Demographic and clinical features of rosacea in North Jordan: a 10-year university hospital retrospective study

Abstract

Background/Objectives

This study aims to investigate the demographic and clinical characteristics of rosacea within the North Jordan population, focusing on Fitzpatrick skin types III and IV. The intent is to address gaps in dermatological research concerning ethnic and racial variations in rosacea’s presentation and impact.

Methods

We conducted a retrospective cohort analysis at the dermatology department of King Abdullah University Hospital, North Jordan, reviewing medical records of patients diagnosed with rosacea from January 2013 to December 2023. Data collection focused on demographics, rosacea subtypes and environmental factors exacerbating the condition. Statistical analysis utilized Jamovi and GraphPad Prism software.

Results

The study included 610 patients, revealing a rosacea prevalence of 1.5% within the hospital’s catchment area. Most patients were female (84.4%), with a median age of 44. The majority had Fitzpatrick skin types III and IV. The erythematotelangiectatic subtype was most common (73.6%), followed by papulopustular (23.4%) and phymatous (3%). Environmental triggers like sun exposure and temperature changes were nearly universally reported as exacerbating factors.

Conclusions

Rosacea shows significant gender disparities and is influenced by environmental factors. The study underscores the need for targeted research and treatment strategies that consider ethnic and racial variations, along with gender-specific presentations of the disease.

Introduction

Rosacea, a chronic inflammatory disease characterized by recurrent flushing, erythema, telangiectasia, papules or pustules on the nose, chin, cheeks and forehead, is a significant health concern [1]. It is a lifelong condition with periods of flare-ups and remissions, demonstrating the unpredictable nature of its course [2,3]. Predominantly affecting individuals with fair skin (Fitzpatrick types I and II) and women, rosacea commonly emerges in middle age, between 30 and 60 years. However, rare cases in children and adolescents have been reported [2,4].

Despite its prevalence, the global incidence and population-based prevalence of rosacea still need to be discovered, underscoring a gap in dermatological research. A handful of population-based studies provide a glimpse into its prevalence and association with other dermatological conditions, estimating that approximately 5.5% of the adult population is affected [5]. This statistic suggests that a significant portion of the population contends with rosacea, underscoring the need for further investigation into its epidemiology.

The pathogenesis of rosacea is complex and not fully understood, implicating abnormal neurovascular signalling, dysregulation of the immune response and microbial colonization as potential contributors [6]. These proposed mechanisms highlight the multifactorial nature of rosacea, pointing to the interplay between genetic, environmental, and microbial factors in its development.

Rosacea’s clinical presentation can be categorized into four subtypes, underscoring the disease’s heterogeneity. This classification not only aids in diagnosis but also in tailoring treatment approaches. The mutual exclusivity of erythematotelangiectatic and papulopustular rosacea highlights the distinct pathophysiological mechanisms underpinning these subtypes. In contrast, the possibility of concurrent subtypes in patients illustrates the clinical complexity of the disease [7]. External factors, such as environmental conditions and lifestyle choices, exacerbate rosacea symptoms, further complicating its management [8].

The underdiagnosis and undertreatment of rosacea, particularly among those with darker skin tones, is a pressing issue. This oversight can lead to significant distress, impacting an individual’s quality of life and social interactions [9]. The study seeks to bridge this gap by exploring the demographic and clinical characteristics of rosacea in the North Jordan population, predominantly consisting of individuals with Fitzpatrick skin types III and IV. This focus addresses a neglected area in the current literature and underscores the importance of considering ethnic and racial variations in dermatological research [10–12].

Materials and methods

Participants and study setting

This retrospective cohort analysis was conducted in the Dermatology Department at King Abdullah University Hospital, North Jordan. We examined records from January 2013 through December 2023, targeting patients diagnosed with rosacea who had comprehensive medical documentation available. Our cohort comprised individuals across diverse demographic backgrounds, with data including age, gender, occupation, Fitzpatrick skin type, comorbidities, smoking habits, rosacea subtype, disease duration, prior diagnoses, and clinical symptoms meticulously extracted from medical records. Additional details on disease exacerbation factors such as sun exposure, temperature variations, emotional stress, consumption of spicy foods, family history, previous steroid use, history of acne, and smoking habits were collected through telephone interviews. Any instances of missing information were carefully noted. Only patients with a definitive rosacea diagnosis, as per the National Rosacea Society Expert Committee’s (NRSEC) guidelines, were included in our study [12].

Data collection and analysis

To ascertain potential associations, demographic and clinical data were analysed based on gender and specific rosacea subtypes. Cases presenting with multiple subtypes were omitted from the subtype-centric analysis. The prevalence rate calculations employed data from 2015 onwards. Our statistical evaluations were performed using Jamovi software (version 2.2.5), employing the Chi-squared or Fisher’s exact tests for categorical variables, depending on the sample size. Continuous variables, following a non-normal distribution, were expressed as medians with interquartile ranges (IQR) and analysed using the Mann–Whitney U-test. A p-value of less than 0.05 was considered statistically significant. Graphical representations were created using GraphPad Prism (version 10.0.0).

Ethical considerations

The study received approval from the Institutional Review Board (IRB) at King Abdullah University Hospital, ensuring adherence to ethical guidelines and patient confidentiality. The IRB approval number is (6/158/2023).

Result

In our retrospective cohort study conducted at the dermatology clinic of King Abdullah University Hospital (KAUH), we identified 610 patients diagnosed with rosacea out of a hospital visitation population of 40,300 individuals spanning from 2013 to 2023. This yields a rosacea prevalence rate of approximately 1.5% within the hospital’s catchment area, with a 95% confidence interval ranging from 1.4% to 1.6%. Notably, the incidence of new rosacea cases demonstrated an upward trend, with 374 (61%) diagnoses occurring in the final three years of the study period, thereby highlighting an increasing burden of rosacea diagnoses in recent years (Table 1).

Table 1.

Demographic characteristics of the patients (N = 610).

Variable (N, %)	Gender (N, %)		P value
	Females (515, 84.4)	Males (95, 15.6)
Age (years), Median (IQR)	44 (19)	50 (20.5)	< 0.001*
Occupation			< 0.001*
Indoor	488 (94.8)	60 (63.2)
Outdoor	27 (5.2)	35 (36.8)
Skin Type			0.007*
I	1 (0.2)	0 (0.0)
II	40 (7.8)	4 (4.2)
III	302 (58.8)	42 (44.2)
IV	166 (32.3)	46 (48.4)
V	4 (0.8)	3 (3.2)
VI	1 (0.2)	0 (0.0)
Comorbidities			0.033*
Autoimmune	33 (6.4)	4 (4.2)
Non-Autoimmune	74 (14.4)	24 (25.3)
None	408 (79.2)	67 (70.5)
Smoking			< 0.001*
Yes	63 (12.2)	46 (48.4)
No	452 (87.8)	49 (51.6)

The geographic distribution of patients indicated that a predominant majority, 545 (89.34%), resided in Irbid, while the remainder hailed from neighbouring regions, including Mafraq, Ajloun, Jerash and Amman. This distribution underscores the regional impact of rosacea in North Jordan (Figure 1).

Figure 1.

Number of rosacea cases per area of residency.

Demographically, our cohort was chiefly female, comprising 515 (84.4%) female patients against 95 (15.6%) male patients. A significant age difference was observed between genders; the median age for females was 44, compared to 50, suggesting a later onset in males (p < 0.001). Most of the cohort, 548 (89.8%), reported employment in indoor settings, and smokers constituted 109 (17.9%). Fitzpatrick skin types III and IV distribution was notable, representing 56.4% and 34.8% of patients, respectively (Table 2).

Table 2.

Gender-associated clinical characteristics of the patients (N = 610).

Variable (N, %)	Gender (N, %)		P value
	Females (515, 84.4)	Males (95, 15.6)
Rosacea subtype
ET	414 (80.4)	70 (73.7)	0.138
PP	199 (38.6)	28 (29.5)	0.089
PHYM	3 (0.6)	14 (14.7)	< 0.001*
Ocular	72 (14.0)	16 (16.8)	0.466
Disease duration (years), Median (IQR)	3 (3.00)	5 (4.00)	0.060
Previous Different Diagnosis	86 (16.7)	15 (15.8)	0.827
Symptoms
Ocular Symptoms	72 (14.0)	16 (16.8)	0.466
Persistent Facial Erythema	342 (66.4)	59 (62.1)	0.417
Flushing	435 (84.5)	75 (78.9)	0.182
Burning or stinging with skincare products	204 (39.6)	24 (25.3)	0.008*
Risk Factors
Sun exposure	515 (100)	94 (98.9)	0.156
Temperature change	495 (96.1)	91 (95.8)	0.779
Psychological stress	148 (28.7)	25 (26.3)	0.630
Spicy food	127 (24.7)	22 (23.2)	0.754
Family history	184 (35.7)	31 (32.6)	0.562
Prior steroid use	92 (17.9)	10 (10.5)	0.078
Hx of acne dx/ failed acne treatment	206 (40.0)	34 (35.8)	0.440

Subtype analysis among 436 patients with a single subtype diagnosis revealed erythematotelangiectatic rosacea (ETR) as the most common, accounting for 73.6%, followed by papulopustular rosacea (PPR) at 23.4% and phymatous rosacea (PHYMR) at a mere 3%. The distribution of subtypes varied minimally between genders, except for PHYMR, which was significantly more prevalent among males (p < 0.001). Symptomatically, flushing and persistent facial erythema were the most reported symptoms across genders, with no significant gender difference in their prevalence (Table 3).

Table 3.

Clinical characteristics by subtype (N = 436).

Variable (N, %)	Subtype (N, %)			P value
	ET (321, 73.6)	PP (102, 23.4)	PHYM (13, 3)
Gender				< 0.001*
Female	274 (85.4)	89 (87.3)	3 (23.1)
Male	47 (14.6)	13 (12.7)	10 (76.9)
Skin type				< 0.001*
I	1 (0.3)	0 (0.0)	0 (0.0)
II	20 (6.3)	14 (13.7)	0 (0.0)
III	179 (55.9)	71 (69.6)	7 (53.8)
IV	115 (35.9)	15 (14.7)	6 (46.2)
V	5 (1.6)	1 (1.0)	0 (0.0)
VI	0 (0.0)	1 (1.0)	0 (0.0)
Risk Factors
Sun exposure	320 (99.7)	102 (100)	13 (100)	1.000
Temperature change	308 (96.0)	97 (95.1)	12 (92.3)	0.519
Psychological stress	96 (29.9)	17 (16.7)	1 (7.7)	0.008*
Spicy food	84 (26.2)	9 (8.8)	4 (30.8)	< 0.001*
Family history	118 (36.8)	15 (14.7)	6 (46.2)	< 0.001*
Prior steroid use	51 (15.9)	22 (21.6)	0 (0.0)	0.110
Hx of acne dx/ failed acne treatment	122 (38.0)	21 (20,6)	2 (15.4)	0.001*
Symptoms
Ocular Symptoms	5 (1.6)	0 (0.0)	1 (7.7)	0.092
Persistent Facial Erythema	209 (65.1)	72 (70.6)	2 (15.4)	< 0.001*
Flushing	270 (84.1)	95 (93.1)	7 (53.8)	< 0.001*
Burning or stinging with skincare products	133 (41.4)	20 (19.6)	1 (7.7)	< 0.001*

Concerning aggravating factors, virtually all patients (99.8%) cited sun exposure as exacerbating their condition, closely followed by temperature changes (96.1%). The history of acne and family history were significant in 39.3% and 35.2% of patients, respectively, with factors like emotional stress and spicy food consumption also contributing to symptom exacerbation. Notably, emotional stress and acne history were more associated with the ETR subtype, whereas a family history of rosacea and spicy food consumption were significantly linked to the PHYMR subtype. Differences in skin type prevalence by rosacea subtype were also observed, with type III being predominant in PPR and type IV in PHYMR patients.

Discussion

The study analysed 610 rosacea patients at KAUH from 2013 to 2023, finding significant gender disparities: 84.45% were female, with females presenting at a younger age. Males had higher rates of smoking and outdoor work, while females had more indoor jobs, suggesting environmental factors influence rosacea. Subtype analysis showed that males predominantly had the Phymatous subtype, while females had the Erythematotelangiectatic, Papulopustular, and Ocular subtypes. An increase in rosacea cases over the years, especially among females and older age groups, was noted, along with a discussion on comorbidities, misdiagnosis and triggers. The findings advocate for tailored management strategies based on gender and subtype.

Rosacea, a prevalent chronic skin disorder, is not limited by age and affects individuals across diverse demographics, including adolescents [1]. Our study found that females comprised most patients (84.45%). While rosacea predominantly afflicts women aged 30–50, recent studies have identified cases in adolescents and observed a lower female predominance, underscoring the complex nature of the condition [1,2].

The emotional burden, including psychological stress, is recognized as a risk factor for the incidence of rosacea, with numerous reports highlighting depressive symptoms and impaired quality of life among sufferers [2]. Our study has identified a higher prevalence of smoking and outdoor occupations among male patients, which is consistent with findings from previous research [2,3]. Additionally, well-established risk factors for rosacea encompass a family history and a very light skin phototype. Nevertheless, the impact of alcohol and coffee on its development continues to be debated [3]. Interestingly, our analysis revealed no statistically significant differences in the risk factors for rosacea between males and females.

Comorbidities are often linked to an elevated risk of developing rosacea. Studies from the Middle East, including research conducted in Saudi Arabia, have associated rosacea with systemic comorbidities such as hypertension and cardiovascular, gastrointestinal, and respiratory diseases [4]. Our findings indicate that among patients with rosacea, 29.5% of males had comorbidities, either autoimmune (4.2%) or non-autoimmune (25.3%), in contrast to 20.8% of female patients, with this difference being statistically significant (p = 0.03).

The prevalence of rosacea varies widely, affecting up to 20% of European and US populations. It is common among both Western and Asian populations, particularly among Caucasians. China reports a prevalence rate of 3.48% [3,5,6]. Although the condition is more prevalent in individuals with fair skin, it also affects those with darker skin tones, underscoring the need for targeted research and management strategies [7]. Our findings showed that most patients had skin types III and IV, as the North Jordan population predominantly has darker skin tones. Those with skin type III constituted the highest percentage in the PPR group, while skin type IV was most prevalent in the PHYMR group. Prior research has indicated that skin type, particularly Fitzpatrick IV, represents a significant risk factor for rosacea [6].

Our analysis shed light on the patterns associated with rosacea subtypes, revealing a notable predominance of the Phymatous subtype among males. Conversely, the Erythematotelangiectatic (ET), Papulopustular (PP), and Ocular subtypes were more prevalent among females. This dichotomy underscores the multifaceted nature of rosacea, echoing prior research findings, which have delineated variations in subtype prevalence influenced by patient sex, continent of origin, and year of publication [8,9]. Notably, Erythematotelangiectatic and Papulopustular rosacea have emerged as the most commonly identified subtypes, further corroborated by the comprehensive analysis presented in [8]. Berg et al. have contributed to this body of knowledge by highlighting a higher incidence of rosacea among women, predominantly characterized by the erythematotelangiectatic subtype [9].

Moreover, Rainer et al. accentuated the chronic and inflammatory dimensions of rosacea. At the same time, Thyssen et al. have advocated for a nuanced understanding and improved patient care through meticulous subtyping, phenotyping, or endotyping [10,11]. These studies underscore the complex etiology of rosacea, involving a confluence of genetic, immune, neurovascular, and environmental factors [12]. Early histological investigations suggest an initial actinic lymphatic vasculopathy, further exacerbated by neuropeptides and UV light-induced skin alterations [13]. The role of microorganisms such as H. pylori and Demodex mites, alongside external triggers including UV radiation, are acknowledged as significant contributors to the pathology of rosacea [14]. However, the specific histopathology of rosacea, particularly concerning its diverse subtypes and the onset age of lesions, remains an area ripe for further exploration [14]. In addition, Thompson et al. delve into microbial influences, probing the potential interplay between gut and skin dysbiosis [15]. Weinstock et al. extend this discourse by examining microbial variables, positing a correlation between bacterial overgrowth in the small intestine and the development of rosacea [16]. Furthermore, the early stages of rosacea are characterized by neurovascular and neuroimmune dysregulation, a critical aspect of its pathophysiology [17]. This dysregulation of mediators and receptors sheds light on the intricate mechanisms underpinning rosacea, emphasizing the imperative for ongoing research to unravel its complex pathophysiology [17].

Our study, conducted over ten years, analysed gender differences in 610 rosacea patients. Although most patients were female, males exhibited a longer median disease duration and a higher prevalence of the Phymatous subtype. In contrast, females were more frequently diagnosed with other rosacea subtypes, highlighting gender-specific variations in disease presentation. We recently observed a concerning uptick in rosacea cases, underscoring the necessity for gender-tailored interventions.

Critically, our findings underline the significance of acknowledging gender-specific differences in rosacea’s epidemiology and clinical manifestations to refine treatment strategies. The increased incidence of specific rosacea subtypes among males could be attributed to genetic and environmental factors. Notably, the phymatous subtype is predominant in males and more common in individuals with fair skin, especially those of Celtic or Northern European descent [7,18]. Furthermore, male patients with rosacea are at an elevated risk for migraines, complicating diagnosis due to similarities with other inflammatory facial dermatoses [18,19]. Conversely, recent studies claim that rosacea increases the risk of cardiovascular diseases in females [7,18].

Our study illuminates the significant challenge inherent in the accurate diagnosis of rosacea, uncovering a misdiagnosis rate of 65.7%. This underscores the urgent need for increased awareness among healthcare professionals and the refinement of diagnostic criteria. Furthermore, the discovery that many patients report a family history of rosacea hints at its potential genetic foundations, warranting further investigation into its hereditary aspects. These insights emphasize the critical necessity for enhancing diagnostic accuracy and deepening our understanding of rosacea’s familial tendencies, thereby optimizing management strategies. The paramount importance of early and accurate rosacea diagnosis is highlighted, given its potential ocular complications, which can lead to significant morbidity if left untreated [20].

Nevertheless, diagnosing rosacea in individuals with skin of colour introduces added complexity, as various skin disorders can mimic its hallmark symptoms [21]. Additionally, diagnosing rosacea in darker skin tones presents unique challenges due to overlapping features with other dermatologic conditions [22]. Despite these obstacles, timely identification and appropriate therapeutic interventions are crucial for alleviating patient discomfort and preventing long-term complications [23].

Managing rosacea involves a comprehensive approach that includes avoiding known triggers such as sun exposure and certain foods. Additionally, frontline topical medications like brimonidine, ivermectin, metronidazole, and azelaic acid are essential for controlling symptoms effectively [24]. Proper skincare practices mitigate epidermal barrier dysfunction and alleviate symptoms [25]. When topical treatments prove insufficient, various therapeutic options offer differing degrees of success, including systemic medications, lasers, and light-based therapies [24]. Continuous research is vital to validate and improve the effectiveness of these treatment modalities in managing rosacea. Various strategies to enhance the diagnosis and treatment of rosacea have been proposed, emphasizing the importance of addressing the disease’s immunological aspects, particularly inflammation [26]. Drucker et al. advocates for personalized treatment plans that acknowledge the diverse phenotypic presentations of rosacea, leading to more targeted and effective care [27]. Tan et al. suggest a phenotype-led approach for diagnosis and management, aiming to improve patient-centred care by identifying and addressing specific rosacea subtypes [28]. Topical and systemic medications, such as metronidazole, azelaic acid, and doxycycline, have been demonstrated to be effective in managing symptoms [29]. Collectively, these strategies highlight the potential advantages of adopting personalized, immune-focused, and phenotype-led approaches to enhance the accuracy of diagnosis and the efficacy of treatments in rosacea.

While our study provides significant insights into the epidemiology, clinical characteristics, and management strategies for rosacea, it is imperative to recognize several limitations that influence the interpretation and applicability of our findings. Initially, the retrospective design of our study introduces inherent biases and constraints related to data collection methodologies, including potential inaccuracies in patient records and the absence of data due to reliance on historical data. Moreover, the study’s single-centre approach may restrict the extrapolation of our findings to broader populations with rosacea, as characteristics and management practices could vary across different geographical locations and healthcare settings. Additionally, concentrating on a specific geographic area or demographic group may only partially capture the diverse presentations and treatment modalities of rosacea observed in various populations or contexts. Furthermore, the dependence on self-reported data for aspects like trigger factors and comorbidities may introduce recall bias, impacting the accuracy of our findings. Lastly, the cross-sectional nature of our study limits our capacity to establish causal relationships between variables and outcomes, underscoring the necessity for future longitudinal studies to explore temporal associations. To overcome these limitations and provide more compelling evidence, further prospective studies with larger sample sizes and more diverse populations are warranted to deepen our understanding of rosacea’s epidemiology, clinical manifestations, and treatment outcomes.

In conclusion, our in-depth exploration of rosacea’s epidemiology, clinical manifestations, and treatment avenues underscores the complexity of this chronic dermatological condition. The identification of gender-specific disparities in disease manifestation – ranging from variations in subtype prevalence to symptom severity – underscores the necessity of personalized treatment paradigms. Moreover, the significant rate of misdiagnosis and the profound influence of familial history on rosacea incidence highlight the critical need for enhanced diagnostic criteria and heightened awareness among healthcare professionals. Considering rosacea’s heterogeneity, successful management demands a comprehensive strategy integrating self-care measures, pharmacological treatments, and advanced therapeutic interventions. Recent studies hinting at the potential advantages of customized, immune-centric and phenotype-specific treatment approaches further emphasize the importance of continued research and collaboration to improve diagnostic precision and therapeutic outcomes for this intricate skin condition. Our investigation offers valuable insights into the aetiology and management of rosacea, accentuating the imperative for persistent research endeavours and collective initiatives aimed at augmenting patient well-being and life quality.

Funding Statement

This research received no external funding.

Acknowledgments

None.

Author contributions

Conceptualization, D.A.; methodology, D.A., S.A.B., A.A., FA, and A.B.B.; software, S.A.B., A.A., and A.B.B.; validation, S.A.B., A.A., FA, and A.B.B.; formal analysis, A.A. and A.B.B.; investigation, D.A.; resources, D.A. and S.A.B.; data curation, S.A.B.; writing—original draft preparation, D.A., S.A.B., A.B.B., M.A., A.A., S.A., L.A., FA, and L.H.; writing—review and editing, D.A, FA,. and S.A.B.; visualization, D.A. and S.A.B.; supervision, D.A. and S.A.B.; project administration, D.A.; funding acquisition, D.A. All authors have read and agreed to the published version of the manuscript.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of King Abdullah University Hospital (protocol code 6/158/2023 and date of approval).

Informed consent statement

Written informed consent was obtained from all subjects involved in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data supporting the findings of this study are available within the article. Further inquiries can be directed to the corresponding author.