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Phenotype Classification - How does it work?

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There are different approaches offered by the various 'authorities' on rosacea diagnosis into phenotypes. [1] However, they all agree that the phenotype classification is superior to the subtype classification (used since 2002) initially proposed by the NRS 'expert' panel. [2] The phenotype classification began in November 2016.

The general consensus is "at least one diagnostic or two major phenotypes are required in order to diagnose a patient with rosacea." [3]

{1} Diagnostic Cutaneous Signs (only one required)

The ROSCO panel list includes persistent centrofacial erythema associated with periodic intensification by potential trigger factors as a minimum diagnostic feature of rosacea and phymatous changes are individually diagnostic of rosacea. 

Fixed centrofacial erythema, papules and pustules, flushing or blushing, phymatous changes are included in the NRS panel diagnostic list. 

Dr. Tan with the ROSCO panel, as well as the NRS Panel, and Dr. Del Rosso with the AARS panel both concur that facial erythema is essential to a diagnosis of rosacea. [4]


{2} RRDi Phenotypes (two required)

(1) Flushing
(2) Persistent Erythema
(3) Telangiectasia
(4) Papulopustular
 (Papules/pustules Lesion Counts)
(5) Phymatous
(6) Ocular Manifestations

Variances in Phenotype Listings
The ROSCO panel has no numbering phenotype system but lists the above phenotypes. 

The NRS 'expert' committee's approach has no numbering system and divides four phenotypes with three secondary phenotypes. [5]

Galderma tweets four major phenotypes and four minor phenotypes. 

The AAD follows the NRS expert panel recommendations. 

The AARS has its own way of acknowledging the phenotype classification into six phenotypes: 

"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)" 

Medscape recognizes four major phenotypes and three secondary phenotypes following the NRS recommendations

End Notes

[1] ROSCOE PanelNRS Expert PanelGaldermaAADAARS • Medscape

[2] Phenotype Treatment is Superior

[3]  Clinical, Cosmetic and Investigational Dermatology February 2020

[4] Phenotype Classification Uses Signs and Symptoms Better

[5] The four phenotypes the NRS lists are Papules and Pustules, Flushing, Telangiectasia, and  Ocular manifestations. The secondary phenotypes are  Burning or stinging, Edema, and Dry Appearance. 
Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

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