Introduction to Rosacea: An Underrecognized and Undertreated Medical Condition

Payer Perspectives in Dermatology
Caroline Helwick

Welcome to the second “Payer Perspectives in Dermatology” series. This series will shine a light on the skin condition known as rosacea—an underrecognized and undertreated disorder that is frequently misunderstood. The goal is to update readers about its causes, manifestations, and treatments, including current and emerging therapies. A better understanding of rosacea among the payer community should lead to greater access to effective treatments for patients.

An estimated 16 million Americans have rosacea; however, few patients receive appropriate treatment for this common facial condition, and their clinical manifestations often remain undiagnosed.1 Rosacea exacts a high emotional toll on patients, who are typically embarrassed about their skin’s appearance.

“Rosacea’s impact on appearance can be a disabling blow to the emotional and social lives of those who suffer from this poorly understood condition,” said Mark Dahl, MD, Chairman of the National Rosacea Society Medical Advisory Board.2

Rosacea sufferers who do seek help can now be treated effectively. Besides the conventional topical and systemic treatments for the inflammatory papules and pustules of rosacea, the vasoconstrictive agent brimonidine tartrate was approved in 2013, becoming the first and only US Food and Drug Administration–approved treatment specifically developed for the facial erythema (redness) of rosacea.3 For additional unmet needs, exciting novel compounds are in the pipeline. Future articles in this series will provide details about treatments for rosacea.

A Medical Condition with an Emotional Toll
Although rosacea elicits cosmetic concerns, it is a medical condition with a complex underlying pathophysiology. Its etiology is unclear, but the basic features are inflammation and vascular reactivity that lead to the erythema and bumps or pimples (papulopustules) that are its hallmarks. The signs and symptoms of rosacea can be sporadic and can be triggered by environmental factors.

A survey conducted in Germany using validated research questionnaires explored the relationship between symptom severity, discomfort, stress, quality of life, and psychologic symptoms among 168 patients with rosacea, and found a link between the physical signs of rosacea and the occurrence of depression and anxiety, which are mediated through quality of life and stigmatization.4 The findings were striking enough that the authors suggested, “Physicians treating rosacea patients should consider recommending psychological co-treatment for patients who have experienced stigmatization or who report low life quality.”4

A survey of patients by the National Rosacea Society further described the substantial emotional impact of rosacea.5 Of the 1675 patients queried, 90% said that rosacea’s effect on their personal appearance had lowered their self-esteem and self-confidence, and 88% reported embarrassment. Other negative feelings expressed by the respondents included frustration (76%), anxiety (54%), helplessness (54%), depression (43%), anger (34%), and isolation (32%). The emotional impact of rosacea tended to increase as symptoms progressed.5

Responding to these findings, Richard Fried, MD, who is a dermatologist and psychologist in Yardley, PA, commented, “Even the most common signs of rosacea can lead to negative emotions….Fortunately today, medical therapy is available for the first time to treat the redness as well as the inflammation associated with rosacea, which should go a long way toward easing the emotional impact of the disorder for a far greater number of people.”5

A Common Reason for Medical Visits
A recent study from the Mayo Clinic highlighted the general public’s concern about skin conditions, including rosacea.6 St Sauver and colleagues conducted an extensive review of a large database and found that more patients seek medical help for skin disorders than for back pain, colds, arthritis, and other common ailments.6 The 2009 study captured 142,377 patients, of whom approximately 43% had received a diagnosis of a skin disorder in the past 5 years. Although skin disorders are not typically a major driver of disability or death, they are an important and overlooked driver of healthcare utilization and costs, because skin disorders often require continued observation and treatment, the authors indicated.6

Furthermore, a recent examination of data from the National Ambulatory Medical Care Survey between 1993 and 2010 shows that rosacea is a major reason for office visits in the United States, accounting for more than 1.7 million office visits annually to providers, primarily dermatologists.7

High Copay for Rosacea Treatments
According to a survey by the National Rosacea Society, many prescription medications for rosacea are being covered by insurance; however, not all treatments are covered, and many patients reported high copays that made access to treatment difficult.8 In a survey of 1259 patients with rosacea, 90% of respondents reported having health insurance, and of these, 72% reported coverage for oral and topical rosacea therapies. By contrast, medical procedures, such as light-based treatments, were rarely covered, because they were considered cosmetic therapies. Only 5% of respondents were sure that these procedures were covered by insurance.8

The lack of coverage or high copays kept 47% of patients from obtaining medical care for their rosacea at some point. Overall, 33% of respondents paid less than $100 out of pocket; 35% paid $100 to $500 out of pocket; 12% paid between $500 and $1000; and 11% paid more than $1000 for their rosacea treatment.8 Because maintenance therapy is required to keep rosacea controlled, the financial burden of many patients with rosacea can be considerable, and this impedes access to care.

References

  1. National Rosacea Society. If you have rosacea, you’re not alone. www.rosacea.org/patients/index.php. Accessed April 10, 2014.
  2. National Rosacea Society. Rosacea awareness spotlights social impact, warning signs. Rosacea Review. Spring 2013. www.rosacea.org/rr/2013/spring/article_1.php. Accessed April 10, 2014.
  3. FDA approves Mirvaso: Galderma receives FDA approval of Mirvaso for the topical treatment of facial erythema of rosacea. August 26, 2013. www.drugs.com/newdrugs/galderma-receives-fda-approval-mirvaso-topical-facial-erythema-rosacea-3881.html. Accessed April 14, 2014.
  4. Böhm D, Schwanitz P, Stock Gissendanner S, et al. Symptom severity and psychological sequelae in rosacea: results of a survey. Psychol Health Med. 2013 Oct 3. Epub ahead of print.
  5. National Rosacea Society. Emotional toll of facial redness equal to bumps, pimples: survey. Rosacea Review. Fall 2013. www.rosacea.org/rr/2013/fall/article_3.php. Accessed April 10, 2014.
  6. St Sauver JL, Warner DO, Yawn BP, et al. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clin Proc. 2013;88:56-67.
  7. Davis SA, Feldman SR. Patterns of ambulatory care usage and leading treatments for rosacea. J Dermatolog Treat. 2014;25:275-277.
  8. National Rosacea Society. Survey shows insurance covers medication for most patients. Rosacea Review. Winter 2014. www.rosacea.org/rr/2014/winter/article_3.php. Accessed April 10, 2014.
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Last modified: May 2, 2014
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