The global ROSacea COnsenus (ROSCO) expert panel recently issued new recommendations that aim to transition current rosacea classification, diagnosis, and treatment from subtypes to a phenotype-led approach that addresses individual rosacea features. The recommendations published in British Journal of Dermatology1 allow for clinicians to focus on personalized treatment based on the signs and symptoms that are most bothersome to each patient.
Rosacea is a common chronic inflammatory disease of the skin predominantly affecting the centrofacial region.2 This cutaneous disorder, which typically first appears between 30 and 60 years of age, is estimated to affect 16 million Americans. In addition to its many potential physical effects, the patient burden of rosacea can be significant regarding the psychological, emotional, and occupational problems if left untreated. The pathogenesis of rosacea is unknown; however, several potential pathways are under investigation.3 This article reviews the recommendations from the ROSCO panel and touches on how this new approach to diagnosing and clarifying rosacea by phenotype can support dermatologists in their daily practice.
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Related Content
Actress Kristin Chenoweth Named Spokeesperson for Rosacea Awareness
Alcohol Consumption Increases Rosacea Risk in Women
________________________________________________________________________
ROSCO Recommendations
Current diagnostic practice largely follows the 2002 recommendations4 of the National Rosacea Society (NRS). The NRS classification identified the most common presentations of rosacea’s primary features (transient erythema, persistent erythema, inflammatory papules/pustules, and telangiectasia) and secondary features (phymatous changes, burning or stinging sensations, ocular manifestations, etc.) as subtype 1, erythematotelangiectatic rosacea; subtype 2, papulopustular rosacea; subtype 3, phymatous rosacea; and subtype 4, ocular rosacea. Although didactically useful, the subtype designations were widely utilized individually and construed as distinct disorders.
“The subtype approach has uses, but also limitations, because rosacea features can span several subtypes and limit its diagnosis and treatment,” said lead author of the ROSCO position paper Martin Schaller, MD, PhD, deputy medical director, department of dermatology, Eberhard-Karls University of Tuebingen (Germany), about the rationale for the new recommendations in an interview with The Dermatologist. “A better approach would be to diagnose and treat rosacea by a patient’s individual features (transient erythema, persistent erythema, teleangiectasia, papules/pustules, phyma, and ocular signs) instead of confining them to a subtype.”
Coauthor Jerry Tan, MD, FRCPC, adjunct professor, Schulich School of Medicine and Dentistry, Western University (London, Ontario, Canada) and adjunct professor, department of psychology, University of Windsor (Windsor, Ontario, Canada), also acknowledged the limitations with the NRS 2002 criteria. “The flaws in these recommendations include their lack of specificity. Flushing is seen in many other conditions and is not by itself independently diagnostic of rosacea (eg, emotional, medication induced, postmenopausal, and systemic causes of flushing). Inflammatory papules/pustules are also seen in acne, folliculitis, pityriasis folliculorum (demodicosis), and perioral/periorificial dermatitis. Finally, almost all adults have centrofacial telangiectasia demonstrable by examination of perinasal and alar creases demonstrating the lack of specificity of this criterion,” he said.
As a result, the ROSCO panel of 17 dermatologists and 3 ophthalmologists convened to address the shortcomings of treatment according to subtypes and establish consensus to improve outcomes for patients with rosacea. The international panel used a modified Delphi process, consisting of e-surveys and a group meeting, to reach consensus. The panel integrated clinical experience and evidence from the 2015 Cochrane systematic review5 on interventions for rosacea to achieve agreement on a recommended treatment approach for signs and symptoms of rosacea.
Story continues on page 2
Treatment Options
Management options for rosacea include medical therapy, lifestyle modifications, and appropriate skin care.3 The panel achieved consensus on initial, combination, and maintenance therapy relating to a phenotype-based approach for treating cutaneous rosacea features, which has been developed into an algorithm for first-line therapy, detailing treatment by individual major features (Table 1). The panel agreed that 2 features diagnostic of rosacea in the absence of other features were persistent erythema associated with periodic intensification by potential trigger factors and phymatous changes.1
“Designating individual phenotypes would simplify and more accurately represent patient presentation for clinical care, epidemiologic, and interventional research,” explained Dr Tan.
The recommendations also underscored the importance of education and instruction on general skin care for all patients with rosacea undergoing treatment. Essential skin care includes the use of SPF 30+ sunscreen, frequent use of moisturizers, use of gentle over-the-counter cleansers, and avoidance of known triggers. Furthermore, general skin care is the primary management strategy for the secondary features of rosacea, which included dry appearance, dry sensation, and stinging sensation.1
For patients with multiple cutaneous features of rosacea, treatment with more than one agent simultaneously is recommended. If treatment is inadequate given appropriate duration, clinicians should either consider an alternative first-line option from Table 1 or the addition of another first-line agent. The panel also agreed that moderate and severe presentations of major features “requires a combination of treatments, which could include general skin care or physical modalities as well as pharmaceutical agents.”1
Maintenance therapy depends on treatment modality and patient preferences.1 “The minimum treatment to maintain control should be used. Additionally, treatments should be used for sufficient duration before switching to an alternative. The definition of ‘sufficient duration’ is specific to the treatment,” the panel stated.
Treatment for ocular rosacea by severity level is shown in Table 2. For patients with severe ocular rosacea, referral to an ophthalmologist should be considered. General eye care factors for managing ocular rosacea are UV-coated sunglasses and lid hygiene. Recommended lid hygiene includes warm compresses, meibomian gland expression, diluted baby shampoo scrubs, and lubricating drops.1
“When treating patients who have ocular rosacea in addition to other cutaneous features, the ideal scenario is to treat the ocular rosacea and cutaneous features with an optimized combination of therapies targeted for the presenting features,” said the panel.
Incorporating Recommendations in Daily Practice
Drs Tan and Schaller discussed how these recommendations may help dermatologists in their daily practice.
“Dermatologists are trained to derive diagnoses based on elicitation of signs and symptoms (phenotypes) for rosacea as for any other disease condition. These recommendations will rationalize diagnostic criteria, focus on issues relevant to patient concerns, and streamline treatment recommendations based on signs and symptoms rather than on subtypes,” said Dr Tan.
“These recommendations provide a basis for adaptation and development of local clinical practice guidelines, considering access factors such as treatment availability, patient values/preferences, and cost,” added Dr Schaller.
The Dermatologist contacted the NRS for comments on the ROSCO recommendations. “Independent of the ROSCO publication, the National Rosacea Society is reappraising its criteria,” said the Society.
References
1. Schaller M, Almeida LM, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471.
2. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):431-438.
3. Koutnik-Fotopoulos E. Examining rosacea and comorbidities. The Dermatologist. 2017;25(4):21-25.
4. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):584-587.
5. van Zuuren EJ, Fedorowicz Z, Cater B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;28(4):CD003262. doi:10.1002/14651858.CD003262.pub5
The global ROSacea COnsenus (ROSCO) expert panel recently issued new recommendations that aim to transition current rosacea classification, diagnosis, and treatment from subtypes to a phenotype-led approach that addresses individual rosacea features. The recommendations published in British Journal of Dermatology1 allow for clinicians to focus on personalized treatment based on the signs and symptoms that are most bothersome to each patient.
Rosacea is a common chronic inflammatory disease of the skin predominantly affecting the centrofacial region.2 This cutaneous disorder, which typically first appears between 30 and 60 years of age, is estimated to affect 16 million Americans. In addition to its many potential physical effects, the patient burden of rosacea can be significant regarding the psychological, emotional, and occupational problems if left untreated. The pathogenesis of rosacea is unknown; however, several potential pathways are under investigation.3 This article reviews the recommendations from the ROSCO panel and touches on how this new approach to diagnosing and clarifying rosacea by phenotype can support dermatologists in their daily practice.
________________________________________________________________________
Related Content
Actress Kristin Chenoweth Named Spokeesperson for Rosacea Awareness
Alcohol Consumption Increases Rosacea Risk in Women
________________________________________________________________________
ROSCO Recommendations
Current diagnostic practice largely follows the 2002 recommendations4 of the National Rosacea Society (NRS). The NRS classification identified the most common presentations of rosacea’s primary features (transient erythema, persistent erythema, inflammatory papules/pustules, and telangiectasia) and secondary features (phymatous changes, burning or stinging sensations, ocular manifestations, etc.) as subtype 1, erythematotelangiectatic rosacea; subtype 2, papulopustular rosacea; subtype 3, phymatous rosacea; and subtype 4, ocular rosacea. Although didactically useful, the subtype designations were widely utilized individually and construed as distinct disorders.
“The subtype approach has uses, but also limitations, because rosacea features can span several subtypes and limit its diagnosis and treatment,” said lead author of the ROSCO position paper Martin Schaller, MD, PhD, deputy medical director, department of dermatology, Eberhard-Karls University of Tuebingen (Germany), about the rationale for the new recommendations in an interview with The Dermatologist. “A better approach would be to diagnose and treat rosacea by a patient’s individual features (transient erythema, persistent erythema, teleangiectasia, papules/pustules, phyma, and ocular signs) instead of confining them to a subtype.”
Coauthor Jerry Tan, MD, FRCPC, adjunct professor, Schulich School of Medicine and Dentistry, Western University (London, Ontario, Canada) and adjunct professor, department of psychology, University of Windsor (Windsor, Ontario, Canada), also acknowledged the limitations with the NRS 2002 criteria. “The flaws in these recommendations include their lack of specificity. Flushing is seen in many other conditions and is not by itself independently diagnostic of rosacea (eg, emotional, medication induced, postmenopausal, and systemic causes of flushing). Inflammatory papules/pustules are also seen in acne, folliculitis, pityriasis folliculorum (demodicosis), and perioral/periorificial dermatitis. Finally, almost all adults have centrofacial telangiectasia demonstrable by examination of perinasal and alar creases demonstrating the lack of specificity of this criterion,” he said.
As a result, the ROSCO panel of 17 dermatologists and 3 ophthalmologists convened to address the shortcomings of treatment according to subtypes and establish consensus to improve outcomes for patients with rosacea. The international panel used a modified Delphi process, consisting of e-surveys and a group meeting, to reach consensus. The panel integrated clinical experience and evidence from the 2015 Cochrane systematic review5 on interventions for rosacea to achieve agreement on a recommended treatment approach for signs and symptoms of rosacea.
Story continues on page 2
Treatment Options
Management options for rosacea include medical therapy, lifestyle modifications, and appropriate skin care.3 The panel achieved consensus on initial, combination, and maintenance therapy relating to a phenotype-based approach for treating cutaneous rosacea features, which has been developed into an algorithm for first-line therapy, detailing treatment by individual major features (Table 1). The panel agreed that 2 features diagnostic of rosacea in the absence of other features were persistent erythema associated with periodic intensification by potential trigger factors and phymatous changes.1
“Designating individual phenotypes would simplify and more accurately represent patient presentation for clinical care, epidemiologic, and interventional research,” explained Dr Tan.
The recommendations also underscored the importance of education and instruction on general skin care for all patients with rosacea undergoing treatment. Essential skin care includes the use of SPF 30+ sunscreen, frequent use of moisturizers, use of gentle over-the-counter cleansers, and avoidance of known triggers. Furthermore, general skin care is the primary management strategy for the secondary features of rosacea, which included dry appearance, dry sensation, and stinging sensation.1
For patients with multiple cutaneous features of rosacea, treatment with more than one agent simultaneously is recommended. If treatment is inadequate given appropriate duration, clinicians should either consider an alternative first-line option from Table 1 or the addition of another first-line agent. The panel also agreed that moderate and severe presentations of major features “requires a combination of treatments, which could include general skin care or physical modalities as well as pharmaceutical agents.”1
Maintenance therapy depends on treatment modality and patient preferences.1 “The minimum treatment to maintain control should be used. Additionally, treatments should be used for sufficient duration before switching to an alternative. The definition of ‘sufficient duration’ is specific to the treatment,” the panel stated.
Treatment for ocular rosacea by severity level is shown in Table 2. For patients with severe ocular rosacea, referral to an ophthalmologist should be considered. General eye care factors for managing ocular rosacea are UV-coated sunglasses and lid hygiene. Recommended lid hygiene includes warm compresses, meibomian gland expression, diluted baby shampoo scrubs, and lubricating drops.1
“When treating patients who have ocular rosacea in addition to other cutaneous features, the ideal scenario is to treat the ocular rosacea and cutaneous features with an optimized combination of therapies targeted for the presenting features,” said the panel.
Incorporating Recommendations in Daily Practice
Drs Tan and Schaller discussed how these recommendations may help dermatologists in their daily practice.
“Dermatologists are trained to derive diagnoses based on elicitation of signs and symptoms (phenotypes) for rosacea as for any other disease condition. These recommendations will rationalize diagnostic criteria, focus on issues relevant to patient concerns, and streamline treatment recommendations based on signs and symptoms rather than on subtypes,” said Dr Tan.
“These recommendations provide a basis for adaptation and development of local clinical practice guidelines, considering access factors such as treatment availability, patient values/preferences, and cost,” added Dr Schaller.
The Dermatologist contacted the NRS for comments on the ROSCO recommendations. “Independent of the ROSCO publication, the National Rosacea Society is reappraising its criteria,” said the Society.
References
1. Schaller M, Almeida LM, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471.
2. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):431-438.
3. Koutnik-Fotopoulos E. Examining rosacea and comorbidities. The Dermatologist. 2017;25(4):21-25.
4. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):584-587.
5. van Zuuren EJ, Fedorowicz Z, Cater B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;28(4):CD003262. doi:10.1002/14651858.CD003262.pub5
The global ROSacea COnsenus (ROSCO) expert panel recently issued new recommendations that aim to transition current rosacea classification, diagnosis, and treatment from subtypes to a phenotype-led approach that addresses individual rosacea features. The recommendations published in British Journal of Dermatology1 allow for clinicians to focus on personalized treatment based on the signs and symptoms that are most bothersome to each patient.
Rosacea is a common chronic inflammatory disease of the skin predominantly affecting the centrofacial region.2 This cutaneous disorder, which typically first appears between 30 and 60 years of age, is estimated to affect 16 million Americans. In addition to its many potential physical effects, the patient burden of rosacea can be significant regarding the psychological, emotional, and occupational problems if left untreated. The pathogenesis of rosacea is unknown; however, several potential pathways are under investigation.3 This article reviews the recommendations from the ROSCO panel and touches on how this new approach to diagnosing and clarifying rosacea by phenotype can support dermatologists in their daily practice.
________________________________________________________________________
Related Content
Actress Kristin Chenoweth Named Spokeesperson for Rosacea Awareness
Alcohol Consumption Increases Rosacea Risk in Women
________________________________________________________________________
ROSCO Recommendations
Current diagnostic practice largely follows the 2002 recommendations4 of the National Rosacea Society (NRS). The NRS classification identified the most common presentations of rosacea’s primary features (transient erythema, persistent erythema, inflammatory papules/pustules, and telangiectasia) and secondary features (phymatous changes, burning or stinging sensations, ocular manifestations, etc.) as subtype 1, erythematotelangiectatic rosacea; subtype 2, papulopustular rosacea; subtype 3, phymatous rosacea; and subtype 4, ocular rosacea. Although didactically useful, the subtype designations were widely utilized individually and construed as distinct disorders.
“The subtype approach has uses, but also limitations, because rosacea features can span several subtypes and limit its diagnosis and treatment,” said lead author of the ROSCO position paper Martin Schaller, MD, PhD, deputy medical director, department of dermatology, Eberhard-Karls University of Tuebingen (Germany), about the rationale for the new recommendations in an interview with The Dermatologist. “A better approach would be to diagnose and treat rosacea by a patient’s individual features (transient erythema, persistent erythema, teleangiectasia, papules/pustules, phyma, and ocular signs) instead of confining them to a subtype.”
Coauthor Jerry Tan, MD, FRCPC, adjunct professor, Schulich School of Medicine and Dentistry, Western University (London, Ontario, Canada) and adjunct professor, department of psychology, University of Windsor (Windsor, Ontario, Canada), also acknowledged the limitations with the NRS 2002 criteria. “The flaws in these recommendations include their lack of specificity. Flushing is seen in many other conditions and is not by itself independently diagnostic of rosacea (eg, emotional, medication induced, postmenopausal, and systemic causes of flushing). Inflammatory papules/pustules are also seen in acne, folliculitis, pityriasis folliculorum (demodicosis), and perioral/periorificial dermatitis. Finally, almost all adults have centrofacial telangiectasia demonstrable by examination of perinasal and alar creases demonstrating the lack of specificity of this criterion,” he said.
As a result, the ROSCO panel of 17 dermatologists and 3 ophthalmologists convened to address the shortcomings of treatment according to subtypes and establish consensus to improve outcomes for patients with rosacea. The international panel used a modified Delphi process, consisting of e-surveys and a group meeting, to reach consensus. The panel integrated clinical experience and evidence from the 2015 Cochrane systematic review5 on interventions for rosacea to achieve agreement on a recommended treatment approach for signs and symptoms of rosacea.
Story continues on page 2
Treatment Options
Management options for rosacea include medical therapy, lifestyle modifications, and appropriate skin care.3 The panel achieved consensus on initial, combination, and maintenance therapy relating to a phenotype-based approach for treating cutaneous rosacea features, which has been developed into an algorithm for first-line therapy, detailing treatment by individual major features (Table 1). The panel agreed that 2 features diagnostic of rosacea in the absence of other features were persistent erythema associated with periodic intensification by potential trigger factors and phymatous changes.1
“Designating individual phenotypes would simplify and more accurately represent patient presentation for clinical care, epidemiologic, and interventional research,” explained Dr Tan.
The recommendations also underscored the importance of education and instruction on general skin care for all patients with rosacea undergoing treatment. Essential skin care includes the use of SPF 30+ sunscreen, frequent use of moisturizers, use of gentle over-the-counter cleansers, and avoidance of known triggers. Furthermore, general skin care is the primary management strategy for the secondary features of rosacea, which included dry appearance, dry sensation, and stinging sensation.1
For patients with multiple cutaneous features of rosacea, treatment with more than one agent simultaneously is recommended. If treatment is inadequate given appropriate duration, clinicians should either consider an alternative first-line option from Table 1 or the addition of another first-line agent. The panel also agreed that moderate and severe presentations of major features “requires a combination of treatments, which could include general skin care or physical modalities as well as pharmaceutical agents.”1
Maintenance therapy depends on treatment modality and patient preferences.1 “The minimum treatment to maintain control should be used. Additionally, treatments should be used for sufficient duration before switching to an alternative. The definition of ‘sufficient duration’ is specific to the treatment,” the panel stated.
Treatment for ocular rosacea by severity level is shown in Table 2. For patients with severe ocular rosacea, referral to an ophthalmologist should be considered. General eye care factors for managing ocular rosacea are UV-coated sunglasses and lid hygiene. Recommended lid hygiene includes warm compresses, meibomian gland expression, diluted baby shampoo scrubs, and lubricating drops.1
“When treating patients who have ocular rosacea in addition to other cutaneous features, the ideal scenario is to treat the ocular rosacea and cutaneous features with an optimized combination of therapies targeted for the presenting features,” said the panel.
Incorporating Recommendations in Daily Practice
Drs Tan and Schaller discussed how these recommendations may help dermatologists in their daily practice.
“Dermatologists are trained to derive diagnoses based on elicitation of signs and symptoms (phenotypes) for rosacea as for any other disease condition. These recommendations will rationalize diagnostic criteria, focus on issues relevant to patient concerns, and streamline treatment recommendations based on signs and symptoms rather than on subtypes,” said Dr Tan.
“These recommendations provide a basis for adaptation and development of local clinical practice guidelines, considering access factors such as treatment availability, patient values/preferences, and cost,” added Dr Schaller.
The Dermatologist contacted the NRS for comments on the ROSCO recommendations. “Independent of the ROSCO publication, the National Rosacea Society is reappraising its criteria,” said the Society.
References
1. Schaller M, Almeida LM, Bewley A, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471.
2. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):431-438.
3. Koutnik-Fotopoulos E. Examining rosacea and comorbidities. The Dermatologist. 2017;25(4):21-25.
4. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):584-587.
5. van Zuuren EJ, Fedorowicz Z, Cater B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;28(4):CD003262. doi:10.1002/14651858.CD003262.pub5
