Abstract
Background Data on the clinical presentation of rosacea among darker-skinned ethnic groups is scarce. This article presents the clinical spectrum of rosacea in Saudi female patients with differences highlighted according to skin types.
Methods Female patients diagnosed with rosacea at the dermatology clinic in King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia, between February 2010 and May 2011 were studied prospectively. Data collected included demographics, duration of the disease, personal history of any atopic disorder, aggravating factors, cutaneous and ocular symptoms, the presence of migraine, Helicobacter pylori infection, skin phototypes, and the clinical types and severity of rosacea.
Results Fifty patients consented to join the study: 20 (40%) were patients with skin type 4, 9 (18%) had skin type 5, and 21 (42%) had skin type 6. The cheeks, glabella, and chin were involved in 26 (52%) patients. Extrafacial lesions affecting chest, back, and ears were identified in 7 patients (14%). Severe erythematotelangiectatic rosacea was diagnosed in 21 patients (42%): skin type 4 comprised 50%, higher than the incidences for skin type 5 (22%) and skin type 6 (42.9%). The severe papulopustular subtype of rosacea was noted in 7 patients (14.0%), affecting 20% with skin type 4 and 14% with skin type 6. Severity of the erythematotelangiectatic or papulopustular subtypes of rosacea was not significantly associated with skin type (P=0.5691 and P=0.7740, respectively).
Conclusion This study addresses the growing interest in skin diseases in dark-skinned individuals. Rosacea is one of the skin disorders that had always been described for fair-skinned populations, but our results indicate that darker-skinned individuals also can be affected by rosacea and the clinical presentation is similar to that seen in patients with fair skin.
INTRODUCTION
Rosacea was once thought to be a disease of northern European origin, but this view is now being disputed because individuals of any racial/ethnic group have been shown to be afflicted.1,2 The true incidence of rosacea in people with dark skin has yet to be identified. Some reports assert that approximately 4% of rosacea patients are of African, Latino, or Asian descents.3-5 Recently, Al-Dabagh et al analyzed the 1993-2010 data from the National Ambulatory Medical Care Survey (NAMCS) in the United States for visits associated with the diagnosis of rosacea in different racial and ethnic groups.6 The data indicated 980 visits for rosacea per 100,000 whites in 2000 compared to 130/100,000 for blacks, 430/100,000 for Asians and Pacific Islanders, and 370/100,000 for Hispanics and Latinos. The prevalence of rosacea visits did not change over time. Fewer rosacea visits may denote that patients with darker-colored skin may not be bothered by subtle changes in their skin, leading to fewer physician visits, or they may not be diagnosed with rosacea even when they have symptoms suggesting it.6
Arabs are part of the Caucasoid race that includes some or all of the population of Europe, North Africa, the Horn of Africa, Western Asia (including the Middle East), and South and Central Asia. The report of Khaled et al from Tunisia, North Africa, of 224 cases of rosacea and a hospital prevalence of 0.2% in a population mostly comprised of darker skin types establishes rosacea as a frequent dermatosis.7 This study describes the clinical features of rosacea in dark-skinned people and highlights the peculiarities of the disease in the Caucasoid/Saudi ethnic group.
METHODS
This prospective study included patients diagnosed with rosacea at the Dermatology Clinic in King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia, who were seen between February 2010 and May 2011. The study included 50 patients of variable skin types, ranging from type 4 through 6. We adopted the skin phototype system for classifying the skin types: type 4 (light brown), type 5 (brown), and type 6 (dark brown or black).8 A detailed history of rosacea was obtained from each patient, including the duration, exacerbating factors (including sunlight, heat, cosmetics, spicy food, and others), family history, and cutaneous symptoms (including scaling, pruritus, dry appearance, and burning). All patients were evaluated by an ophthalmologist. Ocular symptoms and signs (including dryness, itching, redness, tearing, decreased visual acuity, chalazion, foreign body sensation, blepharitis, conjunctivitis, and keratitis) and treatments used were documented. Previous treatment modalities including oral antibiotics such as doxycycline, metronidazole gel, sunscreens, lasers, over the counter, or herbal medicaments were documented, as were coexisting problems like migraine.9 Helicobacter pylori10,11 and the presence or absence of allergic conjunctivitis suggested by the presence of itching, whether seasonal or perennial (where seasonal is defined as itching occurring during high seasons of allergens such as summer and spring and perennial is defined as symptoms lasting the entire year) were noted.12 Personal or family histories of allergic rhinitis, bronchial asthma, and/or atopic dermatitis were also obtained because they are considered essential for the diagnosis of allergic conjunctivitis.10
The 13C urea breath test with specificity of 98% and sensitivity of 97% has become the noninvasive test of choice for the diagnosis of H. pylori and was used in this study.13,14
A standard grading system developed by the National Rosacea Society Expert Committee was used for the classification and grading of rosacea. The erythematotelangiectatic (ETR), the papulopustular (PPR), and the phymatous subtypes of rosacea ratings were graded based on a 4-point scale with 0=absent, 1=mild, 2=moderate, and 3=severe.15 ETR was diagnosed based on the findings of persistent facial erythema and telangiectasia, while PPR was diagnosed based on the findings of persistent facial erythema with papules, pustules, or both. Noninflammatory; hard; brown, yellow, or red cutaneous papules; or nodules of uniform size were used to diagnose the granulomatous variant of rosacea. To overcome the difficulty in visualizing the erythema and telangiectasia, especially in skin type 6, we used Burton wave plus fluorescent magnifier light (3.5 dioptics) that enhances the optical performance. A phymatous subtype diagnosis was based on the presence of patulous follicles, contour changes, and nodular components. Ocular involvement was suspected based on the complaints of tearing, redness, foreign body sensation, itching, dryness, styes, and decreased visual acuity. All patients were referred to the ophthalmology clinic, and slit lamp examination was performed to look for any signs of eyelid, conjunctiva, and corneal pathology. The patient's history of postinflammatory hypopigmentation or hyperpigmentation was obtained and documented if present at the time of the initial examination and during the study period. Reports of the presence of melanoma and nonmelanoma skin cancers, including basal cell and squamous cell carcinoma, during follow-up were collected. The study was approved by the Institutional Review Board of the College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Data were collected and analyzed using predictive analytics software (IBM-SPSS, Inc., version 18.0). Descriptive data were expressed in percentages. The group statistics were assessed using Student t test for paired samples and the Pearson correlation test to determine the correlation between variables. Statistical difference was defined as P<0.05.
RESULTS
A total of 50 female patients with the diagnosis of rosacea were included in the study: 20 (40%) with skin type 4, 9 (18%) with skin type 5, and 21 (42%) with skin type 6 (Table 1). The mean age of all patients was 42.2 years (standard deviation [SD] 6.7 years, median 42.0 years, range 22-62 years), and the mean duration of the disease was 6.1 years (SD 5.8 years, median 4.5 years, range 0.4-25 years). Family history of rosacea was positive in 9 (18%) patients. Comparative analyses of different skin types showed no significant difference regarding age, duration, and family history. The mean duration between the onset of symptoms and the initial consultation was 24 months. Twenty-six (52%) patients had lesions that involved the glabella, cheek, and chin; 10 (20%) had lesions on the glabella, cheek, chin, and nose; and 14 (28%) had lesions on the glabella and the cheek only. Extrafacial lesions involving the chest, back, and ears were seen in 7 (14%) patients. Comparative analyses of the different skin types showed no significant difference regarding location of lesions.
Demographic Characteristics, Clinical Presentation, and Associated Disorders
Pruritus was the most common skin symptom (n=46, 92%), followed by scaling (n=38, 76%). Burning was the least common cutaneous symptom, occurring only in 1 (2%) patient.
Ocular symptoms were documented in 32 (64%) patients; the most frequent eye symptoms were itching and redness observed in 24 (48%) and 19 (38%) patients, respectively. Foreign body sensation, dry eyes, low visual acuity, and tearing were present in 8 (16%), 7 (14%), 3 (6%), and 1 (2%) patients, respectively. Blepharitis and conjunctivitis were reported in 12 (24%) and 15 (30%) patients, respectively. Patients with dry eyes received natural teardrops with eyelid hygiene and oral doxycycline for blepharitis. Comparative analyses of different skin types showed no significant difference regarding eye and skin symptoms.
Allergic conjunctivitis was seen in 17 (34%) patients, whereas allergic rhinitis and bronchial asthma were seen in 30 (60%) and 15 (30%) patients, respectively. Eight (16%) patients experienced migraine. H. pylori infection was documented in 11 (22%) patients.
Comparative analyses of different skin types and rosacea subtypes showed no significant distinction regarding migraine. H. pylori infection showed no significant correlation with rosacea subtypes ETR (P=0.403) or PPR (P=0.83).
Severe PPR was reported in 7 (14%) patients: 4 (20%) patients with skin type 4 and 3 (14.3%) patients with skin type 6 (Table 2). Severe ETR was reported in 21 (42%) patients: 10 (50%) patients with skin type 4, 2 (22.2%) patients with skin type 5, and 9 (42.9%) patients with skin type 6.
Rosacea Subtypes Severity and Aggravating Factors
No significant association existed between the skin types and the severity of PPR and ETR (P=0.7740 and P=0.5691, respectively) (Table 2). None of the patients showed the phymatous subtype or the granulomatous variant of rosacea. Postinflammatory hypopigmentation or hyperpigmentation was not reported in any patient. Melanoma and nonmelanoma skin cancers were not reported in any of the patients during the study period or upon follow-up. Treatment modalities included oral doxycycline and metronidazole gel combination (in 82% of patients), metronidazole gel (15%), pimecrolimus cream (1%), sunscreens (40%), and vascular laser (4%). Over-the-counter medications such as moisturizers were used by 10 (20%) patients.
Sun exposure was the most common exacerbating factor for rosacea in 36 (72%) patients, and no significant correlation was found between sun exposure and skin types (P=0.924). Heat was reported as an exacerbating factor for 22 (44%) patients, sweat in 3 (6%), spicy food in 2 (4%), and use of cosmetics in 2 (4%) patients. Twenty-six (52%) patients reported dust as an exacerbating factor of their skin disease (Table 2).
DISCUSSION
Rosacea typically manifests in people with fair skin and has a reported prevalence of 0.5%-10%.16 Although rosacea has been reported in patients with dark skin, the visual characteristics of the disease in dark-skinned individuals have yet to be identified.17 Our prospective study was therefore designed to collect information about rosacea's clinical presentation in Saudi females with skin types 4-6 and to help understand the disease peculiarities. Our patients shared the same clinical presentation of rosacea with patients having light skin; however, some points of divergence were noted.
Family history was reported in 18% of patients, which is lower than the rate reported in the literature of one-third of light-skinned individuals having a positive family history.18 The erythema and telangiectasia may be difficult to determine depending on the degree of constitutive skin pigmentation, which might explain the lower family history among relatives of Saudi patients with rosacea.19,20 Similar to the presentation in light-skinned individuals, the central and peripheral portions of the face including cheeks, glabella, chin, and nose were generally involved in all our patients. Extrafacial lesions, which rarely have been reported in the literature,21 were seen in regions such as the ears, neck, upper part of the chest, and back in 7 (14%) patients, indicating clinicians should be attentive to these locations during examination.
Interestingly, hyperpigmentation or hypopigmentation secondary to inflammation, another major concern of patients with darker-colored skin, was not reported by our patients or noted during the duration of the study. This finding is consistent with the clinical observation of Alexis20 that postinflammatory hyperpigmentation secondary to rosacea is rare compared to acne. Alexis hypothesized that the severity of inflammation or possibly the inflammatory mediators are different from acne.20 Inflammatory lesions of rosacea in this population might heal with no sequelae or with postinflammatory erythema that cannot be distinguished from the erythematous background of the disease. This hypothesis and the hypothesis of Alexis require further investigation. Phymatous rosacea rarely has been documented in female patients with light skin, and our study population of dark-skinned individuals did not include any cases of this subtype.22 In a study of 108 fair-skinned patients with rosacea, rhinophyma was reported in 14% of patients of whom 93% were men.23 Pruritus and scaling were reported in 92% and 76% of our population, respectively, possibly reflecting low-grade dermatitis.
Exposure to sunlight aggravated the condition in 72% of the patients in the present study. This percentage is high compared to several epidemiological studies that demonstrated only 17%-31% of rosacea patients reported worsening of symptoms upon exposure to sunlight.24-27 In a Polish study done by Jaworek et al, the most often mentioned aggravating factors were stress (58%) and sun (56%).28 In the report from Khaled et al from Tunisia, sun exposure was noted as a triggering factor in 64% of patients and thermal stimuli in 25%.7 The dark complexion of the skin of our patients and possibly the non-ultraviolet light protective clothing 29 of Saudi women that covers most of their face and torso may not offer much photoprotection against the strong ultraviolet rays of the sun in Saudi Arabia, highlighting the inherent photosensitive nature of the disease. Other exacerbating factors in our patient population included heat (44%), dust (52%), sweat (6%), and the use of cosmetics (4%). Dust as an exacerbating factor has not been recognized in the literature yet,18,24 suggesting dust as an aggravating factor of rosacea in this region where sandy storms are frequent. Numerous epidemiologic studies from Japan suggest an association between dust and several health hazards including respiratory, cardiovascular, cerebrovascular diseases, and allergic conditions such as conjunctivitis and rhinitis.30,31 Such reports and our current finding should alert healthcare providers to pay attention to the effect of sandstorms on skin diseases pertinent to their region.
Ocular symptoms were identified in 64% of our patients, marginally higher than a report by Zug et al that reported an incidence of 3%-58% dependent on the population studied.32 We argue that having a higher incidence of ocular involvement in our study might be attributed to the coexisting allergic conjunctivitis in 34% of our patients or to population differences. Allergic conjunctivitis and ocular rosacea share similar ocular signs, such as itching, conjunctival hyperemia, and tearing, that make differentiating between the 2 conditions difficult.33
The diagnosis of allergic conjunctivitis is generally made by personal or family history of allergic rhinitis, bronchial asthma, and/or atopic dermatitis.12,32-34 Itching, the most important symptom that aids in the diagnosis of allergic conjunctivitis, is precipitated by airborne allergens or dust mites. The bouts of itching might be intermittent (seasonal) or persistent (perennial).32-34 Because of the similarity in the clinical presentation of both diseases, such as itching, conjunctival hyperemia, foreign body sensation, and the high probability of coexistence, distinguishing between allergic conjunctivitis and ocular rosacea is often difficult. Detection of immunoglobulin E (IgE) in tears can be helpful to confirm the diagnosis of allergic conjunctivitis and differentiate between allergic conjunctivitis and ocular rosacea.35
Patients with signs of ocular rosacea were managed with eyelid hygiene and systemic doxycycline.34 Topical azithromycin represents an additional treatment for ocular rosacea blepharitis, with a short duration of treatment and lack of gastrointestinal side effects compared to systemic doxycycline.36
A history of migraine was documented in 16% of our patients, which is lower than the rate reported by Berg and Lidén who found 27% of rosacea patients suffered from migraine compared to 13% in the control group.24,37 The lower incidence of migraine in our patients might be attributed to lower genetic vulnerability, which is consistent with the report of Stewart et al that showed more Caucasians (20%) than African Americans (16%) have migraines.37
Infection with H. pylori was confirmed in 22% of our patients, which was comparable to a previous study by Aroni et al that reported an incidence of 24%.38 This finding reflects the similarity in the prevalence of this disease in different countries. Diaz et al reported a positive association between the severity of rosacea and H. pylori. 39 Treatment of H. pylori in our study did not offer any significant decrease in the severity of rosacea subtypes, which is consistent with the results reported by Bamford et al.14
CONCLUSION
Despite the major limitation of this study, the small sample size, we have contributed to the growing interest in ethnic skin behavior. This study has shown that rosacea in Saudi females with their inherent dark-skin complexion presents in a manner similar to its presentation in light-skinned individuals with a few unique characteristics. First, extrafacial sites are more likely to be involved, making examination of these sites significant. Second, postinflammatory pigmentary changes, which present a major concern in lighter skin, are an uncommon feature of rosacea in patients with darker skin. The rarity of postinflammatory hyperpigmentation in this situation may reflect a different inflammatory pattern that spares the epidermis, or inflammation could have resulted in erythema that becomes indistinguishable from the erythematous nature of the disease. These hypotheses require further investigation. Third, dust can be considered among the aggravating factors of rosacea in Saudi Arabia where dust storms are frequent. Last, ocular rosacea must be differentiated from allergic conjunctivitis because both conditions can coexist and have similar clinical presentations. IgE detection in tears might help differentiate between the 2 conditions. Therefore, patients with ocular symptoms should be referred to ophthalmology for differential diagnosis because the conditions require different treatments.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.
Footnotes
The authors have no financial or proprietary interest in the subject matter of this article.
- © Academic Division of Ochsner Clinic Foundation
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