Face to Face with Rosacea

Highlights from the 2013 American Academy of Dermatology Annual Meeting
Payer Perspectives in Dermatology - Rosacea
Caroline Helwick

Miami Beach, FL—Rosacea remains underdiagnosed and is “certainly undertreated,” according to Richard G. Fried, MD, PhD, Clinical Director of Yardley Dermatology Associates, PA, and past president of the Association of Psychocutaneous Medicine of North America.

Speaking at a symposium during the 2013 American Academy of Dermatology annual meeting, Dr Fried noted that although rosacea affects more than 16 million Americans, 80% of persons have no knowledge of the disorder. “Healthcare providers can help patients by proactively diagnosing their condition and letting them know that, with treatment and trigger management, rosacea can be controlled,” he said. “The important first step is to initiate a discussion about rosacea, as well as to formulate an effective treatment plan.”

Dr Fried encouraged busy dermatologists to ask their patients about the signs and symptoms of rosacea. “This 15-second prolongation of the patient encounter will pay back in spades,” he maintained.

Flor A. Mayoral, MD, Associate Clinical Professor in the Department of Dermatology and Cutaneous Surgery, the University of Miami Leonard M. Miller School of Medicine, and dermatologist at Mayoral Dermatology, Coral Gables, FL, added that dermatologists need to listen carefully to patients and need to elicit information that the patient may be hesitant to share. “These 15 seconds are important. Just start by asking, ‘Do you ever get red when you go outside, or feel hot?’ Many will say they do.”

The Psychosocial Toll of Rosacea
For susceptible individuals, environmental factors and triggers cause the epidermal changes, small-vessel dilation, and leakage of proinflammatory factors that converge into the “final common pathway” of inflammation. What follows are the bothersome signs and symptoms that can diminish the patient’s quality of life, said Dr Fried, who is also a psychologist.

He called rosacea a “staircase of misery,” noting that living with rosacea exacts a psychosocial toll on many of its sufferers. According to Dr Fried, of patients with rosacea, 18% report isolation and 25% report depression, along with anxiety, frustration, embarrassment, and other emotions. Rosacea is “pernicious,” he said, because its course is uncertain and, if left untreated, it can rob patients of “functional status and happiness.”

“Don’t assume patients are not affected by this condition,” Dr Fried noted. “A 2-star general came in to see me and began to cry. He had been avoiding important meetings. He would have been the least likely suspect for an emotional impact. We want to give hope to these patients. It gives them control. We want to give the patient a solution and a script. We tell them, ‘I can fix this, I know how, I care about rosacea, and I care about you.’”

Patients need concrete recommendations for skin care, appropriate and effective treatment, and proper monitoring. Dr Fried schedules the first follow-up visit in 2 to 3 weeks, at which time he confirms his patients are following recommendations and using medications appropriately. Within several months, the patient’s rosacea has almost always improved, sometimes dramatically. “We can give patients control over their disease,” he said.

When successfully treated, patients usually report a return to the activities that they enjoy. “One patient said, ‘I didn’t realize how much I’d lost until I got it back,’…and we have the tools to give these things back to the patient,” Dr Fried maintained.

Dr Mayoral reiterated the need to address the psychosocial component of rosacea. “Taking care of rosacea requires 3 things at the same time,” she said, “and these are teaching the patient how to care for the skin, treating the patient effectively, and dealing with the psychosocial problems stemming from rosacea.”

Understanding Cutaneous Inflammation
Without a laboratory test for rosacea, its diagnosis is based largely on knowledge of the spectrum of its clinical manifestations. Current evidence supports the notion that rosacea is an inflammatory condition, and that the efficacy of tetracycline therapies may be attributed to effects that are separate from their antimicrobial properties. These effects include inhibition of matrix metalloprotease enzymes and subsequent suppression of the vasodilation- and inflammation-promoting LL-37 peptide, according to J. Mark Jackson, MD, Clinical Professor of Medicine and Dermatology, University of Louisville, and a dermatologist at Dermatology Specialists, PSC, KY.

Antimicrobial peptides, such as cathelicidin, are part of the skin’s innate immune system. Cathelicidin functions by 2 distinct pathways to inhibit microbial activity or to initiate an inflammatory host response. These peptides are seen at higher levels in patients with rosacea, as are the LL-37 peptide and stratum corneum enzymes; altogether they induce a proinflammatory cascade that keeps the inflammatory process going, Dr Jackson said.

Tetracyclines reduce metalloproteinases, impact neutrophils, and have an inflammatory effect on bumps and redness. In particular, low-dose (40-mg) sustained-release doxycycline (Oracea) works in rosacea by suppressing these inflammatory factors, not by achieving an antibiotic effect, he said.

In closing, Dr Jackson said that disease severity in rosacea should drive the choice of treatment. “The goal is to get the patient to the point where he or she is controlled and happy,” he said.

Actress Cynthia Nixon Speaks Out
Cynthia Nixon, the actress best known for her role as Miranda Hobbes on HBO’s Sex and the City, is the new “voice” of rosacea, speaking out about the condition in public service announcements by the National Rosacea Society. Ms Nixon, who now has a flawless creamy complexion, actually has rosacea, but she is able to keep it under control with proper management and with avoidance of triggers.

Ms Nixon was on hand at the symposium to aid dermatologists in talking to their patients. Mirroring her own experience with the disease, Ms Nixon “visited” a dermatologist during the symposium for a mole check, and was informed that her problem skin (mole aside) was indicative of rosacea.

Ms Nixon shared with the audience that she felt fortunate that the dermatologist not only examined her mole but also inquired about her skin. She left the visit educated about her diagnosis and about how to manage her condition. Better skin care treatment alone helped her regain control over her appearance, Ms Nixon emphasized.

“Rosacea is considered rare. Its first treatment was approved as an orphan drug, under the belief that fewer than 200,000 Americans suffered from it,” Ms Nixon said. Rosacea is now known to be common, she noted, but it is still unrecognized by most people who have it, and the diagnosis requires a visit to a dermatologist.

The symposium was sponsored by Galderma, a dermatologic pharmaceuticals company.

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