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Diagnosing Rosacea

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Obtaining a diagnosis for rosacea may seem to be fairly straight forward but considering that there are reports of misdiagnosis it would be good for rosaceans to be educated on this subject so that if one experiences a misdiagnosis it will not be a surprise and will understand better how a diagnosis is obtained. A recent survey by Galderma/NRS says that the results “highlight the low awareness and complicated diagnosis path for this common condition.”

First and foremost is that diagnosis is the sole prerogative legally and ethically of a physician. So the information in this editorial is not meant to substitute or replace a physician’s diagnosis but is simply for a rosacea sufferer to understand the subject of a rosacea diagnosis for educational purposes. Knowing what is involved in obtaining a diagnosis of rosacea is quite helpful in basic Rosacea 101 which is a subject I am quite familiar with and wish to pass on this information freely to those who wish to increase their rosacea knowledge.

There is no histological, serological or other diagnostic tests for rosacea and a diagnosis is simply arrived at by a patient history and physical examination. [1] Some clinical tests may be done, i.e., blood tests and skin biopsies, to rule out rosacea mimics. The NRS Classification System (2002) into subtypes and one variant is the first clearly defined proposal to identify and classify rosacea. [2] It is of interest to note that this classification system is based on morphology rather than causality. Understanding this classification and variant system is the beginning of a nosology for this disease, however, it has been controversial from the beginning. Dermatologists who are using this classification system are somewhat able to better diagnose rosacea. It may be that your physician is familiar with this old classification system but some physicians are not keeping up with this latest system and may be relying on past knowledge on this subject.

Phenotype Classification of Rosacea
The new direction of classifying rosacea is a phenotype based treatment

Physical Examination, History & Tests

Frank Powell, MD, who served on the NRS ‘expert committee‘ that classified rosacea says in his book, “There is no laboratory test or investigation that will confirm the diagnosis of PPR. Specific investigations may be required to rule out similar appearing conditions (many of which will be identified by listening carefully to the patient’s medical history and examining the skin lesions). These include skin swabs for bacterial culture, skin scrapings for the presence of demodex mites, scrapings for fungal KOH and fungal culture, skin biopsy for histologic examination, (and rarely culture) skin surface biopsy for demodex mite quantification, patch tests, photopatch tests, and very rarely systemic workup with appropriate blood tests and radiological examinations.” [3]

To rule out demodectic rosacea “Potassium hydroxide examination, standardized skin surface biopsy, skin biopsy, or a combination of these are essential to establish the diagnosis.” [4]

In some cases to rule out rosacea mimics such as lupus and scleroderma it is suggested that obtaining an ANA blood test and other blood tests might be considered. [5] Another test you might consider having is the Autologous serum skin test (ASST) to rule out chronic uticaria.

One report says it is necessary to perform individual bacterial cultures and antibiograms on rosacea patients. [6]

Another report suggests testing mucin to differentiate lupus. [7]

Another test to consider is to rule out Grave’s disease with blood tests. According to Ladonna, “…my husband took me to the dermatologist and she said it was Rosacea and couldnt be anything but….So he took me to many doctors, and finally a wonderful doctor took a shot in the dark blood test and discovered my problem. Later more involved tests and scans confirmed it. I was Hyperthyroid…specifically Graves Disease…”

So from the above tests it shows that a five minute visit to your dermatologist who simply diagnoses you with rosacea and doesn’t take any of the tests mentioned above to differentiate other rosacea mimics might mean you could receive a misdiagnosis. There is anecdotal evidence that many rosaceans report a quick diagnosis in five minutes or less.

Galderma has patented a diagnostic test for rosacea

Taking a Patient History and Biopsies

In Powell’s last chapter, [3] entitled, General Considerations, he suggests asking questions to the patient in taking a history, specifically:

(1) Asking about polycythemia?

(2) Whether the patient has been using a steroid cream?

(3) Any other medication such as niacin or antacids?

(4) Whether there has been any frequent flushing?

(5) Any complementary or alternative medicines, i.e., herbal products?

(6) Eye symptoms?

(7) Any family history of rosacea?

Biopsies to rule out demodectic rosacea is another important consideration. One report suggests a biopsy to rule out Morbus Morbihan.

If you physician neglects to ask any of the above questions you might simply bring the above questions to his attention in a respectful tone so that a proper diagnosis of your skin condition can be obtained. Not knowing the answers to the above questions may hinder a proper diagnosis.

Rosaceanet (ADD) has 15 questions to ask you and then recommends something to you if you would like more info on a diagnosis. [8] If you note the disclaimer it says, "This questionnaire does not provide medical advice. It should not be used to diagnose rosacea. Only a medical doctor such as a dermatologist can make this diagnosis. The purpose of this questionnaire is to help you seek medical care if you believe that you may have rosacea. A dermatologist can provide you with a diagnosis and proper treatment."

As more information on diagnosis is discovered that is pertinent to this article it will be updated.

Dermoscopy

Dermoscopy may prove useful according to this source:

"Dermoscopy, in addition to its well-documented value in evaluation of skin tumours, is continuously gaining appreciation also in the field of general dermatology." [9] "The dermoscopic hallmark of rosacea is represented by the presence of linear vessels characteristically arranged in a polygonal network (vascular polygons) {click for image}." [10]

End Notes

[1] National Rosacea Society, Answer to Question 5
http://www.rosacea.org/patients/faq.php#test

"There is no appropriate and reliable method of evaluating and monitoring severity in rosacea."
Nailfold capillaroscopy as a diagnostic and prognostic method in rosacea.
Fonseca GP, Brenner FM, Muller CD, Wojcik AL.
An Bras Dermatol. 2011 Feb;86(1):87-90.

[2] Classification of Rosacea
http://www.rosacea.org/class/classysystem.php

[3] Rosacea Diagnosis and Management by Frank Powell
with a Contribution by Jonathan Wilkin

[4] Demodicosis: a clinicopathological study.
Hsu CK, Hsu MM, Lee JY.
J Am Acad Dermatol. 2009 Mar;60(3):453-62

[5] Scroll to Alba’s Post #6 about ANA Blood Tests

[6] Necessary to perform individual bacterial cultures and antibiograms in rosaceans?

A new study on acne and rosacea patients concluded these findings:

CONCLUSIONS:
1. In the cases of acne vulgaris the majority of isolated bacteria from conjunctival sac included Streptococcus spp., Staphylococcus spp. and Enterobacteriaceae.
2. In the severe cases of rosacea the main bacteria found in conjunctival sac were S. aureus, S.pyogenes, P.aeruginosa, E. faecalis, A. baumanii, P. fluorescens.
3. Because of changeable drug-sensitivity of bacterial strains, it seems to be necessary to perform individual culture and antibiogram in every patient with inflammatory lesions, in particular in clinically severe and resistant to therapy cases of acne vulgaris and rosacea.
4. The higher frequency of the bacterial colonisations in the conjunctival sac in patients with acne vulgaris and rosacea can be a potential source of ocular infections in the cases of local and systemic disorders of protective mechanisms.
5. Estimation of bacterial flora and antibiotic sensitivity of bacteria isolated from conjunctival sac, the skin of the eyelids and skin lesions should be perform, especially when patients are prepared for eye surgery.

Source of the above information

[7] Mucin is not a rare finding in rosacea is the title of a research study done by A. Fernandez-Flores at the Service of Cellular Pathology, Clinica Ponferrada in Spain.

http://www.ncbi.nlm.nih.gov/pubmed/20191122?dopt=Abstract

http://www.clinicaponferrada.com/

Mucins are a family of high molecular weight, heavily glycosylated proteins (glycoconjugates) produced by epithelial tissues in most metazoans. They are
being investigated for their potential as diagnostic markers.

http://en.wikipedia.org/wiki/Mucin

The study concluded "that: 1. mucin is a common finding in granulomas of rosacea; 2. this mucin is probably not related to any progression to the mucinous variant of rhinophyma; 3. since discoid erythematosus lupus is a clinical differential of rosacea, it is important to be aware of the fact that
mucin is a common finding in the granulomas, in order not to misdiagnose both entities."

Here is another potential diagnostic marker to differentiate rosacea from lupus.

[8] Rosaceanet
American Academy of Dermatology
Could I Have Rosacea?

[9] J Eur Acad Dermatol Venereol. 2013 Mar 12. doi: 10.1111/jdv.12146. [Epub ahead of print]
Dermoscopic patterns of common facial inflammatory skin diseases.
Lallas A, Argenziano G, Apalla Z, Gourhant JY, Zaballos P, Di Lernia V, Moscarella E, Longo C, Zalaudek I.

[10] Dermatol Ther (Heidelb). 2016 Dec; 6(4): 471–507.
Published online 2016 Sep 9. doi:  10.1007/s13555-016-0141-6
PMCID: PMC5120630
Dermoscopy in General Dermatology: A Practical Overview
Enzo Errichetti, Giuseppe Stinco

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