Identifying rosacea in richly pigmented skin
Erythema is a less valuable diagnostic tool in this group, but a history of burning sensations should raise suspicions (460 words, 2.5 minutes)
Diagnosis of rosacea in very dark skin can benefit from reconsidering some of the traditional diagnostic criteria and maintaining a higher level of clinical suspicion when patients report certain sensations, noted dermatologist Dr. Jerry Tan during a presentation at the 2020 virtual Skin Spectrum Summit.
There are also some special considerations toconsidert when treating rosacea in this population, he said. Dr. Tan practices in Windsor, Ont., and is an adjunct professor at the Schulich School of Medicine and Surgery, Western University.
The 2017 diagnostic criteria for rosacea (British Journal of Dermatology, Feb. 2017; 176(2):431-438) indicate two independently diagnostic criteria: persistent central facial erythema and phyma. There are also major criteria, any two of which are required, he said. These include transient facial erythema, inflammatory papules and pustules, telangiectasias, and ocular features for ocular rosacea.
However, erythema should be given less weight in rosacea diagnosis in patients with darker skin, Dr. Tan said.
“The way we use [those diagnostic criteria] in dark phototypes is to realize that the erythema is not as apparent. So we can remove [erythema] from the diagnostic criteria,” said Dr. Tan. Transient facial erythema can also be removed from the major criteria, he said.
Instead of erythema, the rosacea-affected skin may appear more brown or burgundy, he said.
In addition to considering erythema less in this population, it can be helpful for a dermatologist to increase their clinical diagnostic suspicion of rosacea based on history for patients with very dark skin, said Dr. Tan. If a patient reports a history of the sensation of flushing—an episodic sense of warmth or burning and stinging—it is worth considering further investigation to rule out rosacea. Triggers for the patient’s flushing can be compared to known rosacea triggers.
“Evaluating for telangiectasias using a dermatoscope can be very helpful because it will give you much more clarity and a greater sensitivity,” he said.
Special considerations for treating rosacea in dark skin:
Patients of darker phototypes should have a chance to test how sunblocks interact with their skin colour. Some can give their skin a blue or purple hue, which may discourage them from using the sunblock
Hyperpigmentation in these patients may be due to ongoing inflammation rather than being post-inflammatory. In this case, fading creams may be inappropriate and inadequate in controlling and improving their increased pigmentation
Procedural therapies for rosacea carry an increased risk of pigment changes, burning and scarring in this subgroup as well
Bottom line: Clinical diagnosis of rosacea in patients with dark skin phototypes can be improved by using the 2017 criteria and modifying them by reducing the weighting of erythema and enhancing clinical suspicion, particularly in patients who have some relevant clinical symptoms. Current rosacea management options can be applied to patients of skin of colour, with the caveat that using procedural therapies come with a greater risk of hyperpigmentation.
From the literature on rosacea in skin of colour:
Skincare habits and rosacea in 3,439 Chinese adolescents: A university-based cross-sectional study
A survey of young people in China asked about their daily skincare habits. People with rosacea and healthy controls completed the survey. The investigators found that inappropriate skincare habits, including longer baths and frequent use of facial cleansers, significantly increase the risk of rosacea in Chinese adolescents.
Dilemmas in the management of rhinophyma in pigmented individuals
This case report details a patient with dark skin experiencing rhinophyma and the challenges in treating their condition. The authors discuss their recommended approach to counselling, getting treatment consent in, and managing these cases. They also propose further investigation into the role of autologous melanocyte transplantation in reducing the impact of hypopigmentation in this group.
Pediatric rosacea in a patient with a dark phototype: Clinical and dermoscopic features
A case study of a child with dark skin and rosacea highlights pediatric rosacea's dermoscopic and clinical findings in highly pigmented skin. The importance of positive family history in diagnosis is also discussed.
Rosacea in skin of colour: A comprehensive review
This article focuses on the pathogenesis, clinical features, treatment recommendations and other aspects of rosacea in darker skin. The authors also review the existing literature.
VIDEO: Mask wearing may lead to worsening rosacea symptoms
At the intersection of skin and society
Earlier this month, Steven Guilbeault, Minister of Canadian Heritage, announced in a press release the first appointees to a new Office of the Commissioner of Indigenous Languages.
According to the Canadian Government, the office, formed under the Indigenous Languages Act, has several goals. These include:
Help promote Indigenous languages
Support the efforts of Indigenous peoples to reclaim, revitalize, maintain and strengthen their languages
Facilitate the resolution of disputes and review complaints to the extent provided by this Act
Promote public awareness of the richness and diversity of Indigenous languages
Support innovative projects and the use of new technologies in Indigenous language education and revitalization, in cooperation with Indigenous governments and other Indigenous governing bodies, Indigenous organizations, the Government of Canada and provincial and territorial governments
The new Commissioner of Indigenous Languages is Ronald E. Ignace, former chief of the Skeetchestn Indian Band, and is an adjunct professor of anthropology at Simon Fraser University in Burnaby, B.C.
“We celebrate this day where we breathe new life into all of our Indigenous languages for the future. Our languages will no longer stand in the shadow of other languages here in our land. Let us always honour our Indigenous languages,” Ignace said in the release.
The new commissioner is supported by three directors: Robert Watt, Georgina Liberty, and Joan Greyeyes.
Read more here: https://www.canada.ca/en/canadian-heritage/news/2021/06/the-first-commissioner-and-directors-of-indigenous-languages-are-appointed.html
This week
June is Filipino Heritage Month in Canada
June 29 is International Day of the Tropics
July 3 is National Stay out of the Sun Day in the U.S.
Something to think about during the week ahead…
Next Week
Next week Chronicle will launch the first in a series called the Summer of Dialogue: Focus on the Black and Brown Dermatology Patient.
The Summer of Dialogue is an eight-week discussion series on Black skin health. In recognition of the persistent health gaps that BIPOC Canadians experience, this program will be dedicated to promoting and advancing medical knowledge and cultural competence. The series will conclude with a live colloquium to be held in late August of this year.
In line with the Indigenous Skin Spectrum Summit held in March 2021, the Summer of Dialogue series will educate healthcare practitioners about treatment challenges specific to Black and Brown skin.
The series will comprise eight weekly podcast episodes hosted by leaders in dermatology and accompanied by eight weekly newsletters that you can read here.
Please watch this space for links to the podcast and registration information for the colloquium.