Global panel updates rosacea recommendations

Stay up to date on the latest recommendations for rosacea diagnosis, classification and management from the global ROSacea COnsensus (ROSCO) 2019 panel. (Milan Lipowski - stock.adobe.com)

Dermatologists and other providers who care for rosacea patients need to classify these patients by phenotype, recognizing that every patient does not fall exclusively into only one of the prior subtyping approaches, according to updated recommendations for rosacea diagnosis, classification and management from the global ROSacea COnsensus (ROSCO) 2019 panel. The recommendations were published as an open access article in August in the British Journal of Dermatology.

Rosacea phenotypes include transient erythema, persistent erythema, telangiectasia, inflammatory papules/pustules, phymas and ocular abnormalities.

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“Applying a phenotype-based diagnostic approach is inclusive of the real-life presentation of this disorder. This permits more accurate documentation of the manifestations of this disease and recording responses to therapy,” says ROSCO Panel member Richard L. Gallo, M.D., Ph.D., distinguished professor and endowed chair of dermatology at the University of California, San Diego. “This is a major change in classification of patients with rosacea. It will accelerate development of improved therapies for the disease as a whole.”

This update to the 2017 ROSCO consensus recommendations includes disease burden and treatment goals; defining both cutaneous and ocular features to aid in recognition and diagnosis; and updating the treatment algorithm originally presented in 2017 based on recent evidence, according to ROSCO Panel co-chair Jerry Tan, M.D., FRCP, adjunct professor, Western University, Windsor, Ontario, Canada.

“We also developed clinical tools, including seven patient case studies representing common phenotypes exemplifying
practical use of the treatment algorithm along with a phenotype image library with feature descriptions and multiple skin photo types,” Dr. Tan says. “[We included] a rosacea tracking tool for clinical use to provide ongoing record of a rosacea patients features over time. This should help monitor changes in features, patient impact and response to treatment.”

Of the 21 Global ROSacea COnsensus (ROSCO) 2019 expert panel members, 19 were dermatologists, including 6 from the U.S., and 2 were ophthalmologists including one from the U.S.

The panel used a Delphi approach in which members reached consensus on aspects of rosacea diagnosis and treatment by strongly disagreeing, disagreeing, strongly agreeing or agreeing with each statement. Researchers defined a consensus as 75% or more agreeing or strongly agreeing.

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There is concern with using the Delphi approach because it uses clinical opinion rather than published evidence to develop consensus statements, according to the paper.

“However, in assessing the clinical approach to rosacea, where high-quality evidence is limited, the Delphi process is a systematic, egalitarian method well suited to developing clinical recommendations until additional appropriate evidence becomes available,” panel authors write.

DISEASE BURDEN, TREATMENT GOALS
Dermatologists should talk with patients about the toll rosacea takes on their lives. Facial symptoms, including itch, soreness, pain or stinging; embarrassment or self-consciousness; as well as rosacea’s impact on patients’ social lives and activities stand out as relevant to rosacea patients’ quality of life.

The panel recommends dermatologists ask rosacea patients if, in the past month, their signs and symptoms have impacted their quality of lives, and how much the time lost to rosacea affected the quality of their lives. Providers should also ask if, in the past month, rosacea has affected work productivity or education and how well-controlled patients feel their rosacea has been.

Dermatologists should strive to achieve clear versus almost clear as the primary treatment objective, given evidence showing the benefits, including quality-of-life impact and optimal patient satisfaction, when patients reach Investigator Global Assessment 0, according to the paper.

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Panel members point to phymatous changes and persistent erythema as diagnostic features, while major features include flushing/transient erythema, papules and pustules and telangiectases.

When determining the severity of rosacea features such as skin burning sensation, for example, dermatologists should consider duration, frequency, intensity, extent, association with flushing, triggers and quality-of-life impact, according to the panel.

TREATMENT UPDATES
Panel members updated the 2017 ROSCO treatment algorithm with such changes as removing topical alpha-adrenergic modulating agents and oral beta blockers to treat flushing/transient erythema because of limited evidence to support their use.

The recommendations embrace combination treatment for patients with severe disease and those with multiple rosacea features, but the panel writes that more research is needed to support use of combination treatment in rosacea.

It’s important that dermatologists and others monitor patient satisfaction with treatment asking about tolerability, cost and efficacy, they write.

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UNMET NEEDS 
It isn’t clear how best to diagnose ocular rosacea, which the authors note dermatologists might often overlook. But there are features of ocular rosacea, including blepharokeratoconjunctivitis, sclerokeratitis, anterior uveitis and blepharoconjunctivitis, that should prompt dermatologists to refer patients to ophthalmologists, they write.

“Further work is needed, particularly education around ocular rosacea and continued development, refinement and validation of tools to facilitate both daily practice and clinical research,” according to the panel members. ƒ

Disclosures:

Galderma funded the ROSCO project and paid panel members for their participation. Dr. Gallo, according to the paper, has served as a consultant for Sente, as well as for MatriSys, of which he is also cofounder and has equity interest. Dr. Tan has been an advisor and/or speaker for Cipher, Galderma, Pola and Valeant; a consultant to Boots and Galderma; and a clinical investigator for Allergan, Cipher, Dermira, Galderma and Valeant.

References:

1. Schaller M, Almeida LMC, Bewley A, et al. Recommendations for rosacea diagnosis, classification and management: Update from the global ROSacea COnsensus (ROSCO) 2019 panel. Br J Dermatol. 2019;