Diagnosing and Treating Rosacea in Skin of Color Patients

The worldwide prevalence of rosacea is estimated to be between 5.5 percent and 10 percent.1,2 It is a chronic, inflammatory skin disorder that is most commonly associated with fair-skinned patients. In Ireland, the incidence is estimated to be 14 percent, and in Germany, it is estimated to be 12 percent.3,4 The incidence rates in skin of color (SOC) patients are estimated to be much lower. Rosacea is thought to affect two percent of Black patients, 3.9 percent of Hispanic of Latino patients, and 2.3 percent of Asian/Pacific Islanders.5 The lower incidence rate of rosacea in SOC patients may be due to genetics and environmental factors, but it may also be due to a lower index of suspicion.9 At present time, there is no evidence to demonstrate if certain therapeutics respond better in SOC populations, thus it is recommended to follow the current management guidelines from the American Acne & Rosacea Society.10 Here, I review the nuances of diagnosing and treating rosacea in skin of color patients.

Five Pearls for Recognizing and Managing Rosacea in Skin of Color

1 Ask questions. The hallmark signs of rosacea include persistent facial erythema, papules, pustules, telangiectasia, and recurrent flushing. Three of these five hallmark signs (facial erythema, telangiectasia, and recurrent flushing) are more difficult to visualize in skin of color patients due to their richly pigmented skin. Thus, a thorough patient history is necessary. It’s important to not only screen for cutaneous symptoms but also ocular symptoms . One study found the incidence of ocular rosacea in female SOC patients to be 77 percent.13 See Table 1 for pertinent questions to ask.5

TABLE 1.

Pertinent questions to ask when assessing skin of color patients for rosacea5,6

Do you experience a warm sensation over the face?

Do you notice any redness on the face?

Do you feel any stinging or burning with skincare products? If yes, ask which products.

Ask about timing of symptoms. (Are they associated with known triggers? i.e. heat, stress, spicy foods?)

Have you been treated with acne medications recently? If so, have you noticed any improvement? (SOC patients with rosacea are often misdiagnosed as having acne).

Have you or are you currently applying any steroid creams to the face? (Screens for steroid-induced rosacea).

Regarding your eyes, do you experience: itching, burning, a gritty sensation or dryness? If so, how often?

2 Look for non-classic signs. Patients with skin of color may present with dry skin, edema, and hyperpigmentation. In addition, look for skin thickening on the nose and medial cheeks as these may be early signs of phymatous changes.5 In Black patients, it may be difficult to distinguish granulomatous rosacea from sarcoidosis. Look for several firm, monomorphic papules affecting the perioral, periocular, medial, or lateral areas of the cheeks. The papules may be skin-colored, violaceous, or brown. Flushing and erythema are also less likely to occur in granulomatous rosacea.11,12

3 Use tools to help identify telangiectasa. A dermatoscope can be used aid in the visualization of telangiectasa. Alternatively, diascopy can be used to. Diascopy is the act of pressing a microscope slide against the skin and assessing for blanching.6 If the skin blanches, diascopy is positive for erythema from vasodilation.

4 Educate patients on proper skincare. Many cultures think facial dermatoses are due to improper cleansing and will often use alkaline soaps such as glycerine and black soap. However, these soaps can further impair the skin barrier due to their ability to increase the skin pH. SOC patients also tend to more frequently use astringents and toners, which can cause skin irritation.6 Counsel patients to use products that have barrier repairing properties, such as ceramides, hyaluronic acid, and niacinamide.8 Encourage use of light, water-based moisturizers and avoid gels and thin lotions.6

5 Recommend adherence to daily sunscreen. Often SOC patients believe their darker complexion negates the need to apply daily sunscreen. It’s important to dispel this myth and reinforce that sun protection in the setting of rosacea is particularly important, regardless of skin color. In a review by Morgado-Carrasco et al,7 ultraviolet (UV) light was found to impact skin inflammation, neoangiogenesis, telangiectasa/fibrosis, and may also initiate rosacea. A broad spectrum sunscreen with a minimum sun protection factor (SPF) of 30 should be recommended.

WAYS TO HELP MAUI FIRE VICTIMS.

HAWAI’I EMERGENCY MANAGEMENT AGENCY: Donations and volunteer support information at www.ready.hawaii.gov or 808-733-4300.

AMERICAN RED CROSS OF HAWAI’I: Monetary donations should include the designation “Hawaii (Maui) Wildfires.” www.redcross.org/hawaii.

MAUI UNITED WAY: The Fire Disaster Relief Fund is providing financial assistance through grants to nonprofits at the forefront of relief efforts and directly to households that have been deeply affected. www.mauiunitedway.org/disasterrelief.

HAWAI’I COMMUNITY FOUNDATION’S MAUI STRONG FUND: Providing resources for disaster recovery, 100% of funds will go to the community. No fees will be taken. www.hawaiicommunityfoundation.org/maui-strong

HAWAI’I SALVATION ARMY: They will be providing meals in Maui emergency shelters. https://hawaii.salvationarmy.org/

KĀKO’O MAUI FUND: Funds will go to help Maui families and businesses. Donations up to $100,000 will be matched. www.memberplanet.com/campaign/cnhamembers/kakoomaui

MAUI MUTUAL AID FUND: Volunteers are raising money to get support to vulnerable residents like kūpuna, those with physical disabilities, and those without insurance. https://www.paypal.com/donate?hosted_button_id=Y7J26SYUJFQU8