Diagnosing rosacea in darker skin
A lack of erythema may complicate diagnosis of rosacea in some skin types, but all rosacea subtypes present in all populations (1,425 words, 7 minutes)
All types of rosacea can affect all ethnicities, and the skin condition may be under-diagnosed in patients of colour, Dr. Jaggi Rao told the 7th Annual Skin Spectrum Summit on Nov. 4.
Dr. Rao is a clinical professor in the faculty of medicine and dentistry at the University of Alberta and heads the Alberta Dermasurgery Centre in Edmonton.
Dr. Rao warned that rosacea has a significant psychosocial impact on patients, possibly leading to insecurity, embarrassment, depression and even suicide.
The four types of rosacea Dr. Rao listed are:
Erythematotelangiectatic rosacea (ETR), also called flat rosacea. Flushing is characteristic of this type of rosacea. There are no bumps, but the skin appears red, and it can be more challenging to diagnose in darker skin.
Papulopustular rosacea, also known as acne rosacea or bumpy rosacea. It usually follows ETR, although it can sometimes come out of nowhere.
Phymatous rosacea. This is characterized by thickened skin and increased collagen and oil, so there can be discharge and even crusting.
Ocular rosacea. This is characterized by redness and swelling of the conjunctiva and often grittiness or itchiness in the skin around the eyes.
When examining patients of colour, said Dr. Rao, physicians should look for persistent central facial erythema and swelling. However, erythema may not always be apparent in darker skin. As a result, when taking the patient's history, physicians should note if the patient mentions heat, sensitivity to surroundings, tenderness or burning sensations, or if activities or emotions exacerbate it and if there is waxing and waning activity.
He suggested that if there is no visible inflammation, physicians should look for post-inflammatory hyperpigmentation and make sure that rosacea is not misdiagnosed as acne or seborrheic dermatitis.
Bottom Line: All four types of rosacea can be seen in people of all ethnicities and skin colours and can significantly affect mental well-being. Rosacea is probably underdiagnosed in darker-skinned patients because of differences in presentation. Checking for reactions to heat, exertion, emotion, and other triggers is especially important to ensure that rosacea is not missed or misdiagnosed.
From the literature on rosacea in skin of colour
Systemic comorbidities in Korean patients with rosacea: Results from a multi-institutional case-control study
This multi-centre, case-control study suggests that Koreans with rosacea are more likely to experience systemic comorbidity.
This study included 12,936 rosacea patients and 12,936 age- and sex-matched control subjects identified from 2007 to 2018 to identify comorbidities to rosacea and create a reference database. The investigators found significant associations between rosacea and Sjögren syndrome, systemic sclerosis, rheumatoid arthritis, ankylosing spondylitis, autoimmune thyroiditis, and several other skin conditions, infections, and systemic conditions.
There were some sex differences observed, with higher odds for Sjogren syndrome, systemic sclerosis, ankylosing spondylitis, thyroiditis, vitiligo, hepatobiliary cancer, and obesity exclusively seen in female subjects with rosacea. In contrast, increased prevalence of alopecia areata and alcohol abuse was confined to men.
Higher odds for vitiligo, lung cancer and gastroesophageal reflux disease were only seen in individuals with rosacea aged 50 years and older.
Individuals younger than 50 were exclusively associated with hepatobiliary cancer, allergic conjunctivitis, and irritable bowel syndrome.
The authors conclude that clinicians should acknowledge these interrelations between rosacea and comorbid conditions and employ comprehensive care with an individual-based approach.
The efficacy and safety of dual-frequency ultrasound for improving skin hydration and erythema in patients with rosacea and acne
This study found that dual-frequency ultrasound with impulse mode appears to be safe and effective in improving skin hydration and erythema in Asian patients with rosacea and acne.
In the study, 26 Asian subjects with facial erythema received an ultrasound treatment once per week, for four weeks, over both cheeks. Investigators measured erythema index and transepidermal water loss (TEWL) at each visit and assessed the improvement in erythema over the treatment period. The patients reported their satisfaction levels.
At six weeks after the start of treatment, researchers observed average decreases in TEWL and erythema index of 5.37±13.22 g/h/m2 (p=0.020) and 39.73±44.21 (p=0.010), respectively. Both the clinician's erythema assessment and the subject satisfaction questionnaire scores significantly improved at the final follow-up (p<0.001; p=0.003, respectively).
The researchers observed no serious adverse effects during either treatment or follow-up.
Characterization of rosacea in Chinese: An analysis of 254 cases
Findings from a survey of Chinese outpatients with rosacea have shown the condition mainly affects young females in this population. The investigators also identified common signs and symptoms and risk factors.
To conduct the survey, researchers provided a questionnaire to outpatients with rosacea who visited the dermatology department of the university hospital from June 2018 to March 2019. A total of 254 outpatients completed the questionnaire.
The investigators found that more than half (51.6%) of the rosacea cases were the erythematotelangiectatic subtype. Another 39% were of papulopustular subtype, and 9.4% were phymatous.
Subjects with flushing, persistent facial erythema, and telangiectasia accounted for 91.73%, 90.55%, and 83.07%, respectively. Also, 113 subjects (44.49%) had papules or pustules, and 24 subjects (9.40%) had phymatous changes.
Rosacea was most commonly found on the cheeks (93.31%), followed by the nose (82.68%), the perioral area (61.42%), and the forehead (51.97%). Clinical symptoms included burning (93.70%), dryness (90.55%), and itching (75.59%), and the main risk factors were sun exposure (90.94%) and temperature change (87.40%). Roughly one-fifth of the patients had comorbidities.
Excessive cleansing: An underestimating risk factor of rosacea in Chinese population
A study of the daily cleansing habits of 999 rosacea cases and 1,010 healthy controls in China has found that excessive cleansing was a substantial risk factor for the incidence or progression of rosacea in the Chinese population.
Investigators found that cleansing more than once daily and using more than five different cleansing products in a year positively correlated with rosacea occurrence.
However, the duration of cleansing sessions and the types of cleansers used appeared not to be correlated with the onset of rosacea.
Other risk factors included overuse of cleansing tools—more than four times a week, daily use of oil control products or exfoliation, facial masks, or receiving treatments in beauty salons.
The investigators found that patients who prefer deep cleansing were more prone to present an initial symptom of papules and pustules. As well, they found that daily use of exfoliating products presented a positive correlation with the progression of patients’ symptoms from flushing to erythema and telangiectasis, and with an increase in the affected areas from a single area to pan facial involvement.
VIDEO: Rosacea and the skin barrier: Management of sensitive facial skin
At the intersection of skin and society
Nigerian medical student and medical illustrator Chidiebere Ibe is drawing worldwide attention to the shortage of depictions of Black individuals in the medical literature.
Recently, a cut-away illustration by Ibe of a Black woman with a baby in utero went viral on social media and gained coverage in many mainstream news outlets.
On a GoFundMe page Ibe set up to earn money for medical school (as of the time of writing, Ibe has been admitted to Kyiv Medical School in Ukraine), he explained his motivations as a medical illustrator:
“I started medical illustrations to promote the use of black skin illustrations in our medical textbooks to depict a typical African person. Textbooks are essentially invincible to medical training. They walk medical trainees through conditions they will encounter during their practice. Yet, most medical illustrations are on the Caucasian skin. This lack of diversity has important implications for medical trainees and their future patients because many conditions and signs look different based on the patient’s skin colour and therefore the black skin should be equally represented. Recent research on health inequities has found that black students find illustrations in black skin more engaging, amusing and emphatic. The deeper engagement and connection help them understand more, hence my desire to assist my colleagues get a better understanding of medicine and help my future patients be better engaged.”
Many of Ibe’s illustrations, including depictions of eczema and seborrheic dermatitis in Black skin, can be seen on his Instagram page at this link.
This week
December is International Sharps Safety Awareness Month
Dec. 18 is International Migrants Day
Something to think about in the week ahead…
Next week
In our final Skin Spectrum Weekly for 2021, Dr. Jason Rivers talks at the 7th annual Skin Spectrum Summit about the prevalence of melasma in skin of colour, as well as some treatment approaches for this population.