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Rosacea‐like Demodicosis Should Disappear?


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image courtesy of Wikimedia Commons

An article recommends that ‘rosacea‐like demodicosis’, the disease term, should be not used at all, and the rosacea subtype II, Papulopustular (PPR), should be ‘reconsidered and simplified to include all patients with central face papulopustules–with or without persistent erythema’. This article, authored by F.M.N. Forton and V. De Maertelaer, published in the Journal of the European Academy of Dermatology and Venereology in February 2018, was several months after the NRS endorsed the phenotype classification in October 2017* and does indeed mention the ‘global ROSacea COnsensus (ROSCO) panel [that] recently suggested a more phenotype‐based approach’ [1] which the RRDi endorsed in November 2016. The RRDi is the only non profit for rosacea organization that recognizes demodectic rosacea as a rosacea variant in 2016. The NRS endorsed the new phenotype classification a year later. [2]

The article recommends two phenotypes, one for PPR and another 'rosacea‐like demodicosis.' 

Below are some of the highlights of this paper that confirms demodectic rosacea as a valid concern. 

“Our findings therefore demonstrate that a disease usually considered as not being caused by Demodex (PPR) has similar (and perhaps even slightly higher) Dds than a disease in which the role of the mite is accepted (rosacea with papulopustules without persistent erythema). It is difficult to understand how the presence of mites at similar density in these two clinically similar diseases can be considered to have a causative role in one condition, but to be only an epiphenomenon in the other. A more probable hypothesis is that the numerous mites are responsible for both conditions and that these two ‘entities’ should therefore be considered as two phenotypes of a single disease.”

“All our observations therefore highlight the nosological confusion that persists between PPR and rosacea‐like demodicosis and the need to update the consensus concerning the definition and classification of rosacea. Moreover, they suggest that PPR and rosacea‐like demodicosis may be phenotypes of the same disease.”

“In conclusion, while our observations do not prove a causative role of Demodex in rosacea, they nevertheless support the idea that PPR and rosacea‐like demodicosis should no longer be considered as two separate entities, but rather as two phenotypes of the same disease. As such, the definition of rosacea subtype II (PPR) should be reconsidered and simplified to include all patients with central face papulopustules–with or without persistent erythema –and thus also patients with ‘rosacea‐like demodicosis’, which is a term that should therefore disappear.”

The RRDi recognizes and recommends that PPR be considered Phenotype 4 and that 'rosacea‐like demodicosis'  be classified as Demodectic Rosacea and be considered a rosacea variant. This will allow clinicians to diagnose Phenotype 4 and Demodectic Rosacea in the same individual if the diagnosis warrants or separate if treatment for demodex is unresponsive (or little evidence of demodex) allowing for a diagnosis of just Phenotype 4. 

Journal of the European Academy of Dermatology and Venereology
Papulopustular rosacea and rosacea‐like demodicosis: two phenotypes of the same disease?
F.M.N. Forton and V. De Maertelaer

*An article published in the Journal of the American Academy of Dermatology published in January 2018 [Epub 2017 Oct 28]
Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

End Notes

[1] The ROSCO panel published its recommendation for a phenotype classification of rosacea in October 2016 in the British Journal of Dermatology
ROSCO Panel Recommends New Approach on Rosacea Diagnosis by Phenotype

[2] Phenotype Updates

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"Discoid lupus erythematosus (DLE) is a chronic inflammatory erythematous skin disease that can be triggered by several factors. Rosacea is another skin disease that causes facial redness and tenderness. Demodex mites have been reported in rosacea and DLE patients commonly in the literature. These two diseases can be seen concomitant, mimic each other clinically and share common possible etiologic factors."

Dermatol Ther. 2020 Apr 10;:e13394
Demodex positive discoid lupus erythematosus: Is it a separate entity or an overlap syndrome?
Dursun R, Durmaz K, Oltulu P, Ataseven A

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