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Phenotypes Updates

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The RRDi is the first non profit rosacea organization to endorse the new phenotype classification of rosacea in November 2016 after the ROSCO panel published its recommendation in the British Journal of Dermatology in October 2016. 

For a history on categorizing rosacea from subtypes to phenotypes click here

Scroll through the posts below to review any new updates on phenotype classification of rosacea, especially of medical authorities and rosacea organizations that are recognizing this superior classification of rosacea. 

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BJD

"A recent study in the British Journal of Dermatology makes a case for treating and managing rosacea based on the clinical presentation, or phenotype....The international ROSCO panel was able to reach a consensus on initial, combination, and maintenance therapy using a phenotype-based approach for treating skin features of rosacea. Ophthalmologists on the panel also agreed on an approach to managing ocular rosacea. Results suggest that physicians should select a combination of treatments for rosacea based on presenting features, overall disease activity, and the severity of the features."

Global Consensus on Rosacea Treatments by Phenotype, by Jennifer Newton, Clinical Trials and Research, Medical News Bulletin

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"The National Rosacea Society (NRS) announced today (11/8/17) that a new standard classification and pathophysiology of rosacea has been published in the Journal of the American Academy of Dermatology....While the original classification system designated the most common groupings of primary and secondary features as subtypes, the committee noted that because rosacea appears to encompass a consistent inflammatory continuum, it now seems appropriate to focus on the individual characteristics, called phenotypes, that may result from this disease process. Observing the respective phenotypes in clinical practice will also encourage consideration of the full range of potential signs and symptoms that may occur in any individual patient, and assessment of severity and the selection of treatment may be more precisely tailored to each individual....According to the new system, the presence of one of two phenotypes – persistent redness of the facial skin or, less commonly, phymatous changes where the facial skin thickens – is considered diagnostic of rosacea....The committee noted that, as with the original classification of rosacea, the updated standard system is considered provisional and may require modification as the causes and pathogenesis of rosacea become clearer, and its relevance and applicability are tested by investigators and clinicians."

NRS Introduces New Standard Classification and Pathophysiology of Rosacea, Cision, PRWeb

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"While the original classification system designated the most common groupings of primary and secondary features as subtypes, the committee noted that because rosacea appears to encompass a consistent inflammatory continuum, it now seems appropriate to focus on the individual characteristics, called phenotypes, that may result from this disease process. Observing the respective phenotypes in clinical practice will also encourage consideration of the full range of potential signs and symptoms that may occur in any individual patient, and assessment of severity and the selection of treatment may be more precisely tailored to each individual."

NRS Introduces New Standard Classification and Pathophysiology of Rosacea
By Brad Bennett , in PR PR Health on November 8, 2017, The Daily Telescope

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The AARS in June 2019 has now officially at the very least, started to recognize the phenotype classification of rosacea with its published paper stating, "The classification of rosacea in both clinical practice and research previously utilized subtype designations as described by Wilkin et al in 2002 from the National Rosacea Society. However, the current recommendations from multiple organizations with interest in the diagnosis and treatment of rosacea suggest characterizing patients with rosacea by individual clinical manifestations and symptoms that are present at the time of examination. As rosacea is a phenotypically heterogeneous disease, this might include central facial erythema without papulopustular (PP) lesions; central facial erythema with PP lesions; the presence of phymatous changes, ocular signs, and symptoms; extensive presence of facial telangiectasias; and marked, persistent, nontransient facial erythema that remains between flares of rosacea and might exhibit severe intermittent flares of acute vasodilation (flushing of rosacea). Manifestations at various time points in a single patient might differ depending on whether the rosacea is flared or quiescent, the age of the patient, the duration of his or her disease, the frequency and magnitude of rosacea flares, and associated symptomatology."

J Clin Aesthet Dermatol. 2019 Jun; 12(6): 17–24.
Update on the Management of Rosacea from the American Acne & Rosacea Society (AARS)
James Q. Del Rosso, DO, FAOCD, FAAD, Emil Tanghetti, MD, FAAD, Guy Webster, MD, PhD, FAAD, Linda Stein Gold, MD, FAAD, Diane Thiboutot, MD, FAAD, and Richard L. Gallo, MD, PhD, FAAD

While this isn't exactly endorsing the phenotype classification 'officially' and it is odd that the AARS paper on the management of rosacea has such a cursory reference to phenotypes since the ROSCO panel, RRDi, NRS, and Galderma have endorsed the phenotype classification of rosacea. But notice the 'phenotypically' list quoted above how it follows the phenotype classification: 

"central facial erythema without papulopustular (PP) lesions;" (Phenotype 2)

"central facial erythema with PP lesions;" (Phenotype 4)

"the presence of phymatous changes," (Phenotype 5)

"ocular signs, and symptoms;" (Phenotype 6)

"extensive presence of facial telangiectasias;" (Phenotype 3)

"and marked, persistent, nontransient facial erythema that remains between flares of rosacea and might exhibit severe intermittent flares of acute vasodilation (flushing of rosacea)" (Phenotype 1)

The AARS is recognizing the phenotypes in its own way. This is typical of how rosacea non profit medical organizations have to be different yet basically say the same thing, just list in a different order with lots of words. You can probably see that the six phenotypes are an easier way to refer to these 'manifestations' especially in writing down a diagnosis on a patient's chart. 

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Medscape has recognized the phenotype classification of rosacea with the following: 

In 2016, the global rosacea consensus panel recommended a new classification: at least one diagnostic or two major phenotypes are required for the diagnosis of rosacea.
Diagnostic phenotypes
A diagnosis of rosacea may be considered in the presence of one of the following diagnostic cutaneous signs:
Fixed centrofacial erythema in a characteristic pattern that may periodically intensify
Phymatous changes: Patulous follicles, skin thickening or fibrosis, glandular hyperplasia, and bulbous appearance of the nose (rhinophyma is the most common form)
Major phenotypes
Without a diagnostic phenotype, the presence of two or more of the following major features may be considered diagnostic:
Papules and pustules
Flushing: Frequent and typically prolonged
Telangiectasia: Predominantly centrofacial in phenotypes I-IV, rarely seen in darker phenotypes
Ocular manifestations
Secondary phenotypes
The following secondary signs and symptoms may appear with one or more diagnostic or major phenotypes:
Burning and stinging
Edema: Facial edema
Dry appearance: Central facial skin may be rough and scaly
Ocular rosacea
Major features of ocular rosacea are as follows:
Lid margin telangiectasia
Interpalpebral conjunctival injection
Spade-shaped infiltrates in the cornea
Scleritis and sclerokeratitis
Secondary features of ocular rosacea are as follows:
"Honey crust" and collarette accumulation at the base of the lashes
Irregularity of the lid margin
Evaporative tear dysfunction (rapid tear breakup time)
Although ocular manifestations may precede the cutaneous signs by years, in many cases they develop concurrently with dermatologic manifestations.
The diagnosis of rosacea is made clinically, based on the 2016 global rosacea consensus that one diagnostic or two major phenotypes are required for the diagnosis of rosacea. A skin biopsy is sometimes performed to exclude other cutaneous diseases, such as lupus or sarcoidosis.

Agnieszka Kupiec Banasikowska, MD Consulting Staff, Georgetown Dermatology, PLLC
Medscape > Drugs & Diseases > Dermatology > Rosacea

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