Dermatologist Dissects Rosacea Diagnosis Challenges Among Patients of Color

Hilary Baldwin, MD, FAAD, medical director of Atlantic Health’s Acne Treatment & Research Center, covered the complexities of diagnosing and treating rosacea in patients of color at the Skin of Color Update in New York City last Friday.

Hilary Baldwin, MD, FAAD, highlighted diagnostic complexities and shared treatment strategies for rosacea in patients with darker skin tones at the Skin of Color Update last Friday. | Image Credit: annaspoka - stock.adobe.com

Debunking Rosacea Myths

Baldwin began by stating that rosacea is prevalent in about 10% of the US population, equating to about 16 million people. Studies often include that rosacea most commonly occurs in women over 40 years old and of Northern European descent, which she criticized.

“I’ve practiced my whole life in the heart of Brooklyn, and if it only happened in women of Northern European descent, I wouldn’t be here talking about rosacea,” Baldwin said. “It happens in men, it happens in patients of color, and it happens under the age of 40, so let’s stop having that be the first sentence in every rosacea paper.”

Consequently, Baldwin highlighted a study stating that rosacea is not uncommon in patients with darker skin.¹ More specifically, a 1993 to 2010 US National Ambulatory Medical Care Survey found that 2% of patients with rosacea were Black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino. Globally, rosacea is reportedly prevalent in as many as 40 million patients of color, mainly in countries throughout Africa, Asia, and South America.²

She noted that erythema, or redness of the skin, may be harder to find in those with deeper-hued skin, which may be why it is considered less common. Because of this, Baldwin said dermatologists should instead look out for rosacea symptoms, like burning, stinging, itching, or skin sensitivity.

Rosacea Diagnoses in Patients of Color

Baldwin went into more detail about diagnosing rosacea, especially in patients of color. She noted the recent shift in categorizing patients by rosacea subtypes, instead focusing on detailed phenotypic descriptions since most patients have combination disease. Therefore, Baldwin emphasized the importance of examining patients for erythema, papules, pustules, telangiectasias, and ocular symptoms, while also asking about symptoms like burning, itching, and stinging.

Again, she acknowledged that challenges may arise among patients with darker skin where redness may be harder to detect, making diagnosis more difficult. In these patients, clinicians are particularly looking for ocular symptoms and asking about burning, itching, stinging, and sensations of warmth. However, Baldwin highlighted that patients of color rarely receive a rosacea diagnosis, even when they display these symptoms.

Consequently, she stressed that misdiagnoses or delayed diagnoses can lead to worse patient outcomes. For example, a study determined that most patients of color had symptoms for more than a year before a diagnosis was made, increasing morbidity, a decrease in quality of life, and more advanced disease; this can lead to sight-threatening disease or disfiguring phymas.

“Bottom line, a diagnosis not considered is a diagnosis not made, so we really need to do a better job in this regard,” Baldwin said.

Treating Rosacea in Patients of Color 

Baldwin noted that rosacea treatment is similar for all patients, regardless of skin color. She emphasized that clinicians should listen to patients to learn about their symptoms and what is bothering them.

“I like to give them a mirror and show them the aspects of their disease right in front of them and then say, ‘Okay, of all the stuff I just showed you, what bothers you? What do you care about?’,” Baldwin said. “You’d be surprised by the answers you get, it’s not necessarily what would bother you if your face looked like that.”

She said this is important since patients need to “buy in” for this disorder since it’s chronic, meaning they will need long-term treatment, and it may cost them some money out of pocket. Also, she noted that clinicians should ensure they are picking products with “excellent” vehicles and “good” tolerability data to avoid giving patients drug-induced irritation or hyperpigmentation.

Baldwin noted the 3 most recently approved drugs “fit the bill”: ivermectin cream 1%, minocycline foam 1.5%, and microencapsulated benzoyl peroxide 5%. However, due to racial and economic disparities in the US, many patients are unable to get these products. Consequently, she listed several treatment alternatives, including 0.5% ivermectin lotions commercially available over the counter for head lice treatment.

Another option would be for patients to conduct skin barrier repair by using older medications. Baldwin explained that if the skin barrier is repaired for about 2 weeks with skincare, patients can sometimes tolerate the older medications associated with irritation. Conversely, clinicians can switch patients to oral medications, like sub-antimicrobial dose doxycycline or isotretinoin.

Incorporating Skincare in Rosacea Treatment

Baldwin concluded her presentation by stressing the importance of skincare among all patients with rosacea. She explained that improper skincare makes rosacea worse, highlighting studies that showed how a good skincare regimen can improve rosacea without medication.

Skincare has also been shown to improve the tolerability of azelaic acid gel. In clinical trials, Baldwin noted that 26% of patients with rosacea complained of stinging and burning. However, they got better results if pretreated with Cetaphil or CeraVe creams.

Therefore, her recommended skincare regimen for patients with rosacea included a non-alkaline, fragrance-free, emollient cleanser with a pH between 4 and 6. Baldwin noted that it should be used once a day without a washcloth or exfoliants. She also suggested patients use a quality silicone-based, fragrance-free moisturizer and a tinted physical sunblock.

As for makeup, Baldwin suggested they avoid heavy cosmetics that require scrubbing to get off. Instead, she instructed patients to apply quality emollients before foundation application and to add a green tint to concealer to help reduce redness. Overall, patients should use makeup with a matte finish, Baldwin said, because the things that make makeup shiny are “very irritating” to their rosacea.

“The bottom line is no acne and no rosacea visit is complete until you discuss very good quality skincare,” she concluded.

References

1. Alexis AF, Callender VD, Baldwin HE, Desai SR, Rendon MI, Taylor SC. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and clinical practice experience. J Am Acad Dermatol. 2019;80(6):1722-1729.e7. doi:10.1016/j.jaad.2018.08.049
2. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014;20(10). doi:10.5070/d32010024262