Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel.

BACKGROUND: A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups. OBJECTIVES: To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development. METHODS: Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded. RESULTS: Delphi statements on which the panel achieved consensus of ≥ 75% voting 'Agree' or 'Strongly agree' are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements. CONCLUSIONS: The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management. What's already known about this topic? A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups. New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations. What does this study add? We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea. We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.

Acne in South African black adults: A retrospective study in the private sector.

BACKGROUND: Acne vulgaris is the most common skin disorder affecting teenagers and young adults, and is becoming increasingly common in middle-aged women. It affects all skin types and ethnic groups, but dark-skinned individuals are burdened by post-inflammatory hyperpigmentation (PIH) as a sequela. PIH causes distress in acne patients even after the inflammatory lesions have resolved. OBJECTIVE: To describe the characteristics of acne in black South African adults in the private health sector in Durban, KwaZulu-Natal Province. METHODS: A retrospective study of records of patients attending two large private dermatology clinics in central Durban, mainly catering for black patients, was performed. Data were collected for the period January - December 2014. Records with acne as a diagnosis were retrieved and analysed with regard to age, demographics, type and severity of acne, therapy, HIV status and outcomes. RESULTS: Of a total of ~3 000 charts available for the 12-month period, 242 had acne as a diagnosis and were retrieved and analysed. Of these patients, 204 (84.3%) were female and the remainder were male. The mean age was 28.5 years (under-18s were excluded from the study). Inflammatory acne was the most frequently encountered form (58.6%). Fifteen patients (6.2%) were on topical treatment only, and 226 (93.4%) were on topical plus systemic treatment. PIH was the most common sequela (81.0% of patients). CONCLUSIONS: The majority of the patients were young females with inflammatory acne, and PIH was the most common sequela. Early and vigorous treatment of acne may minimise its complications, including those seen mainly in black patients.

Rosacea in black South Africans with skin phototypes V and VI.

Rosacea is a chronic facial dermatosis considered to affect primarily white patients with light phototype skin, and is poorly documented in black patients. The aim of this study was to document the clinical features of rosacea in patients with phototypes V and VI. An 8-year retrospective chart review of patients with a clinical and histological diagnosis of rosacea or acne rosacea was undertaken. Of 6700 patients, 15 (0.2%) had rosacea. All were of African descent with skin phototype V or VI. Mean age was 47 years, and female : male ratio was 14 : 1. Of the 15 patients, 5 (33%) were positive for human immunodeficiency virus; 5 (33%) had used topical steroids to treat the roseacea; 6 (40%) had phototype V and presented with erythema, telangiectasia and erythematous papules, while 9 (60%) had phototype VI skin and presented with skin-coloured papules; and 10 (67%) had histology showing granulomatous rosacea, while 5 (33%) declined a facial skin biopsy. A high index of suspicion is required to diagnose rosacea in black patients as the classic signs of erythema and telangiectasia are difficult to discern.

Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel.

BACKGROUND: Rosacea is currently diagnosed by consensus-defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype-led approach may facilitate patient-centred management. OBJECTIVES: To advance clinical practice by obtaining international consensus to establish a phenotype-led rosacea diagnosis and classification scheme with global representation. METHODS: Seventeen dermatologists and three ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and severity evaluation. All voting was electronic and blinded. RESULTS: Consensus was achieved for transitioning to a phenotype-based approach to rosacea diagnosis and classification. The following two features were independently considered diagnostic for rosacea: (i) persistent, centrofacial erythema associated with periodic intensification; and (ii) phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were not considered to be individually diagnostic. The panel reached agreement on dimensions for phenotype severity measures and established the importance of assessing the patient burden of rosacea. CONCLUSIONS: The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype.

Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel.

BACKGROUND: Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient management. The ROSacea COnsensus panel was established to address this issue. OBJECTIVES: To incorporate current best treatment evidence with clinical experience from an international expert panel and establish consensus to improve outcomes for patients with rosacea. METHODS: Seventeen dermatologists and three ophthalmologists reached consensus on critical aspects of rosacea treatment and management using a modified Delphi approach. The panel voted on statements using the responses 'strongly disagree', 'disagree', 'agree' or 'strongly agree'. Consensus was defined as ≥ 75% 'agree' or 'strongly agree'. All voting was electronic and blinded. RESULTS: The panel agreed on phenotype-based treatments for signs and symptoms presenting in individuals with rosacea. First-line treatments were identified for individual major features of transient and persistent erythema, inflammatory papules/pustules, telangiectasia and phyma, underpinned by general skincare measures. Multiple features in an individual patient can be simultaneously treated with multiple agents. If treatment is inadequate given appropriate duration, another first-line option or the addition of another first-line agent should be considered. Maintenance treatment depends on treatment modality and patient preferences. Ophthalmological referral for all but the mildest ocular features should be considered. Lid hygiene and artificial tears in addition to medications are used to treat ocular rosacea. CONCLUSIONS: Rosacea diagnosis and treatment should be based on clinical presentation. Consensus was achieved to support this approach for rosacea treatment strategies.

Soaps and cleansers for atopic eczema, friends or foes? What every South African paediatrician should know about their pH

Background.Knowledge of the pH level of soaps and cleansers used by patients with atopic eczema and sensitive skin is crucial, as high-alkalinity products are irritants and impair the normal skin barrier, so interfering with the adequate control of atopic eczema.Objectives. The aim of this study was to assess the pH of various bar soaps and cleansers that are usually recommended and used by patients with atopic diseases and dry, sensitive skin in South Africa.Methods. Forty-nine commercial soap bars and cleansers were randomly selected for pH analysis. The samples were prepared as 8% emulsions in tap water. Nine undiluted liquid facial cleansers were also evaluated. Deionised water was used as a negative control. The pH of each emulsion or liquid cleanser was recorded in duplicate using a Metrohm pH meter model 827 (Metrohm, Herisau, Switzerland).Results. Of the 49 samples analysed, 34 (69.4%) were alkaline with a pH ranging from 9.3 - 10.7. Two samples (4.1%) were within the acceptable range of (5.4 - 5.9), and 2 samples (4.1%) had pH levels of below 5. In total, 5 samples (10.2 %) had a pH of 4 - 6.Conclusion. The majority of soaps and cleansers analysed in this study were alkaline, with only 2 falling in the acceptable pH range of 5.4 - 5.9 and 5 within the pH range of 4 - 6, thus raising concerns regarding the optimal management of atopic eczema patients

Primary cutaneous malignancies in the Northern Cape Province of South Africa: A retrospective histopathological review.

BACKGROUND: Excessive sun exposure and a high prevalence of HIV increase skin cancer risk in South Africa (SA). OBJECTIVE: To describe the nature and extent of skin cancers presenting in the public and private health sectors of the Northern Cape Province of SA. METHODS: A retrospective analysis of histologically confirmed new primary cutaneous malignancies from 1 January 2008 to 31 December 2012 was conducted using public and private health sector databases. Types, quantity and distribution of common invasive malignancies by population group, age, gender, anatomical site and health sector were explored. One-year cumulative incidence was calculated and logistic regression models were used to analyse incidence and melanoma thickness trends. RESULTS: A total of 4 270 biopsies (13 cutaneous malignancies) were identified. The commonest was squamous cell carcinoma (SCC), followed by basal cell carcinoma, Kaposi's sarcoma (KS), cutaneous malignant melanoma (CMM) and basosquamous carcinoma, in descending order. The odds of a white male developing SCC increased by 8% each year (odds ratio (OR) 1.08, 95% confidence interval (CI) 1.01 - 1.15; p=0.022), while the odds of a black male developing SCC and KS decreased by 9% (OR 0.91, 95% CI 0.84 - 0.99; p=0.033) and 18% (OR 0.82, 95% CI 0.70 - 0.97; p=0.022), respectively, each year. SCC and CMM were diagnosed at more advanced stages in the public than in the private healthcare sector. CMM is being detected earlier, as indicated by low-stage depth increasing by 72% annually (OR 1.72, 95% CI 1.04 - 3.01; p=0.042). CONCLUSIONS: Results suggest that reported skin cancer patterns are changing. There is a need for further research and equitable appropriation of financial resources and effort towards developing primary skin cancer prevention initiatives in SA.

Skin lightening practices: an epidemiological study of South African women of African and Indian ancestries.

BACKGROUND: Cutaneous adverse sequelae of skin lightening creams present with myriad skin complications and affect dermatology practice, particularly in sub-Saharan Africa where such products are widely used, with a prevalence of 25-67%. OBJECTIVES: To examine the skin lightening practices of both African and Indian women living in South Africa. METHODS: A cross-sectional survey was undertaken in the general outpatient departments of two regional university hospitals in Durban, South Africa. All consenting African and Indian women aged 18-70 years were recruited and asked to complete a questionnaire. RESULTS: Six hundred women completed the questionnaire, of whom 32·7% reported using skin lightening products. The main reasons cited were treatment of skin problems (66·7%) and skin lightening (33·3%). Products were purchased from a variety of sources. Twenty-five percent reported using sunscreen. CONCLUSIONS: The use of skin lightening cosmetics is common among darkly pigmented South African women, including those of both African and Indian ancestries. Despite more than 20 years of governmental regulations aimed at prohibiting both the sale of cosmetics containing mercury, hydroquinone and corticosteroids, and the advertising of any kind of skin lightener, they are far from having disappeared. The main motivations for using these products are the desire to treat skin disorders and to achieve a lighter skin colour. Television and magazine advertisements seem to influence women's choice of these products and, thus, would be efficient channels for raising public awareness about the dangers of using uncontrolled skin lighteners.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response.

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/µL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.

The reliability and validity of outcome measures for atopic dermatitis in patients with pigmented skin: A grey area.

BACKGROUND: Outcome measures for atopic dermatitis (AD) patients with pigmented skin have neither been developed nor validated. OBJECTIVE: To compare the reliability and validity of four common AD outcome measures in patients with various levels of skin darkness. METHOD: The inter- and intra-rater reliability and construct validity of the EASI (Eczema Area and Severity Index), objective-SCORing Atopic Dermatitis (oSCORAD), Three Items Severity index (TIS) and Six Areas, Six Sites Atopic Dermatitis (SASSAD) were evaluated in 18 patients of various levels of skin darkness, using their full body photographs, by five trained clinicians. RESULTS: The inter-rater reliability intraclass coefficient (ICCs) and 95% confidence intervals were poor for highly pigmented patients: EASI -.054(-.200 to .657), oSCORAD -.089(-.206 to .598), TIS -.21(-.24 to .147), SASSAD -.071(-.200 to .631); fair for mildly pigmented patients: EASI .464(.140-.839), oSCORAD .588(.265-.89), TIS.524(.200-.865), SASSAD .41(.045-.775); and fair to good for non-pigmented patients: EASI .64(.330-.908), oSCORAD .586(.263-.889), TIS .403(.09-.809), SASSAD .667(.358-.916). Erythema likely contributed to the inter-rater variability. Construct validity had significant correlations across all measures in non-pigmented patients, but no correlations in highly pigmented patients. CONCLUSION: AD outcome measures have poor reliability and validity in highly pigmented patients, with variations in erythema perception being a contributor.

HIV-associated eosinophilic folliculitis in an infant.

HIV-associated eosinophilic folliculitis (HIV-EF), which is a well-known entity in adults, has not been described in children. Although Ofuji's disease (OD) or eosinophilic pustular folliculitis (EPF) has been described in children and shares histopathologic features with HIV-EF, it is a distinct entity with characteristic clinical features. We report the occurrence of eosinophilic folliculitis in an 8-month-old HIV-positive patient and discuss the clinical, pathologic and possible pathogenetic aspects thereof. In addition, differences in the clinical manifestations of the present case and that of I-EPF are addressed. Because of clinicopathologic similarities between the present case and HIV-associated eosinophilic folliculitis (HIV-EF) in adults, we believe that eosinophilic folliculitis in this patient represents a cutaneous manifestation of HIV infection, rather than co-incidental occurrence of the infantile form of Ofuji's disease in an HIV-positive patient.