A way to test for the presence of telangiectasia or erythema is to test the skin for blanching by using a magnifying glass or microscope slide.2 If the skin pales when pressed under the glass, erythema is present.2 Another option is photographing the patient on a dark blue background, which can make red skin more visible.2 Using a dermatoscope can help identify telangiectasia in dark skin by helping differentiate the skin’s pigment from blood vessels.2

To distinguish rosacea from acne, look for acneiform papules and pustules; if they do not have comedones, it is most likely rosacea.2,4

“In my experience, the most common presenting scenario for rosacea in skin of color patients is the papulopustular subtype, with papules and/or pustules in the central facial region,” said Dr Taylor.4 “To the untrained eye, the clinical appearance of this subtype of rosacea can look very similar to that of acne. A clue that points toward the diagnosis of rosacea vs acne is the absence of comedones or cystic lesions.”4

For ocular rosacea, the symptoms can include itching, foreign body sensation, and irritation.2 It must be differentiated from allergic conjunctivitis because both conditions can have similar clinical presentations and may coexist.5 Testing for immunoglobulin E antibodies in tears might help differentiate between these 2 conditions.5

To rule out other diseases, you may need to order a skin biopsy or other tests. Collagen vascular diseases, including lupus erythematosus and dermatomyositis, are also possible, as are seborrheic dermatitis and keratosis pilaris rubra.2 It is important to mention that granulomatous rosacea can resemble sarcoidosis, which is more common in patients of African ancestry.2 Rosacea also can also look similar to facial Afro-Caribbean childhood eruption, a skin condition that primarily affects black children.2

Rosacea Treatment Options for People of Color

Research shows that the same treatments used for rosacea in lighter skin types, whether topical, oral, laser, light-based, or surgical, will work on those of color, although data are limited.2 It is important to note that patients of color might have unique clinical features that will need to be addressed during treatment, including postinflammatory pigment alteration and the risks associated with laser and light-based therapies.2

Topical medications may help curtail vascular issues for patients of color, particularly foams, creams, and aqueous gels, which are less irritating.2 The most frequently used topical medications for treating rosacea in white patients, metronidazole and azelaic acid, also are appropriate for people of color.4 In addition, topical oxymetazoline cream has been found to be efficacious for patients of all skin colors with persistent erythema.2

To reduce inflammation of papules and pustules, consider also prescribing oral medications. Oral sub-antimicrobial-dose doxycycline is a safe option.2

Laser and light-based therapies can reduce the capillary network or resurface phymatous skin. Particularly, microsecond-pulsed, 1064-nm neodymium-doped yttrium-aluminum-garnet laser treatment was been effective in patients with skin of color.2 With this treatment method, lower fluences are recommended to reduce the risk for pigmentary or scarring issues.2

Medical advice for treating rosacea in patients with darker skin should include reviewing appropriate skin care methods, such as avoiding skin lighteners or brighteners, astringent or abrasive skin care products, or moisturizers such as shea butter or cocoa butter.2 Patients also should be counseled on behavior modifications, such as the use of sunscreen or a physical sunblock, and avoiding dietary, environmental, and lifestyle triggers, such as alcohol, hot foods or drinks, spicy foods, sunlight, temperature extremes, stress, exercise, hot baths, topical corticosteroids, and vasodilatory medications.2,4

Summary

Rosacea affects individuals from all ethnic backgrounds. However, recognition, diagnosis, treatment, and complications may vary for patients of color. Recent reports of rosacea in patients with skin of color signal that a large pool of undiagnosed patients exists. Increased awareness of the incidence of rosacea in these patients and understanding the nuances of diagnosis and treatment will help ensure that all patients receive quality care.

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References

1. US Census Bureau projections show a slower growing, older, more diverse nation a half century from now. US Census Bureau website. https://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Published December 12, 2012. Accessed June 6, 2019.

2. Alexis AF, Callender VD, Baldwin HE, Desai SR, Rendon MI, Taylor SC. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: Review and clinical practice experience. J Am Acad Dermatol. 2019;80:1722-1729.

3. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatology Online J. 2014;20:13.

4. Taylor SC, David JN. Acne and rosacea: a closer look at skin of color. Medscape. https://www.medscape.org/viewarticle/770773. Published September 19, 2012. Accessed May 6, 2019.

5. Al Balbeesi AO, Halawani MR. Unusual features of rosacea in Saudi females with dark skin. Ochsner J. 2014;14(3):321-327.