Treating Rosacea in Skin of Colour

Dr Surbhi Virmani and Dr Neelu Sharma provide an introduction to treating rosacea in patients with darker skin

Rosacea is a chronic inflammatory skin disorder affecting the convexities of the central facial region. It has a high prevalence in the Caucasian population; however, we are increasingly seeing reports of rosacea in skin of colour (SOC).1 A Saudi study (N=50) reported a 42% incidence in skin type VI, 40% in skin type IV and 18% in type III.1,2 In Tunisia, 224 cases of rosacea were reported in the dark-skinned population (hospital prevalence 0.2%).1 In addition, a multicentric study in Colombia identified 291 rosacea patients: 12.4% with skin types IV or V.2 A study of 2,743 Angolan adults with Fitzpatrick skin types V-VI reported only 0.4% of patients had rosacea, meanwhile data from the United States National Ambulatory Medical Care Survey of 31.5 million rosacea visits showed that 2% of patients were types V and VI.2 Diova et al. reported on 15 of 6,700 South African patients with confirmed rosacea of which six (type V) showed erythema, telangiectasia and erythematous papules and nine (type VI) presented with skin-coloured papules.3 None reported flushing and only one had eye symptoms and extra facial lesions. HIV-positivity was likely to predispose to this condition. Histology confirmed 10 out of 15 patients had a granulomatous rosacea. Five patients had used topical steroids in the past year.3 As we can see from these studies, there exists an immense heterogeneity of numbers and symptoms of rosacea reported among SOC patients. This could be attributed to the under detection of the condition in SOC.

What causes rosacea?

The pathogenesis of rosacea is multifactorial and includes genetic susceptibility, class II major histocompatibility complex polymorphism, altered microbiome of the skin and gut, dysregulated immune response, neuro-cutaneous mechanisms and impairment of the skin barrier. All these components are aggravated by triggers such as UV light, alcohol, caffeine, the weather, sun and emotional stress, which activates the sympathetic nervous system.1,4,5 To avoid these triggers, SOC patients should maintain a daily diary of exposure and symptoms to establish a correlation and thus work on avoidance of triggers. How do you diagnose rosacea in SOC?

Rosacea is diagnosed clinically, according to the diagnostic and major criteria recommended by the 2017 Global Rosacea Consensus panel. This requires one diagnostic criterion or two major criteria to be fulfilled (Table 1).6 In patients with a darker phototype, where erythema and telangiectasia (visible blood vessels) are arduous to ascertain, greater significance is placed on other major and minor features, such as burning, stinging, dryness and swelling of facial skin. In addition, we personally check for erythema with blanching (diascopy),2 with photography against a blue background, or with dermoscopy to visualise telangiectasia. Dr Virmani uses a skin analysis imaging system (Canfield’s Visia, OBSERV), which can highlight presence of erythema and telangiectasia in SOC. In cases where there is a diagnostic uncertainty, a skin biopsy may be considered and/or referral to another practitioner more experienced in this area. A skin biopsy could reveal presence of mites, an inflammatory pattern, and helps differentiate it from other skin conditions that can cause similar symptoms. The SOC patient may only report a sensation of facial warmth, product sensitivity, unidentified violet, blue, purple or dusky brown discolouration or dry swollen facial patches. Sometimes patients may present with resistant acne-like spots or with gritty and sensitive eyes. Forehead and nose thickening can develop over time.4 It’s important to consider acne vulgaris, sarcoid, seborrheic dermatitis, steroid induced acne, steroid induced rosacea, systemic lupus erythematosus, dermatomyositis, eczema, pyoderma faciale, periorificial dermatitis or photodamage.2

Treatment options

The NICE guidelines follow the rosacea consensus whereby a phenotypic personcentred approach is used to determine the treatment plan.7 We use the same approach for SOC as for any patient with rosacea, which includes clearance/ reduction of papules and pustules, mitigation and avoidance of post-inflammatory hyperpigmentation (PIH), long-term suppression of erythema and inflammation, management of patient expectations, and education about disease chronicity and long-term treatment.8 Ocular rosacea must be referred to an ophthalmologist.

Diagnostic features

Phymatous changes

Persistent erythema

Flushing/transient erythema

Papules and pustules

Telangiectases

Burning sensation of the skin

Stinging sensation of the skin

Dry sensation of the skin

Oedema

Table 1: Common rosacea features6 Description

Facial skin thickening due to fibrosis and/or sebaceous glandular hyperplasia. Most commonly affects the nose, where it can impart a bulbous appearance.

Background ongoing centrofacial redness. May periodically intensify in response to variable triggers. In darker skin phototypes (V and VI), erythema may be difficult to detect visually.

Major features

Temporary increase in centrofacial redness, which may include sensations of warmth, heat, burning and/or pain.

Red papules and pustules, usually in the centrofacial area. Some may be larger and deeper.

Visible vessels in the centrofacial region but not only in the alar area.

Minor features

An uncomfortable or painful feeling of heat, typically in the centrofacial region.

An uncomfortable or painful sharp, pricking sensation, typically in the centrofacial region.

Skin that feels rough. May be tight, scaly and/or itchy.

Localised facial swelling. Can be soft or firm (nonpitting) and may be self-limited in duration or persistent.

Medical and procedural interventions Existing treatments for rosacea in SOC can be very effective; however, patients must be explained that they will need combination treatments to achieve success in controlling the disease process.5

Transient erythema (flushing) Treatment options include alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline). They are often used infrequently for special occasions such as a wedding or interview as persistent use may result in rebound flushing on discontinuation. Oral beta-blockers (carvedilol) and oral clonidine may reduce flushing.

Persistent erythema Patients should be given alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline, as above), intense pulsed light therapy or vascular laser.

Inflammatory papules/pustules Various treatment options are available which includes topical ivermectin, topical metronidazole (for mild/moderate rosacea only), topical azelaic acid (for mild/moderate rosacea only), topical erythromycin, oral tetracyclines (oxytetracycline, lymecycline, doxycycline), oral macrolides (erythromycin, azithromycin), oral metronidazole and oral isotretinoin often at low dose (for refractory disease only). An oral antibiotic is to be offered as a first-line treatment option for severe papulopustular rosacea.5 Our choices are azithromycin, clarithromycin, doxycycline 40mg (modified release) daily, doxycycline 100mg daily, erythromycin, lymecycline and oxytetracycline. Severe rosacea should consider intermittent courses of low-dose isotretinoin (0.25mg kg–1), keeping in mind the potential side effects and teratogenicity of this drug. Oral propranolol is an option for troubling transient facial erythema.5

Telangiectasia In our experience, electrodesiccation, intense pulsed light (IPL) therapy or vascular laser have been appropriate and successful treatment options for SOC patients suffering with rosacea. Consider pulsed dye laser (PDL), Nd:YAG laser or IPL in people with rosacea where the main presenting feature is persistent facial erythema. The high melanin content in SOC, along with the broad absorption of melanin on the electromagnetic spectrum, presents therapeutic challenges with laser treatment, as the competing chromophore to the intended pigmented target is present throughout ethnic skin.9 PIH, which is rarely seen in light-coloured skin, can be a common outcome during inexperienced laser use in SOC.9 PDL is presently regarded as the treatment of choice for facial telangiectasia, due to its efficacy and safety profile.9 However, purpura and or PIH remain a risk in ethnic skin. Long-pulsed millisecond 1064 nm Nd:YAG lasers target the lesser absorption peak of oxyhaemoglobin in the infrared range and have been used in the treatment of large telangiectasias and reticular veins as they give deeper dermal penetration.9 The longer wavelength offers minimal absorption by epidermal melanin, thus providing a safe and effective treatment in patients with ethnic skin.9 Long-pulsed 755 nm alexandrite laser has also been used, but PIH is seen in 30% of patients.9 IPL remains one of the safest treatment choices but may not deliver equivalent results to the Nd:YAG or PDL.9 Neurogenic rosacea In our experience, treatment options include gabapentin, amitriptyline, oral beta-adrenergic blockers and a consideration of endoscopic sympathectomy.

Phyma If the rosacea is clinically inflamed, then in our experience, doxycycline or isotretinoin are good options. If clinically non-inflamed, then physical modalities to remove excess tissue and reshape the structures (such as ablative CO2 laser, erbium laser, radiofrequency, surgical debulking) should be considered.5 Pimecrolimus and tacrolimus are non-steroidal topical calcineurin inhibitors which would both need extremely cautions short term use if prescribed due to substance P release associated dermatitis.5

Skincare It’s important to avoid rosacea irritants in a patient’s skincare. Patients should use fragrance-free skincare and makeup products. We always get patients to test patch a product on an area of skin in a peripheral area before using on their face in case of a reaction.10 It is pivotal to use a broad-spectrum SPF 50. Often those with SOC do not understand the importance of SPF, so education in this cohort is particularly important.4

Cleansers Cleansers must be individualised and unless a patient has oily skin, non-soap cleansers are the best option with a neutral pH and are easily rinsible.5,10 We recommend patients wait 30 minutes to let the face dry before applying topical medication as stinging occurs on damp skin. Patients must wait another five to 10 minutes before applying SPF or makeup.

SPF UV rays are colour blind, so they hit all skin with equal strength. We advise to apply a mineral sunscreen liberally to exposed sites 15 to 30 minutes before going out into the sun. Sunscreen should be reapplied after vigorous activity and other sun protective measures should also be taken. A big barrier to using sun protection on coloured skin is the cosmetic blending in of the product; often it can be too white or greasy. This requires some trial and error to find the best fit for your patient.

Moisturisers The skin barrier consists of enucleated protein-rich corneocytes with highly organised intercellular lipids (ceramides, cholesterol, and free fatty acids) around and between them which maintain the stratum corneum hydration.11 Rosacea often involves a defective moisture barrier and a larger than normal transepidermal water loss, contributing to irritability and susceptibility to inflammation. Older age groups with drier skin may find that the winter or dry weather is especially challenging for sufferers of rosacea.4 The use of ceramide-containing skincare products has been shown to restore ceramide composition and improve skin function and disease severity.12

Understanding rosacea in SOC

We recommend the diagnosis of rosacea based on symptoms, history of failed acne therapies, presentation of typical triggers, a family history and possibly mixed heritage ancestry of the patient. Signs and symptoms concentrated in the central face, erythema noticeable with blanching or photography, dermoscopy to visualise telangiectasia are all important in establishing a diagnosis. The treatment objectives for SOC are the same as for any patient with rosacea and involves clearance and reduction of papules and pustules, plus mitigation and avoidance of PIH. The patient must be educated about the chronicity and the long-term treatment involved. This would include inclusion of lifestyle changes such as avoiding trigger factors and sunscreen, in addition with a gentle restorative skincare regimen.13

Dr Surbhi Virmani graduated in medicine in 1996 following which she was awarded a MD (Masters) in Anaesthesia, PG Dip in Clinical Dermatology and Bachelor of Laws. With more than 20 years of experience in anaesthetics and critical care working worldwide and for the NHS, Dr Virmani moved to aesthetics and cosmetic dermatology. She runs an acne-rosacea clinic for children and adults from her Harley Street practice. Qual: MBBS, MD (Anaesthetics), PG Dip Clin Dermatology, GDL, LPC, LLB

Dr Neelu Sharma graduated in Medicine in 1996 followed by an MD in Dermatology from New Delhi, India, where she practices as a consultant dermatologist. Her area of expertise is disease in skin of colour patients. Qual: MBBS, MD (Dermatology)

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