MIAMI BEACH — Although considered rare in skin of color, rosacea may actually be unrecognized or misdiagnosed in this population, according to a presentation at a seminar sponsored by the Skin Disease Education Foundation.
Rosacea can occur in all skin types. In particular, a combination of three racial phenotypes—African, Native American, and white—are common to most African Americans. “So … rosacea should not be considered rare in this population,” said Valerie D. Callender, M.D., of Howard University, Washington.
Rosacea is likely the same in patients with lighter and darker skin types in terms of its pathophysiology, but there are clinical differences. Flushing episodes are probably less common, and both erythema and telangiectasias are more difficult to appreciate in darker skin.
There may be less actinic damage in darker skin, but additional research is needed for confirmation. Early or mild cases are undiagnosed and underreported, Dr. Callender noted in her presentation.
“Clinical signs are less apparent—we need to look for erythema in patients with ethnic skin to treat rosacea early,” she said.
Rosacea is easier to diagnose in the lightest skin types (Fitzpatrick skin types I and II). Even individuals with lighter skin do not always have the major components of rosacea simultaneously: inflammatory effects, sebaceous effects, ocular effects, and vascular effects. Because patients with skin of color make up an estimated 33% of the U.S. population, a figure that is expected to grow to 47% by the year 2059, physicians are more likely to encounter rosacea in the darkest skin types (Fitzpatrick skin types IV through VI).
The National Rosacea Society developed a classification system for the condition (J. Am. Acad. Dermatol. 2002;46:584–7). More studies are needed to determine the true incidence of rosacea in darker skin types, said Dr. Callender, who is in private practice in Mitchellville, Md.
Treatment options for rosacea in skin of color include topical and oral agents, although a combination approach is best, Dr. Callender said. “Topical is definitely first line, but most of us use oral antibiotics for some patients.”
Recommended topical agents are sulfacetamide-sulfur, clindamycin, erythromycin, metronidazole, azelaic acid, and retinoids.
Recommended oral antibiotics include tetracycline, minocycline, and doxycycline, as well as submicrobial doses of doxycycline. Submicrobial use of doxycycline is off label, pending Food and Drug Administration approval.
Lasers can be used to treat rhinophyma and light sources to treat telangiectasias. Dr. Callender suggested sunscreens or sunblocks with an SPF of 15 or higher. She also recommended gentle skin care regimens and camouflaging makeup for these patients.
In addition, the use of a 4% hydroquinone combination product to treat postinflammatory hyperpigmentation that can develop from inflammatory lesions is “a major difference in treatment for skin of color patients.”
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Rosacea can occur in all skin types, such as in this 36-year-old African American woman. Multiple erythematous papules, pustules, and post- inflammatory hyperpigmented macules can be seen on her face. Courtesy Dr. Valerie D. Callender