When the National Rosacea Society (NRS) published the first standard classification of rosacea 15 years ago, it ushered in an unprecedented era of research into the disease process of this widespread chronic disorder of the facial skin – and now the first update has been published based on these dramatic advances in scientific knowledge.1 The NRS has designated April as Rosacea Awareness Month to educate the public on the current understanding of this often life-disruptive condition estimated to affect more than 16 million Americans, urging those with warning signs to see a dermatologist for diagnosis and appropriate therapy.
"It's now well established that a consistent multivariate disease process underlies the various clinical manifestations of rosacea, and these are now increasingly well understood," said Dr. Richard Gallo, chairman of dermatology, University of California-San Diego, who chaired the NRS consensus committee and review panel of 28 medical experts that developed the new system. "At the same time, today there is a much wider range of therapeutic options to treat the various signs and symptoms."
Recent studies have shown that the initial redness appears to be the start of an inflammatory continuum initiated by neurovascular dysregulation and the innate immune system. The role of the innate immune system in rosacea has been the focus of groundbreaking studies funded by the NRS, including the discovery of irregularities of key components known as cathelicidins. Research has further demonstrated that a marked increase in mast cells, located at the interface between the nervous system and vascular system, is a common link in all major presentations of the disorder. Other studies have documented a possible genetic component, as well as the potential role of the human microbiome, including Demodex mites and certain bacteria.
While the original standard classification of rosacea identified the most common presentations morphologically as subtypes, the consensus committee emphasized that – given today's knowledge of rosacea's pathophysiology – it is more appropriate to focus on the individual characteristics, called phenotypes, that may result from this consistent disease process. They noted that observing the respective phenotypes in clinical practice not only encourages consideration of the full range of potential signs and symptoms, but the assessment of severity and selection of treatment may also be more precisely tailored to each individual.
According to the new standard system, the presence of one of two phenotypes – persistent redness of the facial skin or, less commonly, phymatous changes where the facial skin thickens – is considered diagnostic of rosacea. Additional major signs, which often appear with the diagnostic features, include papules and pustules, flushing, telangiectasia and certain ocular manifestations. The presence of two or more major phenotypes independent of the diagnostic features is also considered diagnostic of rosacea. Secondary phenotypes, which must appear with one or more diagnostic or major phenotypes, include burning or stinging, swelling and dry appearance.
Signs suggestive of ocular rosacea include telangiectases on the eyelid margin and bloodshot eyes, as well as inflammation and growth of fibrous tissue on the eye. Burning, stinging, light sensitivity and the sensation of a foreign object may also occur, as well as conjunctivitis, inflammation of oil glands at the rim of the eyelids (blepharitis) and crusty accumulations at the base of the eyelashes, in addition to others.
The NRS consensus committee also emphasized the psychosocial effects of rosacea, noting that multiple patient surveys have documented rosacea's substantial adverse impact on emotional, social and occupational well-being. In surveys conducted by the NRS, more than 90 percent of rosacea patients said the disorder had lowered their self-confidence and self-esteem, and 41 percent reported that it had caused them to avoid public contact or cancel social engagements. Among rosacea patients with severe symptoms, 88 percent said the disorder had adversely affected their professional interactions and 51 percent said they had even missed work because of their condition.
"Public awareness and the role of the dermatologist are the keys to relieving the widespread human suffering that is caused by this common disorder," Dr. Gallo said. "Many rosacea patients are actually relieved when they learn they have a disease, and that it can be controlled with long-term medical therapy."
The updated classification and pathophysiology of rosacea was recently published to provide standard criteria essential for performing research, analyzing results and comparing data from different sources, as well as to serve as a diagnostic reference in clinical practice. The new system also serves to provide common terminology for clear communication among a broad range of researchers, clinicians and health officials.
In an accompanying commentary2 on rosacea comorbidities and future research, the committee summarized the many recent studies that have found associations between rosacea and increased risk for a growing number of potentially serious systemic disorders. These include cardiovascular disease, gastrointestinal disease, neurological and autoimmune diseases and certain cancers. Although causal relationships have not been determined, the committee noted these findings may substantially increase the clinical significance of rosacea as evidence that the disorder may be an outcome of systemic inflammation continues to mount.
During Rosacea Awareness Month and throughout the year, the NRS will conduct public education activities to reach the many millions of rosacea sufferers who may not realize they have a medical condition that can be treated, emphasizing the warning signs and urging those who suspect they may have rosacea to see a dermatologist. Bulk quantities of educational materials are available to health professionals for their patients through the NRS website at rosacea.org. Those interested in spreading awareness during the month of April are encouraged to visit the official Rosacea Awareness Month landing page at rosacea.org/ram for ways in which they can participate.
During April and throughout the year, individuals may call the National Rosacea Society's toll-free telephone number at 1-888-NO-BLUSH for information. The NRS offers Rosacea Review, a newsletter for rosacea patients; a "Rosacea Diary" to help patients identify and avoid lifestyle factors that may trigger flare-ups in their individual cases; and other booklets to help patients understand and manage their condition.
Information is also available by visiting the NRS website at rosacea.org; writing the National Rosacea Society, 196 James Street, Barrington, Illinois 60010; or via e-mail at firstname.lastname@example.org.
About the National Rosacea Society
The National Rosacea Society is the world's largest organization dedicated to improving the lives of the estimated 16 million Americans who suffer from this widespread but poorly understood disorder. Its mission is to raise awareness of rosacea, provide public health information on the disorder and support medical research that may lead to improvements in its management, prevention and potential cure.
1. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018 Jan;78(1):148-155. doi: 10.1016/j.jaad.2017.08.037. Epub 2017 Oct 28.
2. Gallo RL, Granstein RD, Kang S, et al. Rosacea comorbidities and future research: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018 Jan;78(1):167-170. doi: 10.1016/j.jaad.2017.06.150. Epub 2017 Nov 1.