Rosacea is well recognized considered in the state of a chronic cutaneous disorder primarily of the convexities of the central stand over against (cheeks, chin, nose, and central front), often characterized by remissions and exacerbations. Based adhering present knowledge, it is considered a syndrome, or typology, encompassing variegated combinations of such cutaneous signs in the manner that flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and rhinophyma.1 In principally cases, some rather than all of these stigmata offer in any given patient.
Rosacea appears to be quite common, and in an epidemiologic study in Sweden its success was 10%.2 It has been ut~ frequently observed in patients with open skin, but has also been diagnosed in Asians and African Americans. Rosacea occurs in both men and women and, although it may occur at somewhat age, the onset typically begins at in ~ degree time after age 30.3
Despite its ostensible high incidence, the nosology of rosacea is not well established, and the mete “rosacea” has been applied to patients and research subjects with a diverse set of clinical tools and materials that may or may not be an integral part of this disturbance. In addition to the diversity of clinical manifestations, the etiology and pathogenesis of rosacea are unexplored, and there are no histologic or serologic markers.
Therefore, the National Rosacea Society assembled a committee to develop a standard classification system that can serve as a diagnostic instrument to scrutinize the manifestations and relationships of the independent subtypes and potential variants of rosacea. Standard criteria by reason of diagnosis and classification of patients are pure to perform research, analyze results and declare similar data from different sources, and may to a greater distance serve as a diagnostic reference in clinical customary course. The standard terminology will also facilitate clear communication among a broad rank of basic, clinical, and other researchers; practicing dermatologists, first care physicians, ophthalmologists and other specialists; soundness and insurance administrators; and patients and the inaccurate public.
The committee based the model classification system on present scientific scholarship and morphologic characteristics. This avoids assumptions attached pathogenesis and progression, and provides a skeleton that can be readily updated and expanded in the manner that new discoveries are made. As comprehension increases, it is hoped that the definition of rosacea may ultimately be based up~ causality, rather than on morphology alone.
The following temporary classification system describes the primary features of rosacea and defines 4 subtypes and 1 variant. Evolution from single subtype to another may or may not occur, and research to investigate this process may supply important insight into the pathogenesis of rosacea. Regardless of subtype, yet, each individual characteristic may progress from gentle to moderate to severe. Early diagnosis and management are therefore recommended.
DIAGNOSTIC CRITERIA Top
Rosacea typically affects the convexities of the central face. The presence of one or besides of the following signs with a central external aspect distribution is indicative of rosacea. These signs are commonly soon past, and each may occur independently. Many patients may at hand with more than one of these diagnostic features.
Flushing (transient erythema). A relation of frequent blushing or flushing is frequent. Nontransient erythema. Persistent redness of the facial skin is the most common sign of rosacea. Papules and pustules. Dome-shaped red papules with or without accompanying pustules, often in crops, are representative. Nodules may also occur. Although patients through concomitant acne may exhibit comedones, comedones should be considered part of an acne action unrelated to rosacea.
Telangiectasia. Telangiectases are common but not necessary for a rosacea diagnosis.
The following signs and symptoms ~times appear with one or more of the primary features of rosacea, but in some patients can occur independently.
Burning or painful. Burning or stinging sensations with or destitute of scaling or dermatitis may occur, especially without interrupti~ malar skin.4 Plaque. Elevated red plaques in the absence of epidermal changes in the surrounding hide may occur. Dry appearance. Central facial skin may exist rough and scaling so as to resemble dry skin and suggest an eczematous dermatitis, and may repeatedly include the coexistence of seborrheic dermatitis. This “dryness” may be associated with burning or stinging sensations, and may be caused by irritation rather than the illness process. Edema. Edema may accompany or follow prolonged facial erythema or flushing. Sometimes easy edema may last for days or be aggravated by inflammatory changes. Solid facial edema (persisting intemperate, nonpitting edema) can occur with rosacea, usually at the same time that a sequel of the papulopustular representative, and also independently of redness, papules and pustules, or phymatous changes. Ocular manifestations. Ocular manifestations are usual, and range from symptoms of powerful or itching to signs of conjunctival hyperemia and cover inflammation. Styes, chalazia, and corneal mischief may occur in many patients with rosacea in addition to cutaneous stigmata. The niceness of ocular manifestations may not have ~ing proportional to those of the pelt. Peripheral location. Rosacea has been reported to occur in other locations,5 ~-end the frequency and occurrence of this are malicious-defined. Rosacea in peripheral locations may or may not have existence accompanied by facial manifestations.
Phymatous changes. These can include patulous follicles, skin thickening or fibrosis, and a like a bulb appearance. Rhinophyma is the most undistinguished form, but other phymas may occur (Table I).
Table I. Guidelines in opposition to the diagnosis of rosacea
Presence of unit or more of the following main features:
Flushing (transient erythema)
Papules and pustules
May hold one or more of the following proxy features:
Burning or painful
The main and secondary rosacea features described aloft often occur together. The most stale patterns or groupings of signs are temporarily designated as specific subtypes of rosacea and are described in the present state (Table II). Each subtype includes the fewest signs adequate to make a diagnosis of the subtype (nevertheless not necessarily limited to these), and patients may have characteristics of more than one rosacea subtype at the same time.
Subtype 1: Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea is principally characterized by flushing and persistent central facial erythema. The color of telangiectases is common but not diffusible for a diagnosis of this subtype. Central facial edema, painful and burning sensations, and roughness or scaling may moreover be reported. A history of flushing alone is trite among patients presenting with erythematotelangiectatic rosacea.
Subtype 2: Papulopustular rosacea
Papulopustular rosacea is characterized through persistent central facial erythema with soon passing papules or pustules or both in a central facial apportionment. However, papules and pustules also may occur periorificially (that is, they may occur in the perioral, perinasal, or periocular areas). The papulopustular subtype resembles acne vulgaris, with the ~ion of that comedones are absent. Rosacea and acne may occur concomitantly, and of the like kind patients may have comedones as well for example the papules and pustules of rosacea. Burning and acute sensations may be reported by patients by papulopustular rosacea.
This subtype has repeatedly been seen after or in connection with subtype 1, including the demeanor of telangiectases. The telangiectases may subsist obscured by persistent erythema, papules, or pustules, and look after to become more visible after prosperous treatment of these masking components.
Subtype 3: Phymatous rosacea
Phymatous rosacea includes thickening skin, irregular surface nodularities, and enlargement. Rhinophyma is the greatest in quantity common presentation, but phymatous rosacea may occur in other locations, including the chin, face, cheeks, and ears. Patients with this subtype besides may have patulous, expressive follicles in the phymatous kitchen-yard, and telangiectases may be present.
This subtype has not rarely been observed after or in conjunction with subtypes 1 or 2, including persisting erythema, telangiectases, papules, and pustules. In the instance of rhinophyma, these additional stigmata may exist especially pronounced in the nasal circuit.
Subtype 4: Ocular rosacea
The diagnosis of ocular rosacea should have existence considered when a patient‘s eyes esteem one or more of the following signs and symptoms: aqueous or bloodshot appearance (interpalpebral conjunctival hyperemia), foreign body sensation, burning or stinging, dryness, uneasy hankering, light sensitivity, blurred vision, telangiectases of the conjunctiva and top margin, or lid and periocular erythema. Blepharitis, conjunctivitis, and abnormity of the eyelid margins also may occur.6 Meibomian gland dysfunction presenting because chalazion or chronic staphylococcal infection like manifested by hordeolum (stye) are public signs of rosacea-related ocular indisposition. Some patients may have decreased visual acuity caused by corneal complications (punctate keratitis, corneal infiltrates/ulcers, or marginal keratitis).7 Treatment of cutaneous rosacea alone may have ~ing inadequate in terms of lessening the hazard of vision loss resulting from ocular rosacea, and each ophthalmologic approach may be needed.8
Ocular rosacea is greatest part frequently diagnosed when cutaneous signs and symptoms of rosacea are too present. However, skin signs and symptoms are not prerequisite to the diagnosis, and limited studies indicate that ocular signs and symptoms may occur before cutaneous manifestations in up to 20% of patients by ocular rosacea. Approximately half of these patients actual trial skin lesions first, and a pupilage have both manifestations simultaneously.9
Table II. Subtypes and variants of rosacea and their characteristics
Erythematotelangiectatic Flushing and tenacious central facial erythema with or destitute of telangiectasia.
Papulopustular Persistent central facial erythema through transient, central facial papules or pustules or the couple.
Phymatous Thickening skin, devious surface nodularities and enlargement May occur up~ the body the nose, chin, forehead, cheeks, or ears.
Ocular Foreign visible form sensation in the eye, burning or stinging, dryness, itching, ocular photosensitivity, blurred illusion, telangiectasia of the sclera or other quarters of the eye, or periorbital edema.
Granulomatous Noninflammatory; unsusceptible; brown, yellow, or red cutaneous papules; or nodules of regular size.
Variants of rosacea, that do not represent morphologic patterns or combinations for example seen in rosacea subtypes, may occur. To age, the committee has recognized one like variant.
Granulomatous rosacea is characterized ~ the agency of hard, yellow, brown, or red cutaneous papules or nodules that may have ~ing severe and lead to scarring. These lesions guard to be less inflammatory than papules and pustules and remain upon relatively normal-appearing skin. They have power to vary in size among patients end are monomorphic in each individual contented, and typically appear on the cheeks and periorificial areas. Granulomatous rosacea may occur in locations other than those in that the phymas are observed. The demeanor of other rosacea signs is not needed with regard to a diagnosis of the granulomatous rosacea variant.
The committee conspicuous that certain disorders may have been too early identified as associated with rosacea or in the same manner with a variant of rosacea, and in the place of clarity should be recognized at this time as separate entities. There is insufficient groundwork at present to include the following terms as types of rosacea.
Popularly known being of the kind which pyoderma faciale, the grouping of this jumble as a type of rosacea is too forward. It is characterized by the quick appearance of papules, pustules, and nodules, beside with fluctuating and draining sinuses that may subsist interconnecting. The condition appears primarily in women in their 20s, and severe redness and edema also may exist prominent.
Steroid-induced acneiform eruption
Steroid-induced acneiform exanthema is not a variant of rosacea and can occur as an inflammatory response in at all patient during or after chronic corticosteroid conversion to an act. The same inflammatory response may in like manner, of course, occur in patients by rosacea.
Although rosacea papules may occur in the perioral area, as illustrious earlier, perioral dermatitis without rosacea symptoms cannot have ~ing classified as a variant of rosacea. Perioral dermatitis is characterized by such stigmata as microvesicles, scaling, and peeling.
This investigational agent is intended to set the field for a better understanding of rosacea and its subtypes among researchers and practitioners by fostering despatch and facilitating the development of a examination-based classification system. As a provisional standard classification system, it is agreeable to require modification in the yet to be as the pathogenesis and subtypes of rosacea change to clearer, and as its relevance and applicability are assayed by investigators and clinicians. The committee welcomes reports without ceasing the usefulness and limitations of these criteria.
The Committee thanks the following individuals who reviewed and contributed to this document: Dr Joel Bamford, Department of Dermatology, St. Mary’s/Duluth Clinic; Dr Mats Berg, Department of Dermatology, Mälar Hospital, Eskilstuna, Sweden; Dr Albert Kligman, Department of Dermatology, University of Pennsylvania; Dr Mark Mannis, Department of Ophthalmology, University of California-Davis; Dr Ronald Marks, Department of Dermatology, University of Wales Medical Center, Cardiff, Wales; Drs Gerd Plewig and Claudia Borelli, Department of Dermatology, Ludwig-Maximilians University, Munich, Germany; Dr Alfredo Rebora, Department of Dermatology, University of Genoa, Italy; Dr Diane Thiboutot, Department of Dermatology, Pennsylvania State University; and Dr Guy Webster, Department of Dermatology, Thomas Jefferson University. The last document does not necessarily reflect the views of a single one single individual, and not all comments were incorporated.
In addition, Vitamin B12 deficiency can potentially ~ership to this disorder.