (21%) and telangiectasia (18%). Of the subjects with rosacea, 78% had erythematotelangiectatic rosacea and 22% had papulopustular rosacea. Fifteen percent of the study subjects had experienced frequent episodes of flushing without permanent features of rosacea. No significant gender-related differences were found between study groups. In conclusion, according to the NRSEC, rosacea is a more common skin condition over the age of 30 years than previously thought.

Rosacea, acne rosacea, and actinic telangiectasia: In reply

To the Editor: The National Rosacea Society Expert Committee on the Classification and Staging of Rosacea read with interest the letter of Dr F. William Danby1 to this journal with comments relating to the standard classification of rosacea. As noted in its publication, and in the more recent publication of a standard grading system, this is a provisional system that is expected to require modification as the pathogenesis and subtypes of rosacea become clearer, and as its relevance and applicability are tested by researchers and clinicians.

Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea*1, *2

A standard classification system for rosacea was published in the April 2002 issue of the Journal of the American Academy of Dermatology.1 Developed by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea and reviewed by rosacea experts worldwide, it describes primary and secondary features of rosacea and recognizes 4 patterns of signs and symptoms, designated as subtypes.

Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea

A standard classification system for rosacea was published in the April 2002 issue of the Journal of the American Academy of Dermatology.1 Developed by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea and reviewed by rosacea experts worldwide, it describes primary and secondary features of rosacea and recognizes 4 patterns of signs and symptoms, designated as subtypes. To enhance the utility of the system for both clinicians and researchers, the committee has devised a standard method for assessing gradations of the severity of rosacea. In addition to the classification system, a standard grading system is often essential to perform research, analyze results, and compare data from different sources, and in turn provides a common reference for diagnosis, treatment, and assessment of results in clinical practice.2,3 Standard parameters and terminology also

Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea

J Am Acad Dermatol 2002;46:584-7