Treating Rosacea in Patients of Color

A woman of African descent and her doctor are indoors in a medical clinic. They are sitting and talking about the woman’s health problems.
Treatment options and concerns unique to patients with skin of color are reviewed.

Once thought to exclusively affect light-skinned individuals with Northern European heritage, continuing clinical research has identified that rosacea affects “a broad spectrum of populations,” including those with skin of color. Despite these findings, rosacea prevalence in patients of color is substantially less studied.1

“In order to effectively diminish the physical and psychosocial burden of rosacea, considering the diverse populations groups affected by this condition is paramount,” wrote Ahuva Cices, MD, and Andrew F. Alexis, MD, MPH, both from the Skin of Color Center at the Icahn School of Medicine at Mount Sinai in New York City.1

Rosacea affects an approximate 10% of predominantly fair-skinned populations, including 16 million American adults. Primarily, patients are women, and onset often occurs in those older than 30 years. Findings from a study of data collected from the National Ambulatory Medical Care Survey between 1993 and 2010 indicated that 2% of patients with rosacea were black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino. “These findings challenge the long held belief that rosacea is a disease largely limited to white individuals of Northern European heritage with Fitzpatrick skin types I-III,” the researchers noted.1

It is a combination of factors that contribute to the lower prevalence of rosacea in nonwhite populations, including underreporting, underrecognition, the protective effects of melanin, and a “lower incidence of genes conferring susceptibility in diverse populations.”1

Rosacea pathophysiology is multifactorial, Dr Cices and Dr Alexis noted, incorporating many abnormal responses to a variety of environmental stressors in those who are genetically predisposed to both immune and vascular dysregulation.1 Researchers have indicated that in addition to these abnormal responses, a positive family history, and therefore genetics, plays an important role in the condition. Confirming this, researchers of a study published in JAMA Dermatology found that the genetic contribution to rosacea development was approximately 46%.2

Disease Oversimplification

Guidelines from the National Rosacea Society provided pioneering criteria for the diagnosis and categorization of rosacea. These criteria were based on the presence of 1 one or more primary features, including flushing, persistent erythema, papules, pustules, and telangiectasia; variable secondary features included burning, stinging, erythematous plaques, dryness, edema, ocular manifestations, and phymatous changes. The guidelines also identified 4 four rosacea subtypes, including erythematotelangiectatic, papulopustular, phymatous, and ocular. In addition, a granulomatous variant was identified on the basis of the presence of combinations of various primary and secondary disease features.3

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Despite the continued use of these classification criteria, Dr Cices and Dr Alexis note that these criteria “fall short in [their] failure to accurately address the broader scope of clinical presentations.”1 Disease oversimplification often overlooks the presence of simultaneous subtypes.

Among people of color, erythematotelangiectatic is the most common rosacea subtype, closely followed by papulopustular.3 Dr Cices and Dr Alexis attribute the higher frequency of papulopustular rosacea to likely difficulty in recognizing the clinical features of erythematotelangiectatic rosacea in patients with darker skin. In this population, the granulomatous subtype is common, as well as ocular rosacea.