How to diagnose Rosacea has radically changed (Phenotypes are now in)

Written by on November 22, 2016 in in the news, Rosacea Fact Sheets, Rosacea Symptoms with 6 Comments

A recent meeting of dermatologists and ophthalmologists has made a significant change to what constitutes a diagnosis of rosacea. This change will likely reframe many discussions on how practitioners come to make a diagnosis of rosacea. Also, given the internet age and easy access for patients to disease information, these changes will also affect how sufferers of facial skin symptoms find a name to describe their condition.

Rosacea Diagnosis Previously

Since 2002 the `official’ criteria to diagnose rosacea was a schedule sponsored by the NRS. You needed to have at least one of the following primary features to achieve a diagnosis of rosacea;

  • flushing,
  • non-transient erythema,
  • papules/pustules, or
  • telangiectasia

The reason for a change to this list of symptoms that define rosacea has been described as;

“While the rosacea management landscape has advanced, the current subtype-based view of the disease can hinder progress by limiting the way we consider treatment options.

and the possible benefits of a new diagnosis regime are ;

These new ROSCO recommendations should help to make a positive impact on future treatment development and ultimately help improve the lives of people with rosacea through a symptom-led approach

New Rosacea Diagnosis Regime

The global panel responsible for this declaration have reached consensus on what they consider should constitute a diagnosis of rosacea – any of the 2 following  features;

  • persistent, centrofacial erythema associated with periodic intensification, or
  • phymatous changes

So the recommendation of the panel was that a rosacea diagnosis should be considered when you have

  • a) centralised redness of the face that varies with intensity, but persists and/or
  • b) swelling of sebaceous glands as seen as phymatous changes

What is Phymatous Rosacea?

The new ROSCO remmendations suggest that `phymatous changes’ are on their own an indication of rosacea. So what are phymatous changes ? The term may be unfamiliar but it refers to the  swelling of sebaceous glands that leads to the sorts of overgrowth of facial tissue seen in rhinophyma.

So what has changed?

The difference between the 2 schedules is that now flushing, papules/pustules and telangiectasia on their own are not enough to be diagnosed with rosacea. A red face or or sebaceous / phymatous swelling is now key.

It isn’t clear to me how this altered definition of a diagnosis of rosacea will naturally lead to improvements due to now being part of a `symptom-lead’ approach, but I’m willing to see how doctors and patients see things in a new light now.

Rosacea Diagnostic Schedule

Diagnostic Features

(>= 75% consensus)
Major Features

(>= 50% agreement)
Secondary Features

(>= 75% consensus)
Persistent centrofacial erythema associated with periodic intensification by potential trigger factorsFlushing/ transient erythemaBurning sensation of the skin
Phymatous changesInflammatory papules and pustulesStinging sensation of the skin
Ocular manifestations - lid margin telangiectasia, blepharitis, keratitis/ conjuctivitis/ sclerokeratitisDry sensation of the skin

Press Release

The publication of this new diagnosis guide had been accompanied by a press release highlighting the

Global ROSacea COnsensus (ROSCO) expert panel calls for new approach to diagnosis and treatment of rosacea to improve outcomes for patients

  • Expert insights reveal need for shift in current rosacea management to a symptom-led approach and provide new guidance as a catalyst for change
  • Consensus panel experts share vision for rosacea patients to be treated according to their specific signs and symptoms (known as phenotypes), leading to individualised rosacea therapy
  • ROSCO rosacea algorithm sets out new approach to appropriate individualised treatment

LONDON–(BUSINESS WIRE)–International recommendations that aim to transition current rosacea classification, diagnosis and treatment from subtypes to a phenotype approach, based on signs and symptoms of rosacea, have been published in the British Journal of Dermatology.1,2 These recommendations address a need to improve outcomes for patients with rosacea through better identification and personalised treatment of signs and symptoms that bother each patient most.

Article Abstract

Updating the diagnosis, classification and assessment of rosacea: Recommendations
from the global ROSacea COnsensus (ROSCO) panel

J. Tan, L. Almeida, A. Bewley, B. Cribier, N. Dlova, R. Gallo, G. Kautz, M. Mannis, H.
Oon, M. Rajagopalan, M. Steinhoff, D. Thiboutot, P. Troielli, G. Webster, Y. Wu,
E. van Zuuren, M. Schaller

Br J Dermatol. 2016 Oct 8

Rosacea is currently diagnosed by consensus-defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype-led approach may facilitate patient-centred management.

OBJECTIVES: To advance clinical practice by obtaining international consensus to establish a phenotype-led rosacea diagnosis and classification scheme with global representation.

METHODS: Seventeen dermatologists and three ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and severity evaluation. All voting was electronic and blinded.

RESULTS: Consensus was achieved for transitioning to a phenotype-based approach to rosacea diagnosis and classification. Two features were independently considered diagnostic for rosacea: persistent, centrofacial erythema associated with periodic intensification; and phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were not considered individually diagnostic. The panel reached agreement on dimensions for phenotype severity measures and established the importance of assessing the patient burden of rosacea.

CONCLUSIONS: The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype.

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About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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6 Reader Comments

  1. Hi David, Really appreciate your concise explanation of the paper. Another more recent paper that supplements the first paper published in October is the latest on in November in the BJD:
    Br J Dermatol. 2016 Nov 12. doi: 10.1111/bjd.15173.
    Rosacea treatment update: Recommendations from the global ROSacea COnsensus (ROSCO) panel.
    Schaller M, Almeida L, Bewley A, Cribier B, Dlova N, Kautz G, Mannis M, Oon H, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren E, Tan J.

    I too haven’t wrapped my head around all this but I see it as a benefit to rosacea sufferers since this panel is trying to improve diagnosing rosacea. Dr Schaller explained to me that the phenotypes are the following:

    Persistent erythema
    Papules/pustules Lesion counts
    Ocular manifestations

    One of the advantages of the RRDi is that we have contact info with the RRDi MAC members. Dr. Schaller is on the ROSCO panel as well.

  2. John says:

    If you only have transient flushing and in between no redness (no persistent erythema), the new diagnostic guidelines do not class you as having Rosacea. Is that correct david??

    Also the ‘Rosacea diagnostic schedule’ table above says the major features (>50%) of phymatous changes are inflammatory papules and pustules.
    Now this really confuses me, as past guidelines have stated severe flushing as the main symptom of phyamous changes.
    What I take from that table is people with just flushing and redness are unlikely to have phymatous changes compare to people with pastules and pustules, is that correct?

    • Yes this schedule is saying that there needs to be some residual/persistent erythema for an official diagnosis of rosacea.

      The “>50%” mentioned there is meaning that more than half of the experts agreed that a major feature of diagnosis should be the 4 symptoms in that column – it has nothing to do with prevalence of symptoms, just consensus on how to diagnose rosacea.

      So that is just a contrast to >75% who agreed that “Persistent centrofacial erythema associated with periodic intensification by potential trigger factors” and “Phymatous changes” be the key criteria for consideration.

  3. Leon Bateman says:

    I am a new sufferer of rosacea and I’m very much struggling with the whole thing. I have gone from having the odd blister to being virtually 50% covered in a thick crust on my forehead, cheeks and nose. My doctor initially gave me doxicycline, and betnovate to get it under control with the intention of coming off the betnovate to a milder steroid cream and then to stop it completely. Unfortunately, every time I stop the steroid cream, my face erupts into this thick, crusty, painful, itchy, burning layer. My doctor has advised staying off the steroid cream regardless of the severity of the appearance. My worry is that if I leave it, I may progress onto phymatous rosacea which looks Alot like what I have now. I’m so worried that this may continue to worsen but my doctor has assured me the initial rebound reaction to the steroid will subside. The way I look right now, I’m seriously doubting it. Any advice would be gratefully received.

  4. I’m considering putting Vicks Vaporub on my face to at least cool the burning sensation I experience after so many hours. Has anyone tried that?

  5. Mark says:

    I found this page after searching for the diagnostic criteria for Rosacea.
    According to my Dermatologist I do not have Rosacea because, in his words,
    Permanent redness (aka persistent erythema) as well as flushing are the required features of type 1 Rosacea.

    I have really severe flushing only on my nose, happens every day , without fail. I also get stinging during the flush and nose swelling that then goes away after a few hours.
    A few hours after flushing my nose returns to normal white color.
    I wonder what category this falls in to. Is this the key difference between type 1 and Neurogenic Rosacea????, not having permanent redness, just massive flushing bouts.
    I think people who have daily facial flushing without permanent redness are left helpless by dermatologists.

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