New guidance on rosacea therapy according to phenotype

A practical algorithm for choosing the right treatment option has been developed by the ROSCO group for the 7 most common phenotypes of rosacea, as current management in clinical practice should be based on the features of the disease [1].

In his talk, Prof. Bernard Cribier (Strasbourg University Hospital, France) noted that the classification of rosacea according to stages is obsolete as there is considerable overlap of rosacea features between the traditionally used stages and subtypes. This is in line with the global 2019 ROSCO group’s update of their feature-based approach for classification and management decisions [2-4]. “With the new ROSCO approach, you just describe what you see and it is easier to pick a therapy according to the phenotype,” Prof. Cribier said.

Based on contemporary publications, the new treatment ROSCO recommendations revise the 2017 guidance particularly with regard to 3 points: (1) although there is insufficient evidence supporting the use of oral beta-blocker or topical alpha-adrenergic modulating drugs for flushing, they could be considered due to clinical experience; (2) for persistent centrofacial erythema, vascular lasers constitute a supplementary choice of therapy; and (3) due to the risk of depigmentation, application of vascular lasers like pulsed-dye lasers (PDL) and intense pulsed light (IPL) on darker skin should be considered by an experienced healthcare provider [5].

Prof. Martin Schaller (University of Tübingen, Germany) and his colleagues presented their practical algorithm for the treatment of rosacea according to 7 common phenotypes [5]. They consisted of A) the clinically inflamed phyma with persistent centrofacial erythema, B) the clinically inflamed phyma with papules and pustules plus persistent centrofacial erythema, C) persistent centrofacial erythema with papules and pustules, D) the clinically inflamed phyma, E) the clinically inflamed phyma with papules and pustules, F) the clinically non-inflamed phyma, and G) the persistent centrofacial erythema.

For all phenotypes, sunprotection and general skincare belong to the general advice to the patient (see Table). Apart from the clinically inflamed and non-inflamed phyma, all patients should also be encouraged to avoid triggers for rosacea. For patients suffering from rosacea of the A, B, D, or E phenotype, anti-inflammatory topical and/or oral treatments combined with or followed by physical modalities are recommended. For patients with features of type C, there are 2 parallel suggestions of treatment: either the use of topical alpha-adrenergic modulation agents and/or IPL or vascular laser or therapy with anti-inflammatory topicals and/or oral treatments. For rosacea in form of persistent centrofacial erythema, topical alpha-adrenergic modulation agents and/or IPL or vascular laser are endorsed. Whenever centrofacial erythema is present in a patient, IPL or vascular laser could be considered preceding topical use of alpha-adrenergic drugs. The use of oral antibiotics combined with topical agents may be justified in patients with extensive papules and pustules.

Table: 2019 ROSCO guidance for treatment of rosacea by a feature-driven approach [5]

1. 
   
   1. Cribier B. PLB01, EADV 2019, 9-13 Oct, Madrid, Spain.
   2. Scaller M, et al. Br J Dermatol. 2019 Aug 7. [Epub ahead of print]
   3. Gallo RL, et al. J Am Acad Dermatol. 2018;78:148-155.
   4. Van Zuuren EJ, et al. Br J Dermatol. 2019;181:65-79
   5. Schaller M, et al. P0028, EADV 2019, 9-13 Oct, Madrid, Spain.

 



Posted on 9 October 201912 March 2021