Rosacea [Speaker Name] [Title] This non promotional presentation has been sponsored and developed by OTH18-07-0214 DOP: September 2018 Learning Objectives To review current guidelines for best practice in diagnosis and management of rosacea To distinguish different sub types and phenotypes To evaluate the psychological aspects of living with rosacea To recognise when to refer Pre-Quiz 1 1. What part of facial skin in rosacea is commonly affected? 2. In what age group is rosacea commonly seen? 3. Is rosacea more common in males or females? 4. What is the most common rosacea trigger? 5. List 3 potential psychological aspects of rosacea 1
Pre-Quiz 2 1. What would be a common primary feature seen on clinical examination? 2. What type of secondary feature may be present? 3. In rosacea, thickening of the skin and enlarged pores is termed as what? 4. In ocular rosacea what common symptoms may a patient experience? 5. Cite 4 patients types with rosacea who should be referred Background Rosacea is a common and chronic inflammatory disorder, affecting the cheeks, nose, chin and forehead 1 Clinical features include flushing, erythema, papules and pustules, telangiectasias, dryness, burning, edema, or skin thickening 2 Many patients have >1 of these clinical features 3 There is no diagnostic test for rosacea 4 1. Del Rosso JQ, et al. Cutis. 2013;91(3 Suppl):1-8. 2. NICE CKS https://cks.nice.org.uk/rosacea-acne. 3. Tan J, et al. Br J Dermatol. 2013;169(3):555-562. 4. Tan J; ROSCO coauthors. Br J Dermatol. 2017;177(2):598-599. Epidemiology 1 Rosacea most commonly affects people aged 30-50 years More prevalent in fair-skinned people of northern and western European descent More common in women, but tends to be more severe in men A proportionately larger number of men may also develop phymatous changes The prevalence of acne rosacea varies up to >20%, depending on populations studied and methodological approach used Rosacea affects 1/10 people in the UK 1. NICE CKS https://cks.nice.org.uk/rosacea-acne. 2
Subtype 1 Erythematotelangiectatic Subtype 2 Papulopustular Subtype 3 Phymatous Subtype 4 Ocular Pathogenesis 1 The pathophysiology of rosacea has yet to be fully determined. Theories include: Genetic Environmental - chronic exposure to UV Immune response innate and adaptive Microorganisms Vascular and inflammatory factors 2 1. Tan J; et al. Br J Dermatol. 2017;177(2):598-599. 2. Gerber PA,et al. J Investig Dermatol Symp Proc. 2011;15(1):40-47. Clinical Features 1 Rosacea s diverse features may be part of a continuum of inflammation Common presentations of flushing and fixed centrofacial erythema may progress to include papules and pustules and potentially phymas Erythema and flushing often remain in patients successfully treated for their papules and pustules 3
Assessment and Diagnosis 1 Current diagnostic practice follows 2002 recommendations from the National Rosacea Society (NRS) expert panel Identified a number of primary features and secondary features Subtypes classification grouping common presentations into 4 subtypes 1. Wilkin J, et al. J Am Acad Dermatol. 2002;46(4):584-587. 2002 National Rosacea Society (NRS) Diagnostic Criteria 1 Primary Features Flushing (transient erythema) Nontransient erythema Papules and pustules Telangiectasia Secondary Features Burning or stinging Plaque Dry appearance Oedema Ocular manifestations Peripheral location Phymatous changes 1. Wilkin J, et al. J Am Acad Dermatol. 2002;46(4):584-587. 2002 National Rosacea Society (NRS) Diagnostic Subtypes 1 Subtype 1 Subtype 2 Erythematotelangiectatic Papulopustular Flushing and persistent central facial erythema +/-telangiectasia Sparing of periocular and nasolabial region Oedema, stinging/ burning, scaling may be present Central facial erythema and telangiectasia Transient pustules and/or papules present centrally or peri-orally. Frequently associated burning/ stinging 1. Wilkin J, et al. J Am Acad Dermatol. 2002;46(4):584-587. 4
2002 National Rosacea Society (NRS) Diagnostic Subtypes 1 Subtype 3 Subtype 4 Phymatous Ocular Thickening skin, irregular surface nodularities with enlargement and prominent pores Tissue hyperplasia Typically on the nose (Rhinophyma) Males > females 10:1 Burning, stinging, dryness Foreign-body sensation Eye photosensitivity, itching, blurred vision Telangiectasia of conjunctiva + lid margin, stye, infections. Lid/periocular erythema Blephritis, conjunctivitis 1. Wilkin J, et al. J Am Acad Dermatol. 2002;46(4):584-587. 2017 ROSCO Panel Guidance 1 The Global ROSacea COnsensus (ROSCO) Panel Classification of rosacea based on disease phenotype rather than subtype Established importance of assessing the patient burden of rosacea 1. Tan J; ROSCO coauthors. Br J Dermatol. 2017;177(2):598-599. ROSCO Phenotype v. Subtype 1 Rosacea features can span multiple subtypes Subtype based assessment may not fully address the range of clinical features Phenotype based diagnosis and severity grading helps facilitate an individualised disease management plan 1. Tan J; ROSCO coauthors. Br J Dermatol. 2017;177(2):598-599. 5
ROSCO Phenotype v. Subtype 1 Potential overlap of rosacea features with subtype classification: ETR PPR Phymatous Ocular Facial erythema (transient and persistent) Telangiectasia Inflammatory lesions (papules/pustules) Phymatous changes Adapted from Tan J; 2017 Ocular symptoms 1. Tan J; ROSCO coauthors. Br J Dermatol. 2017;177(2):598-599. 2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance 2017 National Rosacea Society (NRS) Assessment Scales 1 Phenotypes Papules and pustules Flushing Telangiectasia Persistent erythema Assessment Scale Lesion counts, IGA FAST, GFSS None CEA/PSA CEA, Clinician s Erythema Assessment; FAST, Flushing Assessment Tool; GFSS, Global Flushing Severity Score; IGA, Investigator s Global Assessment; PSA, Patient s Self-Assessment. 6
Exacerbating Factors Exposure to extremes of Sun exposure 1 Hot beverages 1 Spicy foods 1 temperature 1 Alcohol 1 Exercise 2 Skin barrier disruption 2 Emotional stress 1 Irritation from topical products 2 Psychologic feelings, especially anger, rage, and embarrassment 3 Certain drugs such as nicotinic acid and vasodilators (eg, calcium-channel blockers) 1 1. NICE. CKS. Rosacea. 2018. 2. Mikkelsen, et al. Dermatol Reports. 2016;8(1):6387. 3. Drake L. National Rosacea Society. In: Rosacea Review. Winter 2017. Triggers 1 Sun exposure Emotional stress Hot weather Wind Heavy exercise Alcohol consumption Hot baths Cold weather Spicy foods Humidity Certain skin care products Indoor heat Heated beverages Certain cosmetics 27% 57% 56% 52% 51% 46% 45% 44% 41% 41% 36% 75% 81% 79% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1. Adapted from: NRS. http://www.rosacea.org/patients/materials/triggersgraph.php. Psychosocial Aspects 1 Rosacea has an adverse impact on emotional, social, and occupational well-being Psychologic burden includes depression, anxiety, and worry Scales include the Rosacea Quality of Life Index (RosaQoL) 7
Primary Care Dermatology Society (PCDS) Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. Self Care 1 Provide patient with BAD PIL Protect skin with perfume-free sun block Avoid rubbing or scrubbing the face Avoid perfumed soaps Avoid exacerbating factors Generally emollients are soothing Use an unperfumed moisturiser on a regular basis 1. BAD. http://www.bad.org.uk/shared/get-file.ashx?id=229&itemtype=document. Patient Education The following may improve the effectiveness of provider-patient encounters and the outcome of therapy: Rosacea characteristics Details of skin-care regimens Avoidance of triggers Medical and self-care treatment choices Adherence to therapy Correct use of medications 8
When to Refer Severe psychological distress 1 Severe ocular involvement (to ophthalmologist) 2 Patient might benefit from Intense Pulsed Light (IPL) or Pulsed Dye Laser (PDL) - limited NHS availability 1 Not responding to treatment 1 Surgical reduction for bulbous phymatous rosacea 2 1. PCDS Guidelines: Rosacea Treatment Options, 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 2. BAD. http://www.bad.org.uk/shared/getfile.ashx?id=229&itemtype=document. In Summary Rosacea is a common and chronic inflammatory disorder, affecting the cheeks, nose, chin and forehead 1 Rosacea most commonly affects people aged 30-50 years and women 2 Clinical features include flushing, erythema, papules and pustules, telangiectasias, dryness, burning, oedema, or skin thickening 2 Many patients have >1 of these clinical features 3 There is no diagnostic test for rosacea 4,5 Rosacea has an adverse impact on emotional, social, and occupational well-being 6 1. Del Rosso JQ, et al. Cutis. 2013;91(3 Suppl):1-8. 2. NICE CKS https://cks.nice.org.uk/rosacea-acne. 3. Tan J, et al. Br J Dermatol. 2013;169(3):555-562. 4. Forton FM et al. Acta Derm Venereol. 2017;97(2):242-248. 5. Tan J; ROSCO coauthors. Br J Dermatol. 2017;177(2):598-599.6. Gallo RL, et al. J Am Acad Dermatol. 2018;78(1):148-155. Pre-Quiz 1 1. What part of facial Cheeks, forehead, chin skin in rosacea is and nose. commonly affected? 1 2. In Middle what aged group 3. Is rosacea more individuals is rosacea (30-50 common Females. in males commonly years of age). seen? or females? 4. What is the most Sun common exposure. 3 rosacea trigger? Rosacea has an adverse 5. impact List 3 on potential emotional, social, and occupational psychological well-being, caused by depression, aspects of anxiety, rosacea and worry. 4 1. Del Rosso JQ, et al. Cutis. 2013;91(3 Suppl):1-8. 2. NICE CKS https://cks.nice.org.uk/rosacea-acne. 3. NRS http://www.rosacea.org/patients/materials/triggersgraph.php. 4. Gallo RL, et al. J Am Acad Dermatol. 2018;78(1):148-155. 9
Pre-Quiz 2 Fixed centrofacial 1. What would be a erythema, Phymatous changes, common Papules primary and feature pustules, seen Flushing, on Telangiectasia, clinical examination? Ocular manifestations. 1 Secondary 2. What type of phenotypes: Burning secondary or stinging; Facial feature oedema; may Dry be present? appearance; Ocular manifestations. 1 3. In rosacea, thickening of the skin and Phymatous. enlarged pores 1 is termed as what? 4. Lid In margin ocular telangiectases; rosacea Interpalpebral conjunctival what common injection; Spade-shaped infiltrates symptoms in the may cornea; a patient Scleritis experience? and sclerokeratitis. 1 Severe psychological distress; 5. Cite 4 patients Not responding to treatment; Patient types might with benefit rosacea from IPL)or who PDL) should Severe be ocular referred involvement; bulbous phymatous rosacea. 2 2 PCDS Guidelines: Rosacea Treatment Options, 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. Case Studies* *all case studies presented are fictional for demonstrative purposes Case 1 58 year old female Celtic origin Fixed redness across cheeks, nose and chin Embarrassed Distressed by preconceptions Skin very sensitive 10
2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance Triggers 1 Sun exposure Emotional stress Hot weather 75% 81% 79% Wind Heavy exercise Alcohol consumption Hot baths 57% 56% 52% 51% Cold weather Spicy foods Humidity Certain skin care products Indoor heat 46% 45% 44% 41% 41% Heated beverages 36% Certain cosmetics 27% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1. Adapted from: NRS. http://www.rosacea.org/patients/materials/triggersgraph.php. Primary Care Dermatology Society (PCDS) Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 11
Case 2 62 year old female Presents with multiple papules and a few pustules None of the medicines the GP has prescribed have had any benefit Seeking a dermatology referral Embarrassed by her facial appearance and affecting her Quality of Life (QOL) 2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance Primary Care Dermatology Society (PCDS) Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 12
Case 3 49 year old lady Eyes dry with stinging sensation Eyes appear red and feel like there is something in them Sometimes vision appears blurry Has redness on both cheeks, forehead and nose Otherwise fit and well 2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance Primary Care Dermatology Society (PCDS) Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 13
Case 4 68 year old man with lumps on the end of his nose Skin feels hard and thickened Embarrassed by appearance 2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance Primary Care Dermatology Society (PCDS) Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 14
Case 5 27 year old woman Been applying moderate topical steroids to face for supposed eczematous rash for 4 weeks Now has more redness with some papules and pustules 2017 National Rosacea Society (NRS) Diagnostic Criteria 1 A diagnosis of rosacea may be considered in the presence of 1 of the following diagnostic cutaneous signs: Fixed centrofacial erythema in a characteristic pattern Phymatous changes Primary Phenotypes Papules and pustules Flushing Telangiectasia Ocular Secondary Phenotypes Burning or stinging Facial oedema Dry appearance PCDS Guidance Rosacea 1 Product Flushing, Erythema & Telangiectasia Papules & Pustules Occular Ivermectin 1% Cream +++ Azelaic Acid Gel ++ Metronidazole Gel or Cream 0.75% + Brimonidine Gel 0.33% ++ Eye Lubricants +++ Doxycycline MR 40mg +++ Doxycycline 100mg ++ ++ Lymecycline 408mg caps Oxytetracycline 250-500mg + + Erythromycin/Clarithromycin 250-500mg + Isotretinoin ++ Intense Pulsed Light (IPL) +++ Pulsed Dye Laser (PDL) ++ Clonidine 25-50mcg ++ Propranolol 10-40mg + Carvedilol 3.125-6.25mg + Legend +++ Strong recommendation ++ Moderate recommendation + Low recommendation Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. PCDS Guidance: Rosacea Treatment Options. 2016. Available at http://www.pcds.org.uk/ee/images/uploads/general/rosacea_pcds.pdf. 15
Top Tips for Management 1 Ensure the patient understands that there is no cure for rosacea but symptoms can be managed Discuss trigger factors - rosacea patients can improve their chances of maintaining remission by identifying and avoiding lifestyle and environmental factors that may trigger flare-ups Target treatments to presenting symptom Ask and incorporate the psychological impact the condition may have into your treatment approach Talk about skin care and the use of non-comedogenic, fragrance and perfume free products Discuss sun protection all year round factor 30+ Topical steroid preparations should be avoided Avoid long term use of oral antibiotics 6 months Individual Summaries of Product Characteristics (SPCs) must be consulted prior to prescribing. 1. Mawson R. https://www.guidelinesinpractice.co.uk/skin-and-wound-care/practical-implementation-tips-rosacea/352810.article Thank you for listening 16