Nearly half of rosacea patients thought they had acne before being diagnosed, according to a new patient survey. It’s a finding that doesn’t surprise dermatologist Doris Day, M.D., who practices in Manhattan, N.Y.
“When I tell patients they have rosacea, they still think of it as a form of acne and don’t understand how it can happen now, when they didn’t have it in the past as they were growing up. When I mention they have rosacea, I ask them if they know what rosacea is and most of them don’t know. So, we’re not educating patients properly on what they have and what it means,” Dr. Day says. “Patients cannot wrap their minds around how something that looks like acne is not acne.”
Even dermatologists misdiagnose rosacea, according to Helen M. Torok, M.D., medical director, Trillium Creek Dermatology and Surgery, Medina, Ohio, and Dermatology Times editorial advisory board member.
“Rosacea is not just on the midface. Often patients have rosacea on the scalp, chest and back,” Dr. Torok says. “These are not considered common areas for rosacea. Dermatologists might diagnose the rosacea as folliculitis or acne and treat it with clindamycin and tretinoin, which, unfortunately, is irritating and ineffective.”
Consumers unaware, unlikely to seek care
In May 2015, Galderma Laboratories and the National Rosacea Society released findings of a national survey1 reflecting responses from 500 rosacea patients and 300 dermatologists, which found:
Half of rosacea patients report feeling unattractive, 42% say they’re embarrassed and 30% feel less confident because of the skin condition. More than half of patients don’t feel comfortable talking to their physicians about these emotional challenges. And, while nearly half of doctors say they want hear about their patients’ feelings, only 12% of patients believe this to be true.
There’s a lot patients don’t understand about rosacea. Most don’t know about key rosacea triggers. Twenty-three percent of patients try to cover up symptoms with cosmetics, but otherwise aren’t treating their symptoms. Nearly 30% say they aren’t doing anything to treat their rosacea; yet, 56% of doctors said they wish patients would more proactively manage rosacea.
Education needed, but do derms have time?
Dr. Day says patients who think they have acne often try to treat the condition with over-the-counter acne products, many of which irritate rosacea.
“We’re dealing with a condition that’s very common and is somewhat unpredictable,” Dr. Day says.
Patients don’t always go to the dermatologist for their rosacea as their main complaint; rather, they might be in the office for other things and the dermatologist notices it. If the dermatologist brings up the rosacea and educates patients about what it is, providing information about triggers and treatment, it can be a lengthy discussion that can add to the office visit time, according to Dr. Day.
Nevertheless, Dr. Day initiates discussions with her patients about rosacea and anything else she sees that she can treat.
“I make sure to point out the positives in their skin, but I also pay attention to areas where they could take better care to minimize risks of skin cancer and signs of aging and to optimize their skin health. I tell patients that I see what’s happening and these are the corrective steps I can take to help their skin look its best. I think it is important for patients to understand they have some control over rosacea,” says Dr. Day.
Trigger education is particularly important, according to Dr. Torok.
“The number one trigger for rosacea are environmental—heat and extreme cold. Emotions, including stress, are another big trigger. Exercising and lifestyle activities trigger it. And taking a lot of niacin in vitamins can aggravate rosacea,” Dr. Torok said. “So, you have to ask: What are you taking? What are you doing? What is your lifestyle? What is your environment?”
New rosacea treatments address the different components of the skin condition, including redness, the breakouts and ocular rosacea.
While lasers and light therapies remain the gold standard for treating the redness component of the skin condition, brimonidine topical gel (Mirvaso, Galderma) is the only drug that’s FDA approved to reduce the redness of rosacea.
“I have 14 different devices in my office. I can offer intense pulsed light or pulse dye laser to reduce the redness. But those are not covered by insurance and have to be repeated over time. Some people may have a tan or too much color and they aren’t candidates for the devices,” says Dr. Day.
Another drug, ivermectin (Soolantra, Galderma), is a new category of drug to treat rosacea, according to Dr. Day.
“We’ve had topical metronidazole in different concentrations and I like metronidazole topical, but this is 1% ivermectin cream, so it’s a brand new drug for the breakouts of rosacea,” Dr. Day says. “Other things that we’ve had and still use are Oracea (doxycycline, Galderma). I’ve been taking Oracea for a long time, and I put my patients on it because I believe it helps all the components of rosacea. Also I believe it helps control ocular rosacea, which I think is underdiagnosed and undertreated.”
And derms need to be aware….
One aspect of rosacea that might not be on dermatologists’ radar, according to Dr. Torok, is that rosacea can present as only a flush, which is the erythematotelangiectatic subtype. Treating these patients with topical metronidazole, topical ivermectin or an oral antibiotic doesn’t work as well because there are no papules or pustules to treat, Dr. Torok says, noting that “they don’t have the inflammatory component other than the flushing.”
The best approach with these patients, according to Dr. Torok, is to first explain what triggers their rosacea, including environmental factors and stress.
Lasers can eliminate the redness, offering a more permanent solution. Brimonidine controls the flushing but is temporary and must be reapplied, according to Dr. Torok.
Patients can learn more about rosacea at:
The National Rosacea Society’s website: http://www.rosacea.org/.
The American Academy of Dermatology’s web page for consumers with rosacea: https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/q—t/rosacea
And Galderma Laboratories and the National Rosacea Society have launched the Break Up with Your Makeup campaign, which offers survey findings and information about rosacea treatment at http://breakupwithmakeup.com.