Summary
Background
Rosacea is currently diagnosed by consensus‐defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, ...which has implications for clinical practice and research. Adopting a phenotype‐led approach may facilitate patient‐centred management.
Objectives
To advance clinical practice by obtaining international consensus to establish a phenotype‐led rosacea diagnosis and classification scheme with global representation.
Methods
Seventeen dermatologists and three ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and severity evaluation. All voting was electronic and blinded.
Results
Consensus was achieved for transitioning to a phenotype‐based approach to rosacea diagnosis and classification. The following two features were independently considered diagnostic for rosacea: (i) persistent, centrofacial erythema associated with periodic intensification; and (ii) phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were not considered to be individually diagnostic. The panel reached agreement on dimensions for phenotype severity measures and established the importance of assessing the patient burden of rosacea.
Conclusions
The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype.
What's already known about this topic?
Since the 2002 consensus publication from European and North American experts, rosacea diagnosis has been based largely on the presence of more than one of the following primary features: flushing, nontransient erythema, papules/pustules or telangiectasia.
Secondary features are not considered diagnostic for rosacea, i.e. burning/stinging, plaque, dry appearance, oedema, peripheral location, phymatous changes and ocular manifestations.
Four common presentations are grouped into subtypes, i.e. erythematotelangiectatic, inflammatory papulopustular, phymatous and ocular rosacea.
What does this study add?
This study re‐evaluates the primary and secondary features of rosacea in order to rationalize diagnosis and classification based on a phenotype approach.
This study provides a global perspective on rosacea diagnosis and classification with representation from Africa, Asia, Europe, North America and South America.
Respond to this article
Linked Editorial: Drucker. Br J Dermatol 2017; 176:283–284.
Linked Comment: Egeberg. Br J Dermatol 2017; 176:300–301.
Summary
Background
Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient ...management. The ROSacea COnsensus panel was established to address this issue.
Objectives
To incorporate current best treatment evidence with clinical experience from an international expert panel and establish consensus to improve outcomes for patients with rosacea.
Methods
Seventeen dermatologists and three ophthalmologists reached consensus on critical aspects of rosacea treatment and management using a modified Delphi approach. The panel voted on statements using the responses ‘strongly disagree’, ‘disagree’, ‘agree’ or ‘strongly agree’. Consensus was defined as ≥ 75% ‘agree’ or ‘strongly agree’. All voting was electronic and blinded.
Results
The panel agreed on phenotype‐based treatments for signs and symptoms presenting in individuals with rosacea. First‐line treatments were identified for individual major features of transient and persistent erythema, inflammatory papules/pustules, telangiectasia and phyma, underpinned by general skincare measures. Multiple features in an individual patient can be simultaneously treated with multiple agents. If treatment is inadequate given appropriate duration, another first‐line option or the addition of another first‐line agent should be considered. Maintenance treatment depends on treatment modality and patient preferences. Ophthalmological referral for all but the mildest ocular features should be considered. Lid hygiene and artificial tears in addition to medications are used to treat ocular rosacea.
Conclusions
Rosacea diagnosis and treatment should be based on clinical presentation. Consensus was achieved to support this approach for rosacea treatment strategies.
What's already known about this topic?
The current subtype‐led rosacea diagnosis/classification system does not adequately cover the spectrum of clinical presentation and has implications for patient management.
High‐quality controlled trials for rosacea interventions are increasing, but there are still gaps in the evidence and the recommendations in existing guidance are disparate.
Currently there is no phenotype‐based approach to rosacea management.
What does this study add?
This international expert panel proposes a phenotype‐led approach to rosacea management that addresses individual rosacea features. It incorporates best evidence, clinical experience and recent developments in the management of patients with rosacea.
This article provides current ophthalmological expert perspectives on ocular rosacea for a dermatologist audience.
This article also describes an approach to combination treatment and maintenance therapy of cutaneous rosacea features.
Respond to this article
Linked Editorial: Drucker. Br J Dermatol 2017; 176:283–284.
Linked Comment: Egeberg. Br J Dermatol 2017; 176:300–301.
Summary
Background
A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by ...predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups.
Objectives
To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development.
Methods
Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded.
Results
Delphi statements on which the panel achieved consensus of ≥ 75% voting ‘Agree’ or ‘Strongly agree’ are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements.
Conclusions
The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management.
What's already known about this topic?
A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups.
New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations.
What does this study add?
We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea.
We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.
Linked Comment: Elewski. Br J Dermatol 2020; 182:1090–1091.
Plain language summary available online
Background. Although leprosy, a neglected tropical disease, has been eliminated (<1 case per 10 000 population) in South Africa (SA) since 1926, according to the World Health Organization, new cases ...continue to be reported. The management of leprosy poses several challenges, including patient adherence, education and insufficient training of healthcare practitioners. Objectives. To describe the biographical profile, clinical manifestations and treatment outcomes in patients with leprosy in KwaZulu-Natal Province. Methods. This retrospective study aimed to analyse the clinical data of leprosy patients in SA from 2002 to 2022. Data collected included patient demographics, comorbidities, cutaneous and neurological manifestations of leprosy, complications, treatment and adverse reactions. Descriptive statistics were used to summarise the data. Results. The study analysed the clinical data of 194 leprosy patients from 2002 to 2022. The majority of patients were male and middle aged, with a disproportionate representation of black South Africans. Regarding socioeconomic status, 80% were unemployed and 40% were social grant recipients. Most cases were clustered in urban centres and diagnosed at secondary care facilities, with 15% being HIV positive. The majority of patients (90%) were classified as having multibacillary leprosy. Common symptoms included upper respiratory tract involvement, hair loss and painful nerves, with the face and limbs being most frequently affected. Cutaneous morphology predominantly included plaques and hypopigmented patches, while neurological signs included ulnar nerve tenderness, muscle weakness and sensory deficits. Debilitating neurological complications were found in one-fifth of patients. Despite initiation of multidrug therapy in most patients, a significant proportion (27.3%) did not complete the full course of treatment, and treatment reactions were noted in 33.5% of patients. Conclusion. These findings emphasise the urgent need for enhanced patient and healthcare worker education, particularly in primary healthcare settings, to improve adherence to treatment, advocate for prophylactic measures and prevent new cases. Achieving leprosy-free status in SA requires the collaboration of many role-players to address these challenges and improve healthcare practices.
Summary
Background
Cutaneous adverse sequelae of skin lightening creams present with myriad skin complications and affect dermatology practice, particularly in sub‐Saharan Africa where such products ...are widely used, with a prevalence of 25–67%.
Objectives
To examine the skin lightening practices of both African and Indian women living in South Africa.
Methods
A cross‐sectional survey was undertaken in the general outpatient departments of two regional university hospitals in Durban, South Africa. All consenting African and Indian women aged 18–70 years were recruited and asked to complete a questionnaire.
Results
Six hundred women completed the questionnaire, of whom 32·7% reported using skin lightening products. The main reasons cited were treatment of skin problems (66·7%) and skin lightening (33·3%). Products were purchased from a variety of sources. Twenty‐five percent reported using sunscreen.
Conclusions
The use of skin lightening cosmetics is common among darkly pigmented South African women, including those of both African and Indian ancestries. Despite more than 20 years of governmental regulations aimed at prohibiting both the sale of cosmetics containing mercury, hydroquinone and corticosteroids, and the advertising of any kind of skin lightener, they are far from having disappeared. The main motivations for using these products are the desire to treat skin disorders and to achieve a lighter skin colour. Television and magazine advertisements seem to influence womens’ choice of these products and, thus, would be efficient channels for raising public awareness about the dangers of using uncontrolled skin lighteners.
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